Neonatal Abstinence Syndrome: Tennessee’s Epidemic and the State’s Response Michael D. Warren, MD MPH FAAP Division of Family Health and Wellness
Jul 14, 2015
Preventing Neonatal Abstinence Syndrome: The Tennessee Story
Neonatal Abstinence Syndrome:Tennessees Epidemic andthe States ResponseMichael D. Warren, MD MPH FAAPDivision of Family Health and Wellness
1ObjectivesDefine the etiology, diagnosis, and management of Neonatal Abstinence Syndrome (NAS)Outline the scope of NAS in TennesseeDescribe Tennessee interventions to reduce the burden of NAS
NAS Epidemiology, Diagnosis,and Treatment
3Prenatal Drug ExposureInfantwithrecognizable syndrome or signsPregnant women who use potentially harmful substancesAll pregnant womenDrug ExposedTobaccoIllicit DrugsPrescription DrugsAlcoholEtcApparently normalNeonatal Abstinence Syndrome (NAS)Fetal Alcohol SyndromeNeurological abnormalitiesPrematurityLow birth weightEtc
All babies with neonatal abstinence syndrome are drug-exposed infants**Almost always prenatal
Not all drug-exposed infants will develop Neonatal Abstinence Syndrome
All drug-exposed infants are potentially at risk for adverse outcomesPrenatal Drug Exposure
Prenatal Drug ExposureWithdrawal symptoms in neonates can be associated with exposure to:AlcoholBarbituratesBenzodiazepinesOpioidsCaffeineAnti-depressantsEtc..
NAS BackgroundNAS can be associated with:Prescription drugs obtained with prescriptionIncludes women on pain therapy or replacement therapyPrescription drugs obtained without prescriptionIllicit drugs
NAS BackgroundOpioid withdrawal symptoms primarily related to:
Central Nervous System: Seizures HyperactivityTremors
Gastrointestinal System: Poor feeding VomitingPoor weight gain DiarrheaUncoordinated sucking
NAS BackgroundOpioid withdrawal symptoms:May appear as early as within the first 24 hoursMay take as many as 4-5 days to appearOccur in 55-94% of exposed infants
NAS IdentificationNAS is a clinical diagnosis
NAS diagnosis based on:History of exposure Evidence of exposure:Maternal drug screenInfant urine, meconium, hair, or umbilical samplesClinical signs of withdrawal (symptom rating scale)
NAS TreatmentInitial treatment: Minimize environmental StimuliRespond early to signalsSupport adequate growthPharmacologic therapy may be needed
Prenatal Drug Exposure OutcomesBabies with prenatal drug exposure are more likely to:Be delivered by cesarean (OR 1.5-1.9)Be born pre-term (OR 3.7-4.6)Be born at low birth weight (OR 4.1-5.2) Have feeding problems (OR 8.2-10.3)Have respiratory distress syndrome (OR 3.4-5.3)
Creanga AA, et al. Maternal drug use and its effect on neonatesa population-based study in Washington state. Obstetrics and Gynecology. 2012. 119(5): 924-33.
Prenatal Opioid Exposure OutcomesNational Birth Defects Prevention Study (1997-2005)Increased risk of:Spina bifida (OR 1.3-3.2)Gastroschisis (OR 1.1-2.9)Any heart defect (OR 1.1-1.7)AVSD (OR 1.2-4.8)Tetralogy of Fallot (OR 1.1-2.8)VSD (OR 1.1-6.3)Hypoplastic Left Heart Syndrome (OR 1.4-4.1)RVOT defects (OR 1.1-2.3)Pulmonary valve stenosis (OR 1.2-2.6)
Broussard CS, Rasmussen SA, Reefhuis J, et al. Maternal treatment with opioid analgesics and risk for birth defects. Am J Obstet Gynecol. 2011;204:314.e1-11.
NAS OutcomesNo definitive long-term syndrome associated with neonatal opioid withdrawalLimited studies show:Mixed outcomes of developmental assessment scores (hyperactivity, short attention span, memory and perceptual problems)Resolution of seizuresConfounding by social/environmental variables
Scope of NAS in TN & US
16NAS Epidemiology (US)Over the past decade:2.8-fold increase in NAS incidence4.7-fold increase in maternal opioid useIncrease in hospital costs $39,400$53,40078% charges to state Medicaid programsSource: Patrick SW et al. Neonatal Abstinence Syndrome and Associated Health Care Expenditures, United States, 2000-2009. Journal of the American Medical Association. 2012;307(18):1934-1940
NAS Hospitalizations in TN:1999-2012Data sources: Tennessee Department of Health; Office of Health Statistics; Hospital Discharge Data System (HDDS) and Birth Statistical System. Analysis includes inpatient hospitalizations with age less than 1 and any diagnosis of drug withdrawal syndrome of newborn (ICD-9-CM 779.5). HDDS records may contain up to 18 diagnoses. Infants were included if any of these diagnosis fields were coded 779.5.
