Frequently Asked Questions
What does MAiN mean?
MAiN stands for Managing Abstinence in Newborns. The MAiN Treatment consists of three components: early medication for healthy newborns exposed to methadone or high doses of buprenorphine during late gestation, full care on the Mother/Baby Unit, and medication weaning under the supervision of an outpatient medical home. The MAiN Model consists of the hospital services and clinical pathways that support the care of all substance-exposed newborns and their mothers. A hospital practicing the MAiN Model should work toward having a comprehensive MAiN Program, with outreach to and partnership with providers caring for pregnant women with opioid use disorders.
Who should consider becoming a MAiN expansion site?
SC hospitals with high case rates of NAS or maternal opioid dependence will benefit from adopting the MAiN Model. Hospitals with lower NAS case rates but high delivery volumes should also consider becoming part of the MAiN expansion, since case rates are expected to continue to rise in the coming decade. A majority of Level II-IV birthing hospitals in SC will be eligible.
Is MAiN a research project?
The MAiN Model is a DHHS funded program in SC. The MAiN expansion project is also IRB-approved and will be evaluated by a team of Clemson researchers after its completion. Participating hospitals will be required to share case-specific patient data with the program administrators ONLY to verify the fidelity of implementation to the model and to identify areas of needed improvement. No identifiable patient data will be shared with research analysts or the public.
What resources will a hospital need to adopt the MAiN model?
To implement the MAiN model successfully, hospitals will need a newborn provider champion, a nursing leadership champion, and a case manager or social worker available to address family needs on the Mother/Baby Unit. Staff in the facility should be engaged and open to change. Implementation will also require physical resources, such as medication and monitoring equipment.
Is it safe for a baby at risk for NAS to stay in a private room with his mother?
Rooming-in with the mother is the safest place for newborns, with few exceptions. Neonates at risk for NAS can be safely monitored while rooming-in unless they are acutely ill or severely symptomatic, which may require intensive nursing care. Early treatment for the highest-risk newborns markedly reduces severe NAS symptoms and complications, such as fever, diarrhea, weight loss, irritability, and seizures. Early treatment also makes it feasible for mothers to provide supportive care safely while rooming-in.
Is it harmful to prolong a newborn’s opioid exposure after birth?
A number of professional organizations recommend maternal use of long-acting opioids for opioid use disorder during pregnancy. They also recommend use of opioids as one modality to prevent and treat pain in the neonatal period. Long-term effects of opioids on early development are not known. For now, however, one might conclude that if fetal exposure to long-acting opioids is generally considered safe, then additional low-level exposure for the first few weeks of life should not significantly increase risk for developmental problems. The alternative—allowing abrupt opioid withdrawal in neonates—leads to a cascade of neurologic effects that are similar to a severe pain experience, which is known to increase morbidity and mortality.
Do you allow mothers taking long-acting opioids to breastfeed?
Yes. Maternal use of long-acting opioids is not a contraindication to breastfeeding. However, if a mother tests positive for an illicit substance (such as marijuana or methamphetamine) at delivery, we do not allow breastfeeding.
What adverse events have MAiN babies in Greenville experienced?
The most common adverse event noted in our MAiN treatment population has been unsafe sleeping. We have had no adverse drug events, injuries, or deaths related to early treatment.
How do you pay for the extra days that the mother stays in the hospital with her baby?
We follow the same model that is applied when a child is admitted to any hospital. If a child does not need intensive care, then he/she is admitted to a patient room, and a caregiver is invited to stay in the same room as a guest. The presence of a caregiver is essential for the support and routine care of the child. When a caregiver is absent, routine care tasks, such as feeding, holding, and diaper changes, must be completed by nursing staff, in addition to the medical care being provided.
When a postpartum room is available and the mother is a candidate for extended stay, the room charge is converted from the mother’s account to the newborn’s and the mother stays as a guest. We have a “rooming in contract” that the mother must sign, outlining staff expectations that a caregiver will remain in the room with the baby on a 24-hour basis.
