Neonatal Abstinence Syndromein TennesseeTara Sturdivant, MDEast TN Regional Health Office
ObjectivesDescribe the burden of NAS in TennesseeIdentify state-level initiatives aimed at preventing NASIdentify East Region specific initiatives aimed at preventing NAS
Prenatal Drug ExposureInfant with recognizable syndrome or signsPregnant women who use potentially harmful substancesAll pregnant womenDrug ExposedTobaccoIllicit DrugsPrescription DrugsAlcoholEtcApparently normalNeonatal Abstinence Syndrome (NAS)Fetal Alcohol SyndromeNeurological abnormalitiesPrematurityLow birth weightEtc
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.
Opioid Prescription Rates by CountyTN, 2007-2011Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.2007
2010 Controlled Substance Prescriptions51 pills per every Tennessean over age 1222 pills per every Tennessean over age 1221 pills per 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.
Narcotics and Contraceptive Use:TennCare Women, CY2012*Data source: Division of Health Care Finance and Administration, Bureau of TennCare. *CY2012 data is provisional.
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%
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.
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.
Drug Dependent Newborns (Neonatal Abstinence Syndrome) Surveillance Summary For the Week of August 24 August 30, 20141Reporting Summary (Year-to-date)Cases Reported: 626 Male: 330Female: 296Unique Hospitals Reporting: 491. 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 Maternal Substance (if known)2# Cases3% CasesSupervised replacement therapy33553.5Supervised pain therapy7712.3Therapy for psychiatric or neurological condition416.6Prescription substance obtained WITHOUT a prescription25941.4Non-prescription substance13621.7No known exposure but clinical signs consistent with NAS20.3No response132.1
Maternal County of Residence(By Health Department Region)#Cases% Cases2Davidson315.0East17928.6Hamilton71.1Jackson/Madison20.3Knox7011.2Mid-Cumberland589.3North East8914.2Shelby274.3South Central203.2South East101.6Sullivan436.9Upper Cumberland7111.3West193.0Total626100.0%
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%63.3%
2013 NAS Rate by Region*Provisional count of births, 2013
RegionNAS CasesBirths*Rate (per 1,000 births)Davidson359,8893.5East2687,79534.4Hamilton174,1394.1Jackson/Madison21,2521.6Knox1025,10020.0Mid-Cumberland5814,7483.9Northeast1383,32141.6Shelby2413,6471.8South Central294,4156.6Southeast123,6633.3Sullivan861,57154.7Upper Cumberland1173,79030.9West335,9005.6TOTAL92179,23011.6
The Levels of PreventionAdapted 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
PRIMARY PreventionSECONDARY PreventionTERTIARY PreventionDefinitionAn 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 NAS
Request for Black Box Warning
TennCare Prior Authorization FormForm 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 (Signed by Governor 4/4/2014)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 ActionsHB1295/SB1391 (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
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
LARC ClinicsLong-Acting Reversible Contraceptives (LARCs)Progestin-only or non-hormonal implantsNexplanonMirenaParagard
Placeable/Removable during in-office procedure
LARC ClinicsSelected two counties (Cocke and Sevier) having 25.8% of the total East Region NAS cases as pilot sites and began implementation in January, 2014Followed the PDCA (PLAN-DO-CHECK-ACT) continuous improvement cycle after each phase of the implementation to ensure success as other counties begin to replicate and implement the programSecuring buy-in from local staffData collection and reportingProcess evaluationRevisions for continuous program improvement
LARC Clinics for InmatesEducational presentation and pamphlet developed for inmatesrisk of NAS associated with using narcotics during pregnancyhow to minimize risk of pregnancy through use of LARCsStandardized clinic documentation tools developedInitial Exam and LARC clinics were conducted in the health department to provide services while participants were still incarceratedCollaborated with UT Family Physicians to provide experience for residents to place LARCs
Partnership with Recovery CourtsMet with Recov