18NAS Unique Patients in TN:2008-2012Data sources: Tennessee Department of Health; Office of Health Statistics; Hospital Discharge Data System (HDDS) and Birth Statistical System. Analysis includes inpatient hospitalizations with age less than 1 and any diagnosis of drug withdrawal syndrome of newborn (ICD-9-CM 779.5). HDDS records may contain up to 18 diagnoses. Infants were included if any of these diagnosis fields were coded 779.5.
TNs Prescription Drug ProblemIn 2011, Tennessee ranked 49th highest in the country for the number of prescriptions filled per capita17.6 prescriptions filled per personNational average: 12.1
Kentucky and West Virginia tied for highest (19.3 prescriptions per person)
Data source: Henry J. Kaiser Family Foundation. Retail Prescription Drugs Filled at Pharmacies (Annual Per Capita), 2011.
20TNs Prescription Drug ProblemData source: CDC, Policy Impact Brief: Prescription Painkiller Overdoses. Available at: http://www.cdc.gov/homeandrecreationalsafety/rxbrief/
Prescription Painkillers Sold By State, 2010TN: 2nd highest in country for kilograms of prescription painkillers sold per 10,000 people
Opioid Prescription Rates by CountyTN, 2007-2011Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.2007
22TNs Prescription Drug Problem
51 pillsper every Tennessean over age 1222 pillsper every Tennessean over age 1221 pillsper every Tennessean over age 12275.5 Million Hydrocodone Pills116.6 Million Xanax Pills113.5 Million Oxycodone PillsData source: Tennessee Department of Health; Controlled Substance Monitoring Database.
The top three most prescribed controlled substances in Tennessee in 2010 were:275.5 million pills of hydrocodone (e.g., Lortab, Lorcet, Vicodin)51 pills per every Tennessean over age of 12116.6 million pills prescribed for alprazolam (e.g., Xanax: used to treat anxiety) 22 pills per every Tennessean over age of 12113.5 million pills prescribed for oxycodone (e.g., OxyContin, Roxicodone)21 pills for every Tennessean over age of 12
23TNs Prescription Drug ProblemIncrease in TN deaths due to prescription drug overdose422 in 20011,093 in 2012More than deaths from:Motor vehicle accidents, homicide, or suicideOpioids (methadone, oxycodone, and hydrocodone) are by far the most-abused prescription drugs
NAS Hospitalizationsby CountyTN, 2010-2012201020112012
25Narcotics and Contraceptive Use:TennCare Women, CY2012*DemographicsTennCare WomenWomen Prescribed Narcotics (>30 days supplied)Narcotic Users Rate per 1,000Women Prescribed Contraceptives and Narcotics% of Women on Narcotics and ContraceptivesWomen Prescribed Narcotics without Contraceptives% of Women on Narcotics Not on ContraceptivesAll Women 296,68742,082141.87.53818%34,54482%15 - 2084,3982,05424.398748%1,06752%21 - 2444,6203,89787.31,43237%2,46563%25 - 2953,3338,689162.92,19925%6,49075%30 - 3448,91210,442213.51,69916%8,74384%35 - 3937,4839,319248.68059%8,51491%40 - 4427,9407,681274.94165%7,26595%Data source: Division of Health Care Finance and Administration, Bureau of TennCare. *CY2012 data is provisional.
Unintended PregnancyAmong All Women & Opioid AbusersData source: For general population: Tennessee Department of Health. Pregnancy Risk Assessment Monitoring System, 2009 Summary Report. Available at: http://hit.state.tn.us/Reports/HealthResearch/PregancyRisk2009.pdf . For opioid-abusing women: Heil SH et al. Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse Treatment. 2011. March; 40(2): 199-202.
Unintended PregnancyAmong All Women & Opioid AbusersIn TN, women with unintended pregnancy:More likely to have no preconception counseling (77.7% vs. 55.4%)More likely to have short interpregnancy interval (45.0% vs. 15.6%)More likely to have late or no prenatal care(28.1% vs. 10.9%)More likely to not take folic acid daily(82.6% vs. 64.7%)National sample of opioid-abusing womenWomen with unintended pregnancy 60% more likely to have used cocaine within past 30 days compared to women with intended pregnancyData source: For Tennessee: Tennessee Department of Health. Pregnancy Risk Assessment Monitoring System, 2009 Summary Report. Available at: http://hit.state.tn.us/Reports/HealthResearch/PregancyRisk2009.pdf . For opioid-abusing women: Heil SH et al. Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse Treatment. 2011. March; 40(2): 199-202.
