Current Management of the Neonatal Abstinence Syndrome: A Critical Analysis of the Evidence

Abstract

Objective: To systematically and critically analyse and summarise the published evidence for the rational choice of pharmacologic treatment of the neonatal abstinence syndrome (NAS), a frequently observed condition in neonates born to mothers who are dependent on physically addicting drugs. Design: Studies comparing different pharmacological agents for the treatment of NAS were identified utilising MEDLINE® and additionally the references cited in pertinent articles. The identified studies were critically analysed regarding their study designs and outcome measures. The reported data for the comparative efficacy of the drugs were summarised and evaluated. Results: Fourteen studies were identified, most of them comparing treatment of NAS with phenobarbital, paregoric or diazepam. However, none of these studies was conducted in a double-blind fashion. Frequently, treatment allocations were not properly randomised. Prenatal drug exposure varied and was often not sufficiently verified. Outcome measures and their evaluations differed widely. Due to the different study objectives and flaws in study design, a combined analysis of the published data in the form of a meta-analysis was not deemed possible. When attempting to compare efficacy, diazepam appears to be less efficacious in treating NAS than phenobarbital or paregoric. The relative efficacy of paregoric and phenobarbital appears to depend upon the antenatal exposure of the neonate and on the outcome measure of the study. Only two studies evaluate the efficacy of pure opioids, none of them in direct comparison to paregoric. It remains questionable whether paregoric, which contains the central stimulant camphor and a large amount of alcohol, should be the opioid of choice for the treatment of NAS. Conclusion: Most published studies were conducted prior to the development of clinical epidemiology and modern study design and thus yielded only very limited comparative data on the benefits of different treatment protocols. There is very little evidence regarding the efficacy of different pharmacological therapy regimens to treat NAS. More studies are required to produce the evidence needed to allow a rational choice between treatment modalities of NAS and thus to ensure optimal care of the neonates suffering from this condition.

Hospital morphine preparation for abstinence syndrome in newborns exposed to buprenorphine or methadone

“…Treatment of NAS has been performed with a wide range of drugs including paregoric, tincture of opium, morphine, methadone, diazepam, chlorpromazine, phenobarbital, and clonidine [7][8][9][10][11]. Neonatologists at our institution consider morphine as a more physiologic substitute for the drug causing the NAS.…”

A randomised controlled trial of morphine versus phenobarbitone for neonatal abstinence syndrome

“…9 10 Studies to date can be criticised on their lack of standardisation of outcome measures, problems with randomisation, and failure to use a pre-evaluated scoring system to allow standardisation of the start of treatment, dosage alterations, and termination of pharmaceutical treatment. [11][12][13] The aim of this study was to compare the efficacy of initial treatment with an opiate versus phenobarbitone for infants with NAS caused by opiate withdrawal. The total duration of pharmaceutical treatment required to achieve symptom resolution was predefined as the primary study end point, and the requirement for higher intensity nursing in the SCBU or the need for an additional second line treatment as secondary end points.…”

Measurement of movement is an objective method to assist in assessment of opiate withdrawal in newborns

“…8 The scoring method was validated in 1977 with sucking behaviour, although there is no clear evidence of a relation with severity of withdrawal and treatment requirements. 9 Secondly, the scoring method is not a blinded assessment, can be prone to bias, and is often cumbersome. 10 In a recent qualitative study of the principal users of the method, 44% of nurses reported that the scoring chart was not very useful, and 59% indicated they would change something about the scoring system.…”