Introduction: Neonatal Abstinence Syndrome (NAS) is an escalating global health challenge driven by rising illicit drug use during pregnancy . In South Asia, the condition remains significantly underreported and underdiagnosed due to the nonspecificity of symptoms and limited access to toxicological testing. This case series explores the clinical complexities and systemic hurdles in managing NAS within a resource-limited setting. Case presentation: We report 23 neonates clinically diagnosed with NAS at two tertiary centers (De Zoysa Hospital for Women and Colombo North Teaching Hospital) in Sri Lanka over 18 months. All 23 mothers had a current or history of illicit substance use; however, only two were identified prior to conception. 16/23 (70%) of mothers were under 25 years. Five deliveries occurred outside hospitals, and 12/23 (52%) babies had low birth weight. 21 neonates manifested clinical symptoms within the first 72 hours of life. The most frequent symptoms were irritability (n=18), excessive high-pitched cry (n=16), jitteriness/tremors (n=21), and hypertonia (n=14). Of the 16 cases with positive toxicology screening, 50% were positive for morphine alone. 17/23 required pharmacological intervention (oral morphine) based on Modified Finnegan Score. 12/23 (52%) infants were placed in probation care. Conclusion: NAS pose significant burden to health system of Sri Lanka. ComprehensiveNational Guideline on managing NAS is a timely need. Strengthening collaboration among the health, legal, and social sectors is vital to mitigate the long-term neurodevelopmental risks faced by these vulnerable infants.