TennCare NAS Costs, CY2012*Data source: Division of Health Care Finance and Administration, Bureau of TennCare. *CY2012 data is provisional.1. This sample contains only children that were directly matched to TennCares records based on Social Security Number.2 . Any infant weighing under 2,500g at the time of birth was considered low birth weight (LBWT). MetricTennCare Paid Live Births1TennCare non-LBWT BirthsTennCare Live LBWT Births2NAS InfantsNumber of Births42,17137,5764,595736Cost for Infant in first year of life$352,516,166$177,959,049$174,557,118$45,870,410Average Cost per child$8,359$4,736$37,988$62,324Average length of stay (days)3.52.015.826.2
TennCare Infants in DCS Custody Within 1 Year of Birth, CY2012*Data source: Division of Health Care Finance and Administration, Bureau of TennCare. *CY2012 data are provisional.This sample contains only children that were directly matched to TennCares records based on Social Security Number.Infants born in CY 2012NAS infantsTotal # of Infants54,984736Total # infants in DCS906179% in DCS1.6%24.3%
TN Efforts to Prevent NAS
31NAS Subcabinet Working GroupConvened in late Spring 2012Committed to meeting every 3-4 weeksCabinet-level representation from Departments:Public Health (TDH)Childrens Services (DCS)Human Services (DHS)Mental Health and Substance Abuse Services (DMHSAS)Medicaid (TennCare)Childrens Cabinet
The Levels of PreventionPRIMARYPreventionSECONDARYPreventionTERTIARYPreventionDefinitionAn intervention implemented before there is evidence of a disease or injuryAn intervention implemented after a disease has begun, but before it is symptomatic.
An intervention implemented after a disease or injury is establishedIntentReduce or eliminate causative risk factors (risk reduction) Early identification (through screening) and treatmentPrevent sequelae (stop bad things from getting worse)
NAS ExamplePrevent addiction from occurring
Prevent pregnancyScreen pregnant women for substance use during prenatal visits and refer for treatmentTreat addicted women
Treat babies with NASAdapted from: Centers for Disease Control and Prevention. A Framework for Assessing the Effectiveness of Disease and Injury Prevention. MMWR. 1992; 41(RR-3); 001. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00016403.htm
Request for Black Box Warning
TennCare Prior Authorization Form
Form available at: https://tnm.providerportal.sxc.com/rxclaim/TNM/TC%20PA%20Request%20Form%20(Long%20Acting%20Narcotics).pdf
Controlled SubstanceMonitoring DatabasePrescription Safety Act of 2012TCA 53-10-300Required prescribers to registerShall check provisionCSMD Successes:4.5M searches (240% increase from 2012)50% decrease in doctor shoppingChange in provider behavior:71% have changed tx plan after viewing CSMD report 73% more likely to discuss substance abuse issues or concerns with a patient Report available at: http://health.tn.gov/statistics/Legislative_Reports_PDF/CSMD_AnnualReport_2014.pdf
Additional Legislative ActionsSafe Harbor Act (TCA 33-10-104, 2013)Pregnant women get priority for treatmentChild cannot be removed solely due to maternal substance use if treatment initiated by 20 weeks gestationHB1427/SB1631 (2014)Authorizes licensed practitioners to prescribe opioid antagonist to person at risk of overdose (or family member, friend or other person in position to assist)Immunity for prescribers and for people who administer antagonist
Additional Legislative ActionsPublic Chapter 820 (2014)Mother can be prosecuted for misdemeanor if mother illegally uses narcotic drug and child born addicted or harmed Addiction recovery program is affirmative defenseTwo year sunset
Drug Drop-Off/Take BackTDH partnered with Department of Environment & Conservation to place 92 drop-off boxes across TennesseeFunded in part with CDC Core Violence and Injury Grant funds (TDH)Local Take Back Days23 locations in 2013Department of Mental Health and Substance Abuse ServicesPartnership w/ county substance abuse coalitions
SBIRT PilotScreening, Brief Intervention, and Referral to Treatment (SBIRT)Partnership with Department of Mental Health and Substance Abuse ServicesSAMHSA Center for Substance Abuse Treatment, State SBIRT GrantPutnam County HD PilotFamily Planning and Primary Care patientsPartnership with local mental health provider to facilitate referralsBillable through TennCare
