Neonatal Abstinence Syndrome:
Tennessee’s Epidemic and
the State’s Response
Michael D. Warren, MD MPH FAAP
Division of Family Health and Wellness
Objectives
• Define the etiology, diagnosis, and
management of Neonatal Abstinence
Syndrome (NAS)
• Outline the scope of NAS in Tennessee
• Describe Tennessee interventions to
reduce the burden of NAS
NAS Epidemiology, Diagnosis,
and Treatment
Prenatal Drug Exposure
Infant
with
recognizable
syndrome or signs
“Drug Exposed”
• Tobacco
• Illicit Drugs
• Prescription Drugs
• Alcohol
• Etc…
Pregnant women
who use potentially
harmful substances
All pregnant women
• Apparently
“normal”
• Neonatal
Abstinence
Syndrome (NAS)
• Fetal Alcohol
Syndrome
• Neurological
abnormalities
• Prematurity
• Low birth weight
• Etc
Prenatal Drug Exposure
• 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 outcomes
Prenatal Drug Exposure
• Withdrawal symptoms in neonates can be
associated with exposure to:
•
•
•
•
•
•
•
Alcohol
Barbiturates
Benzodiazepines
Opioids
Caffeine
Anti-depressants
Etc..
NAS Background
NAS Background
• NAS can be associated with:
– Prescription drugs obtained with prescription
• Includes women on pain therapy or replacement
therapy
– Prescription drugs obtained without
prescription
– Illicit drugs
NAS Background
• Opioid withdrawal symptoms primarily related
to:
• Central Nervous System:
• Seizures
• Tremors
• Hyperactivity
• Gastrointestinal System:
• Poor feeding
• Vomiting
• Poor weight gain
• Diarrhea
• Uncoordinated sucking
NAS Background
• Opioid withdrawal symptoms:
• May appear as early as within the first 24
hours
• May take as many as 4-5 days to appear
• Occur in 55-94% of exposed infants
NAS Identification
• NAS is a clinical diagnosis
• NAS diagnosis based on:
– History of exposure
– Evidence of exposure:
– Maternal drug screen
– Infant urine, meconium, hair, or umbilical samples
– Clinical signs of withdrawal (symptom rating
scale)
NAS Treatment
• Initial treatment:
• Minimize environmental Stimuli
• Respond early to signals
• Support adequate growth
• Pharmacologic therapy may be needed
Prenatal Drug Exposure Outcomes
• Babies 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 3.45.3)
Creanga AA, et al. Maternal drug use and its effect on neonates—a population-based study in Washington state. Obstetrics and
Gynecology. 2012. 119(5): 924-33.
Prenatal Opioid Exposure Outcomes
• National 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 Outcomes
• No definitive long-term syndrome associated
with neonatal opioid withdrawal
• Limited studies show:
– Mixed outcomes of developmental assessment
scores (hyperactivity, short attention span,
memory and perceptual problems)
– Resolution of seizures
• Confounding by social/environmental
variables
Scope of NAS in TN & US
NAS Epidemiology (US)
• Over the past decade:
– 2.8-fold increase in NAS incidence
– 4.7-fold increase in maternal opioid use
– Increase in hospital costs $39,400$53,400
– 78% charges to state Medicaid programs
Source: 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:
1999-2012
Number
Rate
1000
14
12
800
10
700
600
8
500
6
400
300
4
200
2
100
0
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Data 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.
Rate per 1,000 Live Births
Number of Hospitalizations
900
NAS Unique Patients in TN:
2008-2012
Number
Rate
1000
12
10
800
700
8
600
500
6
400
4
300
200
2
100
0
0
2008
2009
2010
2011
2012
Data 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.
Rate per 1,000 Live Births
Number of Hospitalizations
900
TN’s Prescription Drug Problem
• In 2011, Tennessee ranked 49th highest in
the country for the number of prescriptions
filled per capita
– 17.6 prescriptions filled per person
– National 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.
TN’s Prescription Drug Problem
Prescription Painkillers Sold By State, 2010
TN: 2nd
highest in
country for
kilograms of
prescription
painkillers
sold per
10,000 people
Data source: CDC, Policy Impact Brief: Prescription Painkiller Overdoses. Available at:
http://www.cdc.gov/homeandrecreationalsafety/rxbrief/
Opioid Prescription Rates
by County—TN, 2007-2011
2007
2008
2009
2010
2011
Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.
