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
Infantwith
recognizable syndrome or signs
Pregnant women who use potentially harmful substances
All pregnant women
“Drug Exposed”
• Tobacco
• Illicit Drugs
• Prescription Drugs
• Alcohol
• Etc…
• Apparently
“normal”
• Neonatal
Abstinence
Syndrome (NAS)
• Fetal Alcohol
Syndrome
• Neurological
abnormalities
• Prematurity
• Low birth weight
• Etc
• 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
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 • Hyperactivity
• Tremors
• 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 3.4-
5.3)
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
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.
0
2
4
6
8
10
12
14
0
100
200
300
400
500
600
700
800
900
1000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Ra
te p
er 1
,00
0 L
ive
Birth
sN
um
be
r o
f H
os
pit
ali
za
tio
ns
Number Rate
NAS Unique Patients in TN:
2008-2012
0
2
4
6
8
10
12
0
100
200
300
400
500
600
700
800
900
1000
2008 2009 2010 2011 2012
Ra
te p
er 1
,00
0 L
ive
Birth
sN
um
be
r o
f H
os
pit
ali
za
tio
ns
Number Rate
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.
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
Data source: CDC, Policy Impact Brief: Prescription Painkiller Overdoses. Available at:
http://www.cdc.gov/homeandrecreationalsafety/rxbrief/
Prescription Painkillers Sold By State, 2010
TN: 2nd
highest in
country for
kilograms of
prescription
painkillers
sold per
10,000 people
Opioid Prescription Rates
by County—TN, 2007-2011
Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.
2007
2008
2009
2010
2011
TN’s Prescription Drug Problem
51 pills
per every
Tennessean
over age 12
22 pills
per every
Tennessean
over age 12
21 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.
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*
DemographicsTennCare
Women
Women
Prescribed
Narcotics (>30
days supplied)
Narcotic
Users
Rate per
1,000
Women
Prescribed
Contraceptives
and Narcotics
% of Women on
Narcotics and
Contraceptives
Women
Prescribed
Narcotics
without
Contraceptives
% of Women on
Narcotics
Not on
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
86.3%
49.9%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%100.0%
Opioid-Abusing Women
General Population
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): 199-
202.
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*
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).
MetricTennCare Paid
Live Births1
TennCare
non-LBWT
Births
TennCare Live
LBWT Births2
NAS
Infants
Number of Births 42,171 37,576 4,595 736
Cost for Infant in first year
of life$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
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 TennCare’s records based on Social Security Number.
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%
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 PreventionPRIMARY
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
Prevent pregnancy
Screen pregnant
women for substance
use during prenatal
visits and refer for
treatment
Treat addicted
women
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
Source of Maternal Substance (if known)2
#
Cases3
%
Cases
Supervised replacement therapy 394 52.7
Supervised pain therapy 103 13.8
Therapy for psychiatric or neurological condition 49 6.6
Prescription substance obtained WITHOUT a prescription 303 40.6
Non-prescription substance 162 21.7
No known exposure but clinical signs consistent with NAS 2 0.3
No response 14 1.9
Reporting Summary (Year-to-date)
Cases Reported: 747
Male: 400
Female: 347
Unique Hospitals Reporting: 49
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
North East 103 13.79
Shelby 29 3.88
South Central 26 3.48
South East 18 2.41
Sullivan 55 7.36
Upper Cumberland 85 11.38
West 22 2.95
Total 747 100.0
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.
724747
0
100
200
300
400
500
600
700
800
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41
Nu
mb
er
of
Cas
es
Week
Cumulative Cases NAS Reported
2014 Cases 2013 Cases
Source of Exposure
2013 NAS Surveillance
Mutually Exclusive Sources of Exposure
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
31.3
71.6
13.3
SupervisedPain Therapy
SupervisedReplacement
Therapy
Psychiatric orneurologic
therapy
0
10
20
30
40
50
60
70
80
Pe
rce
nt
of
Ca
se
s w
ith
Pre
sc
rip
tio
n D
rug
s O
nly
, %
Class of Prescription Drug* Among Cases Exposed Only to Prescription
Drugs*
*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 % 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%
NAS Incidence by Region, 2013
65% of
cases in
East and
Northeast
TN
23% of
cases in
Middle TN
and
Plateau
NAS Rate by Region, 2013
1.85.6
1.63.9 3.5
6.6
30.9
3.3 4.1
34.4
20.0
41.6
54.7
11.6
0
10
20
30
40
50
60
Rate per 1,000 births
NAS Reported Cases
Exposure Sources (2013)
Only substances
prescribed to
mother
41.7%
Mix of
prescribed
and non-
prescribed
substances
21.6%
Only illicit or
diverted
substances
33.2%
Substance
exposure
unknown
3.5%
*The distribution of exposure source is statistically significant by region; P<0.0001.
NAS Reported Cases
Exposure Sources (2013) by Region
33.327.3
50
25.9
40
17.2
41
50
11.8
49.3
30.4
18.111.6
50
51.5
50
50
42.9
20.7
24.8
41.7
47.1
25
38.2 62.368.6
16.718.2 22.4 11.4
58.6
30
8.3
35.3
24.331.4
12.3 11.6
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Unknown
Prescription andIllicit Drugs
PrescriptionDrugs Only
Illicit/DivertedDrugs Only
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
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