1. Michael D. Warren, MD MPH FAAP Division of Family Health and Wellness
Neonatal Abstinence Syndrome: Tennessee’s Epidemic and the State’s Response
Michael D. Warren, MD MPH FAAP
Division of Family Health and Wellness

2. 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

3. NAS Epidemiology, Diagnosis, and Treatment

4. Prenatal Drug Exposure
Apparently “normal”
Neonatal Abstinence Syndrome (NAS)
Fetal Alcohol Syndrome
Neurological abnormalities
Prematurity
Low birth weight
Etc
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

5. 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

6. Prenatal Drug Exposure
Withdrawal symptoms in neonates can be associated with exposure to:
Alcohol
Barbiturates
Benzodiazepines
Opioids
Caffeine
Anti-depressants
Etc..

7. NAS Background

8. 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

9. 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

10. 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

11. 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)

12. NAS Treatment Initial treatment: Pharmacologic therapy may be needed
Minimize environmental Stimuli
Respond early to signals
Support adequate growth
Pharmacologic therapy may be needed

13. Prenatal Drug Exposure Outcomes
Babies with prenatal drug exposure are more likely to:
Be delivered by cesarean (OR )
Be born pre-term (OR )
Be born at low birth weight (OR )
Have feeding problems (OR )
Have respiratory distress syndrome (OR )
Creanga AA, et al. Maternal drug use and its effect on neonates—a population-based study in Washington state. Obstetrics and Gynecology (5):

14. Prenatal Opioid Exposure Outcomes
National Birth Defects Prevention Study ( )
Increased risk of:
Spina bifida (OR )
Gastroschisis (OR )
Any heart defect (OR )
AVSD (OR )
Tetralogy of Fallot (OR )
VSD (OR )
Hypoplastic Left Heart Syndrome (OR )
RVOT defects (OR )
Pulmonary valve stenosis (OR )
Broussard CS, Rasmussen SA, Reefhuis J, et al. Maternal treatment with opioid analgesics and risk for birth defects. Am J Obstet Gynecol ;204:314.e1-11.

15. 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

16. Scope of NAS in TN & US

17. 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, Journal of the American Medical Association. 2012;307(18):

18. 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

19. NAS Unique Patients in TN: 2008-2012
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

20. 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.

21. 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:

22. Opioid Prescription Rates by County—TN, 2007-2011
2008
2009
2010
2011
Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.

23. TN’s Prescription Drug Problem
51 pills per every Tennessean over age 12
275.5 Million Hydrocodone Pills
22 pills per every Tennessean over age 12
116.6 Million Xanax Pills
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 12
116.6 million pills prescribed for alprazolam (e.g., Xanax: used to treat anxiety)
22 pills per every Tennessean over age of 12
113.5 million pills prescribed for oxycodone (e.g., OxyContin, Roxicodone)
21 pills for every Tennessean over age of 12
21 pills per every Tennessean over age 12
113.5 Million Oxycodone Pills
Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.

24. 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

25. NAS Hospitalizations by County—TN, 2010-2012
2011
2012

26. Narcotics and Contraceptive Use: TennCare Women, CY2012*
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
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%
84,398
2,054
24.3
987
48%
1,067
52%
44,620
3,897
87.3
1,432
37%
2,465
63%
53,333
8,689
162.9
2,199
25%
6,490
75%
48,912
10,442
213.5
1,699
16%
8,743
84%
37,483
9,319
248.6
805 9%
8,514
91%
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.

27. Unintended Pregnancy Among All Women & Opioid Abusers
Data source: For general population: Tennessee Department of Health. Pregnancy Risk Assessment Monitoring System, 2009 Summary Report. Available at: For opioid-abusing women: Heil SH et al. Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse Treatment March; 40(2):

28. 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: For opioid-abusing women: Heil SH et al. Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse Treatment March; 40(2):

29. TennCare NAS Costs, CY2012* Metric TennCare 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
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).

30. 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.

31. TN Efforts to Prevent NAS

32. 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

33. 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
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 ; 41(RR-3); Available at:

34. Request for Black Box Warning

36. TennCare Prior Authorization Form
Form available at:

37. Controlled Substance Monitoring Database
Prescription Safety Act of 2012
TCA
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:

38. Additional Legislative Actions
Safe Harbor Act (TCA , 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

39. 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

40. 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

41. 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

42. 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

43. Funded Research Proposals
Development of a predictive model for NAS
Vanderbilt, with collaboration of East TN Children’s Hospital, TDH, and United Healthcare
Barriers to contraception in women attending substance abuse programs
Knox County Health Dept., with collaboration of UT Dept. of Public Health, Knoxville MIST program
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

44. Funded Research Proposals
Understanding and improving provider knowledge and behavior
ETSU, with collaboration of the Appalachian Research Network
Understanding optimal management of the infant with NAS
Vanderbilt, with collaboration of East TN Children’s Hospital

45. 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

46. 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

47. 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

48. 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

49. Drug Dependent Newborns (Neonatal Abstinence Syndrome) Surveillance Summary For the Week of October 5 – October 11, 20141
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
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
1. Summary reports are archived weekly at:
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.

50. 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
*Percentages may not equal 100% as women may be exposed to drugs from more than one class

51. NAS Incidence by Region, 2013
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%
65% of cases in East and Northeast TN
23% of cases in Middle TN and Plateau

52. NAS Rate by Region, 2013

53. NAS Reported Cases Exposure Sources (2013)
Substance exposure unknown
3.5%
Only substances prescribed to mother
41.7%
Mix of prescribed and non-prescribed substances
21.6%
Only illicit or diverted substances
33.2%

54. NAS Reported Cases Exposure Sources (2013) by Region
*The distribution of exposure source is statistically significant by region; P<

55. 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.

56. 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

57. 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

58. 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

59. NAS Resources NAS Main Page Weekly Surveillance Summary Archive
Weekly Surveillance Summary Archive

60. Contact Information
Michael D. Warren, MD MPH FAAP
Director, Division of Family Health and Wellness