TN’s Prescription Drug Problem
51 pills
per every
Tennessean
over age 12
275.5 Million Hydrocodone Pills
116.6 Million Xanax Pills
113.5 Million Oxycodone Pills
Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.
22 pills
per every
Tennessean
over age 12
21 pills
per every
Tennessean
over age 12
TN’s Prescription Drug Problem
• Increase in TN deaths due to prescription
drug overdose
– 422 in 2001
– 1,093 in 2012
• More than deaths from:
– Motor vehicle accidents, homicide, or suicide
• Opioids (methadone, oxycodone, and
hydrocodone) are by far the most-abused
prescription drugs
NAS Hospitalizations
by County—TN, 2010-2012
2010
2011
2012
Narcotics and Contraceptive Use:
TennCare Women, CY2012*
Women
% of Women on
Prescribed
Narcotics
Narcotics
Not on
without
Contraceptives
Contraceptives
Demographics
TennCare
Women
Women
Prescribed
Narcotics (>30
days supplied)
Narcotic
Users
Rate per
1,000
Women
Prescribed
Contraceptives
and Narcotics
% of Women on
Narcotics and
Contraceptives
All Women
296,687
42,082
141.8
7.538
18%
34,544
82%
15 - 20
84,398
2,054
24.3
987
48%
1,067
52%
21 - 24
44,620
3,897
87.3
1,432
37%
2,465
63%
25 - 29
53,333
8,689
162.9
2,199
25%
6,490
75%
30 - 34
48,912
10,442
213.5
1,699
16%
8,743
84%
35 - 39
37,483
9,319
248.6
805
9%
8,514
91%
40 - 44
27,940
7,681
274.9
416
5%
7,265
95%
Data source: Division of Health Care Finance and Administration, Bureau of TennCare. *CY2012 data is provisional.
Unintended Pregnancy
Among All Women & Opioid Abusers
General Population
Opioid-Abusing Women
49.9%
86.3%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%100.0%
Data 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): 199202.
Unintended Pregnancy
Among All Women & Opioid Abusers
• In 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 women
– Women with unintended pregnancy 60% more likely
to have used cocaine within past 30 days
compared to women with intended pregnancy
Data 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*
TennCare Paid
Live Births1
TennCare
non-LBWT
Births
TennCare Live
LBWT Births2
NAS
Infants
42,171
37,576
4,595
736
$352,516,166
$177,959,049
$174,557,118
$45,870,410
Average Cost per child
$8,359
$4,736
$37,988
$62,324
Average length of stay
(days)
3.5
2.0
15.8
26.2
Metric
Number of Births
Cost for Infant in first year
of life
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 TennCare’s records based on Social Security Number.
2 . Any infant weighing under 2,500g at the time of birth was considered low birth weight (LBWT).
TennCare Infants in DCS Custody
Within 1 Year of Birth, CY2012*
Infants born in CY 2012 NAS infants
Total # of Infants
54,984
736
Total # infants in DCS
906
179
% in DCS
1.6%
24.3%
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 TennCare’s records based on Social Security Number.
TN Efforts to Prevent NAS
NAS Subcabinet Working Group
• Convened in late Spring 2012
• Committed to meeting every 3-4 weeks
• Cabinet-level representation from
Departments:
– Public Health (TDH)
– Children’s Services (DCS)
– Human Services (DHS)
– Mental Health and Substance Abuse Services
(DMHSAS)
– Medicaid (TennCare)
– Children’s Cabinet
The Levels of Prevention
PRIMARY
Prevention
SECONDARY
Prevention
TERTIARY
Prevention
Definition An intervention
implemented before
there is evidence of
a disease or injury
An intervention
implemented after a
disease has begun,
but before it is
symptomatic.