Is it safe to send opioid medications home with a mother who has an opioid use disorder?
The total amount of medication needed for a 30-day infant home weaning is approximately one-quarter to one-third of a single day’s dose for an adult. The baby’s medication is dispensed in pre-filled oral syringes. We have had no cases of suspected medication mishandling during outpatient weaning when the prescription was filled in this manner. Outpatient providers and DHEC nurse home visitors can provide reconciliation of medication dispensed on weekly home visits.
Does Medicaid cover the cost of the newborn’s medication wean?
Most Medicaid plans do not cover the cost of the newborn’s outpatient medication. However, the out-of-pocket cost to caregivers has been less than $11 per case in Greenville. This amount has not been a burden for most families, especially when compared to the cost of treatment services for the mother.
Are babies on outpatient opioid weaning at higher risk for readmission?
We formally track readmission rates in the Greenville MAiN population and have seen no increase in emergency room visits or admissions compared with our normal pediatric population. A majority of urgent visits in our cohort have been for problems unrelated to NAS or medication, such as acute infection.
Is a medical home assigned to a weaning newborn, or are parents allowed to choose?
We strongly recommend to families that they use a practice that is comfortable and experienced with managing an opioid wean. After the wean is completed, they may transfer to any provider that they choose. When families are opposed to seeing a new outpatient provider, we will contact their preferred provider to discuss whether he/she is willing to manage weaning. If so, we provide an overview of the plan of care and treatment goals and answer any questions regarding wean management. We remain a resource for any outpatient partners who have questions related to MAiN patients after discharge.
What technical assistance will be available for our providers while we implement the MAiN model?
Our team will be with you every step of the way! We are happy to answer questions and provide guidance during all phases of implementation.
Why was MAiN developed?
Over a decade ago, the MAiN treatment was developed at Prisma Health Greenville Memorial Hospital as a pilot attempt to prevent the symptoms and complications of neonatal abstinence syndrome (NAS) in otherwise healthy newborns at risk. Just as neonates who require prolonged IV opioids for critical conditions are managed with anticipatory oral weaning, otherwise healthy newborns with chronic fetal exposure to long-acting opioids were provided with immediate oral opioid weaning. The technique was found to be extremely effective and seemed to be associated with low rates of adverse events. In 2016, a retrospective analysis of a MAiN treatment cohort was published to detail formal safety, efficacy, and healthcare utilization outcomes.
How will the MAiN model benefit our patients?
Mothers benefit from being the primary newborn caregiver for the duration of the birth hospitalization. Extended rooming-in, when appropriate, promotes bonding and allows a mother more time to gain experience in recognizing withdrawal symptoms and practicing supportive care techniques under the guidance and supervision of healthcare providers. This increases caregiver knowledge and confidence. Hospital staff have direct contact with the mother-infant dyad throughout the hospitalization, observe interactions, and provide support and education prior to discharge from the hospital. The newborn benefits from frequent supportive care by his mother that rooming-in allows. Home weaning prevents prolonged hospital stays and their associated risks.
How will the MAiN model benefit our hospital?
SC birthing hospitals need an organized approach to managing all aspects of the opioid epidemic, including NAS. The MAiN model, when implemented properly, allows most NAS cases to be managed in a low-acuity setting. This protects neonatal ICU beds for infants in critical condition and prevents diversion to other hospitals, which is beneficial in keeping the family together. The model is more cost-efficient than traditional NAS care. Case rates are expected to continue to rise over the coming decade, and hospitals without a clear plan of care will be more affected over time through escalating costs to both the institution and to the family unit.
Will there be any costs to us?
The MAiN expansion project is a Medicaid program supported by the SC Department of Health and Human Services. Up to ten hospitals will be supported with funding to offset implementation costs. No funding for future expansion is planned.
What if we aren’t ready now but might be interested at a later time?
Ten hospitals will be selected for MAiN implementation through a competitive application process. The first round of applications will be due on December 20, 2017. If ten hospitals are not selected during the first round, then the application process will be repeated in 2018, and annually thereafter as needed until all ten spots are filled. Under the current grant, participation is limited to ten hospitals and no further expansion has been discussed.
