Neonatal Abstinence Syndrome - Tennessee's Epidemic and The State's Response

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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 Background

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

21

Opioid Prescription Rates by CountyTN, 2007-2011Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.2007

2008

2009

2010

2011

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