An intervention
implemented after a
disease or injury is
established
Intent
Reduce or eliminate
causative risk factors
(risk reduction)
Early identification
(through screening)
and treatment
Prevent sequelae
(stop bad things from
getting worse)
NAS
Example
Prevent addiction
from occurring
Screen pregnant
women for substance
use during prenatal
visits and refer for
treatment
Treat addicted
women
Prevent pregnancy
Treat babies with
NAS
Adapted 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 Substance
Monitoring Database
• Prescription Safety Act of 2012
– TCA 53-10-300
– Required prescribers to register
– “Shall check” provision
• CSMD Successes:
– 4.5M searches (240% increase from 2012)
– 50% decrease in doctor shopping
– Change 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 Actions
• Safe Harbor Act (TCA 33-10-104, 2013)
– Pregnant women get priority for treatment
– Child cannot be removed solely due to maternal
substance use if treatment initiated by 20 weeks
gestation
• HB1427/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 Actions
• Public 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 defense
– Two year sunset
Drug Drop-Off/Take Back
• TDH partnered with Department of
Environment & Conservation to place 92
drop-off boxes across Tennessee
– Funded in part with CDC Core Violence and
Injury Grant funds (TDH)
• Local “Take Back Days”
– 23 locations in 2013
– Department of Mental Health and Substance
Abuse Services
– Partnership w/ county substance abuse coalitions
SBIRT Pilot
• Screening, Brief Intervention, and Referral to
Treatment (SBIRT)
• Partnership with Department of Mental Health
and Substance Abuse Services
– SAMHSA Center for Substance Abuse Treatment,
State SBIRT Grant
• Putnam County HD Pilot
– Family Planning and Primary Care patients
– Partnership with local mental health provider to
facilitate referrals
– Billable through TennCare
Collaborative Research Projects
• 5 grants awarded to collaborative research
partnerships
– Address key NAS research questions
– Answerable:
• With TN data and expertise
• Within one year
– Funded with MCH Block Grant funds and
Medicaid Infant Mortality/Women’s Health
grant
Funded Research Proposals
1. Development of a predictive model for NAS
– Vanderbilt, with collaboration of East TN Children’s Hospital, TDH,
and United Healthcare
2.
Barriers to contraception in women attending
substance abuse programs
– Knox County Health Dept., with collaboration of UT Dept. of Public
Health, Knoxville MIST program
3.
Optimal management of the pregnant woman
taking opioids
– Cherokee Health Systems, with collaboration of UT Dept. of
Public Health, and the High Risk Obstetrical Consultants
Group in Knoxville
Funded Research Proposals
4. Understanding and improving provider knowledge
and behavior
– ETSU, with collaboration of the Appalachian Research Network
5.
Understanding optimal management of the infant
with NAS
– Vanderbilt, with collaboration of East TN Children’s Hospital
Additional Activities
• Knox County Health Department and East TN
Regional Health Office
– Partnership with methadone clinics—provide Depo-Provera and
referral to Family Planning Clinic for long-acting reversible
contraceptive
• East TN Regional Health Office
– Primary Prevention Initiative (PPI) Project
– Partnership with jails in Sevier and Cocke counties
– Voluntary provision of long-acting reversible contraceptives to
female inmates of childbearing age
– 19 women have received LARCs thus far
Additional Activities
• TDH: Pilot w/ Families Free (Johnson City)
– Recovery support and wraparound services for
mothers delivering NAS infants
– Funded with mix of MCH Block Grant and Medicaid
Infant Mortality/Women’s Health grant
• DCS: Hospital Liaison (Connie Gardner)
– Coordinate efforts between hospital and regional DCS
staff
• TIPQC: Reducing NAS Length of Stay
– Perinatal Quality Collaborative
– Kickoff in February 2013 with 15 hospitals
NAS—Reportable Disease
• Previous 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
NAS—Reportable Disease
• Add NAS to state’s Reportable Disease list
– Effective January 1, 2013
• Reporting hospitals/providers submit
electronic report
• Reporting Elements
– Case Information
– Diagnostic Information
– Source of Maternal Exposure
Drug Dependent Newborns (Neonatal Abstinence Syndrome)
Surveillance Summary For the Week of October 5 – October 11, 20141
Cumulative Cases NAS Reported
Reporting Summary (Year-to-date)
Cases Reported: 747
Male: 400
Female: 347
Unique Hospitals Reporting: 49
2014 Cases
2013 Cases
800
747
724
Maternal County of
Residence
(By Health Department
Region)
#
Cases
%
Cases2
Davidson
39
5.22
East
211
28.25
Hamilton
11
1.47
Jackson/Madison
2
0.27
Knox
80
10.71
Mid-Cumberland
66
8.84
Number of Cases
700
600
500
400
300
200
100
0
1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41
Week
#
Cases3
%
Cases
Supervised replacement therapy
394
52.7
Supervised pain therapy
103
13.8
Therapy for psychiatric or neurological condition
49
6.6
Source of Maternal Substance (if known)2
North East
103
13.79
Shelby
29
3.88
South Central
26
3.48
South East
18
2.41
Sullivan
55
7.36
Prescription substance obtained WITHOUT a prescription
303
40.6
Upper Cumberland
85
11.38
Non-prescription substance
162
21.7
West
22
2.95
No known exposure but clinical signs consistent with NAS
2
0.3
Total
747
100.0
No response
14
1.9
1. 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.