Collaborative Research Projects5 grants awarded to collaborative research partnershipsAddress key NAS research questionsAnswerable:With TN data and expertiseWithin one yearFunded with MCH Block Grant funds and Medicaid Infant Mortality/Womens Health grant
Funded Research ProposalsDevelopment of a predictive model for NASVanderbilt, with collaboration of East TN Childrens Hospital, TDH, and United Healthcare
Barriers to contraception in women attending substance abuse programsKnox County Health Dept., with collaboration of UT Dept. of Public Health, Knoxville MIST program
Optimal management of the pregnant woman taking opioidsCherokee Health Systems, with collaboration of UT Dept. of Public Health, and the High Risk Obstetrical Consultants Group in Knoxville
Funded Research ProposalsUnderstanding and improving provider knowledge and behaviorETSU, with collaboration of the Appalachian Research Network
Understanding optimal management of the infant with NASVanderbilt, with collaboration of East TN Childrens Hospital
Additional ActivitiesKnox County Health Department and East TN Regional Health OfficePartnership with methadone clinicsprovide Depo-Provera and referral to Family Planning Clinic for long-acting reversible contraceptive
East TN Regional Health OfficePrimary Prevention Initiative (PPI) ProjectPartnership with jails in Sevier and Cocke countiesVoluntary provision of long-acting reversible contraceptives to female inmates of childbearing age19 women have received LARCs thus far
Additional ActivitiesTDH: Pilot w/ Families Free (Johnson City)Recovery support and wraparound services for mothers delivering NAS infantsFunded with mix of MCH Block Grant and Medicaid Infant Mortality/Womens Health grantDCS: Hospital Liaison (Connie Gardner)Coordinate efforts between hospital and regional DCS staffTIPQC: Reducing NAS Length of StayPerinatal Quality CollaborativeKickoff in February 2013 with 15 hospitals
NASReportable DiseasePrevious estimates of NAS incidence came from:Hospital discharge data (all payers but ~18 month lag)Medicaid claims data (only ~9 month lag but only includes Medicaid)Need more real-time estimation of incidence in order to drive policy and program efforts
NASReportable DiseaseAdd NAS to states Reportable Disease listEffective January 1, 2013Reporting hospitals/providers submit electronic reportReporting ElementsCase InformationDiagnostic InformationSource of Maternal Exposure
Drug Dependent Newborns (Neonatal Abstinence Syndrome) Surveillance Summary For the Week of October 5 October 11, 20141Source of Maternal Substance (if known)2# Cases3% CasesSupervised replacement therapy39452.7Supervised pain therapy10313.8Therapy for psychiatric or neurological condition496.6Prescription substance obtained WITHOUT a prescription30340.6Non-prescription substance16221.7No known exposure but clinical signs consistent with NAS20.3No response141.9Reporting Summary (Year-to-date)Cases Reported: 747 Male: 400Female: 347Unique Hospitals Reporting: 49Maternal County of Residence(By Health Department Region)#Cases% Cases2Davidson395.22East21128.25Hamilton111.47Jackson/Madison20.27Knox8010.71Mid-Cumberland668.84North East10313.79Shelby293.88South Central263.48South East182.41Sullivan557.36Upper Cumberland8511.38West222.95Total747100.01. Summary reports are archived weekly at: http://health.tn.gov/MCH/NAS/NAS_Summary_Archive.shtml 2. Total percentage may not equal 100.0% due to rounding.3. Multiple maternal substances may be reported; therefore the total number of cases in this table may not match the total number of cases reported.49Source of Exposure2013 NAS SurveillanceMutually Exclusive Sources of ExposureSourceCasesPercent, %Prescription Drugs Only38441.7Illicit/Diverted Drugs Only30533.2Prescription and Illicit Drugs19921.6Unknown323.5*Percentages may not equal 100% as women may be exposed to drugs from more than one class
Maternal County of Residence(By HD Region)# Cases% CasesDavidson353.8%East26829.1%Hamilton171.8%Jackson/Madison20.2%Knox10211.1%Mid-Cumberland586.3%North East13815.0%Shelby242.6%South Central293.1%South East121.3%Sullivan869.3%Upper Cumberland11712.7%West333.6%Total921100%NAS Incidence by Region, 201365% of cases in East and Northeast TN23% of cases in Middle TN and Plateau
NAS Rate by Region, 2013
NAS Reported CasesExposure Sources (2013)Only substances prescribed to mother41.7%Mix of prescribed and non-prescribed substances21.6%Only illicit or diverted substances33.2%Substance exposure unknown3.5%*The distribution of exposure source is statistically significant by region; P