What is the recommended approach to pharmacotherapy for NAS when severe symptoms are present?

• A. Pharmacologic treatment with benzodiazepines as first line
• B. Pharmacologic treatment with opioids is never used
• C. Pharmacologic treatment with opioids may be used in more severe NAS with gradual taper
• D. Pharmacologic treatment with antipsychotics is first-line

Answer: (C)

When NAS symptoms are severe, the pharmacologic approach centers on replacing the infant’s opioid exposure with a controlled opioid and then tapering the dose gradually. Starting an opioid such as morphine or methadone and slowly reducing the dose over days to weeks helps normalize withdrawal symptoms, improves feeding and sleep, and often reduces hospital stay. This strategy directly addresses the underlying withdrawal biology and provides a defined path to wean the infant off opioids safely. Benzodiazepines are not used as first-line therapy because they can cause respiratory depression and sedation without reliably improving NAS outcomes. Antipsychotics are not considered first-line either, as they do not effectively treat the core withdrawal symptoms and carry additional side effects. The emphasis is on opioid therapy for severe NAS with a careful, gradual taper guided by the infant’s symptoms.