Source of Exposure
2013 NAS Surveillance
Source
Cases
Percent,
%
Prescription
Drugs Only
384
41.7
Illicit/Diverted
Drugs Only
305
33.2
Prescription
and Illicit
Drugs
199
21.6
Unknown
32
3.5
Percent of Cases with Prescription Drugs Only,
%
Mutually Exclusive Sources
of Exposure
Class of Prescription Drug* Among
Cases Exposed Only to Prescription
Drugs*
80
70
60
50
40
30
20
10
0
71.6
31.3
13.3
Supervised
Supervised Psychiatric or
Pain Therapy Replacement
neurologic
Therapy
therapy
*Percentages may not equal 100% as women may be exposed to
drugs from more than one class
NAS Incidence by Region, 2013
Maternal County of Residence
(By HD Region)
65% of
cases in
East and
Northeast
TN
# Cases
% Cases
Davidson
35
3.8%
East
268
29.1%
Hamilton
17
1.8%
Jackson/Madison
2
0.2%
Knox
102
11.1%
Mid-Cumberland
58
6.3%
North East
138
15.0%
Shelby
24
2.6%
South Central
29
3.1%
South East
12
1.3%
Sullivan
86
9.3%
Upper Cumberland
117
12.7%
West
33
3.6%
Total
921
100%
23% of
cases in
Middle TN
and
Plateau
NAS Rate by Region, 2013
Rate per 1,000 births
60
54.7
50
41.6
40
34.4
30.9
30
20.0
20
11.6
10
1.8
0
5.6
1.6
3.9
3.5
6.6
3.3
4.1
NAS Reported Cases
Exposure Sources (2013)
Substance
exposure
unknown
3.5%
Only illicit or
diverted
substances
33.2%
Only substances
prescribed to
mother
41.7%
Mix of
prescribed
and nonprescribed
substances
21.6%
NAS Reported Cases
Exposure Sources (2013) by Region
100%
8.3
90%
16.7
18.2
22.4
11.4
24.3
80%
12.3
11.6
30
35.3
50
70%
60%
31.4
Unknown
41.7
58.6
25
42.9
Prescription and
Illicit Drugs
50
51.5
50%
24.8
50
38.2
62.3
68.6
Prescription
Drugs Only
40%
47.1
30%
20.7
50
20%
10%
50
40
33.3
27.3
Illicit/Diverted
Drugs Only
49.3
41
30.4
25.9
17.2
18.1
11.8
0%
*The distribution of exposure source is statistically significant by region; P<0.0001.
11.6
NAS—Reportable Disease
• Important caveat:
– Reporting is for surveillance purposes only.
– Does not constitute a referral to any agency
other than the Tennessee Department of
Health.
– Does not replace requirement to report
suspected abuse/neglect.
NAS—What Can You Do?
• Connect family with:
– Primary care medical home
– TennCare or other insurance
– TN Early Intervention Services (TEIS)
– Help Us Grow Successfully (HUGS)
– Children’s Special Services (CSS)
– Family Planning
– WIC
NAS—What Can You Do?
• Promote long-acting reversible
contraceptives (LARCs)
– Intrauterine devices
– Subdermal implant
• Collaborate with local prescription drug
“drop-off” efforts
• For prescribers: Register for and use
CSMD
NAS—What Can You Do?
• Decide whether referral to Department of
Children’s Services is appropriate
– State law requires all persons to make a
report when they suspect abuse, neglect
or exploitation of children
NAS Resources
• NAS Main Page
– http://health.tn.gov/MCH/NAS/
• Weekly Surveillance Summary Archive
– http://health.tn.gov/MCH/NAS/NAS_Summary
_Archive.shtml
Contact Information
• Michael D. Warren, MD MPH FAAP
– Director, Division of Family Health and
Wellness
– Michael.d.warren@tn.gov