Is it safe to give opioid medications to newborns on the Mother/Baby Unit, and at home?
Newborns who are allowed to experience opioid withdrawal can have seizures, which are associated with central apnea. For those born opioid-dependent, the risk of not treating and having a seizure is higher than the risk of over-sedation due to early medication treatment. The rate of over-sedation in the MAiN cohort studied in Greenville was 4 percent. All cases of over-sedation were identified during the birth hospitalization, and medication dosing was adjusted. To date, no incidents of over-sedation during outpatient weaning have been reported.
Do newborns on medication require more intensive nursing care?
Newborns on medication can typically be managed with standard levels of nursing care that are allotted for Mother/Baby units. Abstinence scoring should take place every four hours. Monitoring for serious side effects, such as heart rate or breathing abnormalities, can be accomplished with a basic cardiorespiratory monitor in the mother’s room connected to a standard nurse call system. Newborn care for this population is otherwise routine.
With early treatment, what is the risk that babies given medication might not have needed it?
If over-treated, newborns should have signs and symptoms that are detectable during inpatient monitoring. These may include low heart rate or respiratory rate, excessive sleepiness, poor suck or tone. The rate of over-sedation in MAiN babies at Prisma Health Greenville Memorial Hospital is 4 percent. In all cases, symptoms resolved with reduction or cessation of medication. No babies have required NICU transfer or respiratory support for over-treatment. Of note, naloxone should never be given to babies who are presumed opioid-dependent.
How long do MAiN babies typically stay in the hospital?
Newborns who qualify for early medication treatment will typically stay in the hospital for 7-8 days. Babies exposed to short-acting opioids or illicit substances are monitored in the hospital for 3-5 days. A small percentage of these may become symptomatic for NAS and require treatment with medication. When this occurs, and when there are no complications of NAS requiring intensive care, the average length of stay on the Mother/Baby Unit is 11-12 days.
What if we don’t have an outpatient pharmacy to dispense methadone for outpatient weaning?
Most outpatient pharmacies are seeking patient referrals and are willing to partner with hospitals on special projects. Direct outreach and communication can be very effective for initiating collaboration.
With early treatment, how long do babies require outpatient weaning?
MAiN newborns discharged with an outpatient weaning plan typically need 10-30 days to complete the wean. Designing a wean that is no longer than 30 days allows caregivers to take home all the medication they need to complete the wean with one prescription. Eighty percent of newborns have no issues that require slowing the wean.
How do you convince an outpatient practice to manage a newborn’s opioid wean after discharge?
Partnership with at least one outpatient practice to manage weaning after discharge is critical. In Greenville, we have successfully engaged three practices to manage weaning – the Center for Pediatric Medicine, Parkside Pediatrics, and Pediatric Associates of Simpsonville. For us, engaging new practices has involved personal outreach, good communication, and a brief in-person question-and-answer session prior to managing the first patient.
Do you refer all mothers taking long-acting opioids to the Department of Social Services (DSS)?
Many mothers with opioid use disorders in recovery have stable social situations and make healthy choices during pregnancy. Each mother in treatment can benefit from social work or case manager consultation to assess for needed services and behavioral concerns during pregnancy. SC law mandates that concern for abuse or neglect must be reported to DSS and/or law enforcement. In Greenville, approximately 50 percent of families in the MAiN treatment program require DSS involvement sometime before, during, or immediately after the birth hospitalization. Regardless of DSS involvement, every mother and newborn should have a plan of safe care in place at hospital discharge that includes available wraparound services for ongoing support beyond the infant’s participation in the MAiN program.
The Scope of NAS in the US
The Scope of NAS in SC
The MAiN Solution
Early treatment for neonatal abstinence syndrome: A palliative approach.
Hudson, J., Mayo, R., Dickes, L., Chen, L., Sherrill, W. W., Summey, J., Dalton, B. & Dankovich, K. (2016). DOI: 10.1055/s-0036-1596054