User:H. Lee, Future UCSF Pharm.D./sandbox

Sign and Symptoms of NAS usually appears within 48 to 72 hours of birth.

Causes

The drugs involved may be, for example, opioids, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), ethanol, and benzodiazepines. Opioids may be more likely to cause the syndrome than others due to increase in their usage. Exposure to heroin and methadone claimed to be correlated with a 60 to 80% occurrence of neonatal withdrawal, whereas buprenorphine has been associated with a lower risk. Studies however, demonstrate conflicting results. Neonatal abstinence syndrome does not happen in prenatal cocaine exposure. Prematurity and exposure to other drugs may instead be the cause of symptoms.

The main mechanistic pathway of prescribed and illicit substance induced Neonatal Abstinence Syndrome is the hyperactivity of the central and autonomic nervous system and Gastrointestinal tract. There are several potential mechanisms and pathways that have been proposed, which includes the interaction between the neurotransmitters and lack of adequate expression of opioid receptors. However, the main pathophysiology of this syndrome remains unknown. Most of the opioid induced NAS are due to opioid exposure during pregnancy for pain relief or misuse or abuse of prescribed opioids or other medication-assisted treatment of opioid use disorder.

Neonatal withdrawal is prevented by the mother abstaining from substance abuse. In some cases, a prescribed medication may need to be discontinued during the pregnancy to prevent addiction by the baby. Early prenatal care can identify addictive behaviors in the mother and family system. Referrals to treatment centers is appropriate. Some prescribed medicines should not be stopped without medical supervision, or harm may result. Suddenly stopping a medication can result in a premature birth, fetal complications, and miscarriage. Women can discuss all medicines, and alcohol and tobacco use with their health-care provider and get assistance to help stop drug use as soon as possible. Indications that a woman needs help are if she is:

• Using drugs nonmedically
• Using drugs not prescribed to her
• Using alcohol or tobacco

There are several strategies to prevent the incidence of Neonatal Abstinent Syndrome.

• Primary Preventions
  • Encourage to follow 2016 CDC Guideline for Prescribing Opioids for Chronic Pain
  • Utilize Prescription drug Monitoring Programs (PDMPs)
  • Ensure access to family planning and preconception care of women who use opioids
• Provision of treatment for opioid use disorder among pregnant woman
• Nonpharmacological strategies via minimizing environmental stimuli

However, there are some barriers to prevention which includes lack of consensus to screening tools to identify substance use while pregnant, also includes, stigma, provider bias, and legal consequences.