Presentation on theme: "Michael D. Warren, MD MPH FAAP Division of Family Health and Wellness"— Presentation transcript:
1Michael D. Warren, MD MPH FAAP Division of Family Health and Wellness Neonatal Abstinence Syndrome: Tennessee’s Epidemic and the State’s ResponseMichael D. Warren, MD MPH FAAPDivision of Family Health and Wellness
2ObjectivesDefine 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
4Prenatal Drug Exposure Apparently “normal”Neonatal Abstinence Syndrome (NAS)Fetal Alcohol SyndromeNeurological abnormalitiesPrematurityLow birth weightEtcInfant with recognizable syndrome or signs“Drug Exposed”TobaccoIllicit DrugsPrescription DrugsAlcoholEtc…Pregnant women who use potentially harmful substancesAll pregnant women
5Prenatal Drug Exposure All babies with neonatal abstinence syndrome are drug-exposed infants**Almost always prenatalNot all drug-exposed infants will develop Neonatal Abstinence SyndromeAll drug-exposed infants are potentially at risk for adverse outcomes
6Prenatal Drug Exposure Withdrawal symptoms in neonates can be associated with exposure to:AlcoholBarbituratesBenzodiazepinesOpioidsCaffeineAnti-depressantsEtc..
8NAS Background NAS can be associated with: Prescription drugs obtained with prescriptionIncludes women on pain therapy or replacement therapyPrescription drugs obtained without prescriptionIllicit drugs
9NAS Background Opioid withdrawal symptoms primarily related to: Central Nervous System:Seizures • HyperactivityTremorsGastrointestinal System:Poor feeding • VomitingPoor weight gain • DiarrheaUncoordinated sucking
10NAS Background Opioid 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
11NAS Identification NAS is a clinical diagnosis NAS diagnosis based on: History of exposureEvidence of exposure:Maternal drug screenInfant urine, meconium, hair, or umbilical samplesClinical signs of withdrawal (symptom rating scale)
12NAS Treatment Initial treatment: Pharmacologic therapy may be needed Minimize environmental StimuliRespond early to signalsSupport adequate growthPharmacologic therapy may be needed
13Prenatal 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):
14Prenatal 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.
15NAS 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
17NAS 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, Journal of the American Medical Association. 2012;307(18):
18NAS 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
19NAS 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
20TN’s Prescription Drug Problem In 2011, Tennessee ranked 49th highest in the country for the number of prescriptions filled per capita17.6 prescriptions filled per personNational average: 12.1Kentucky 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.
21TN’s Prescription Drug Problem Prescription Painkillers Sold By State, 2010TN: 2nd highest in country for kilograms of prescription painkillers sold per 10,000 peopleData source: CDC, Policy Impact Brief: Prescription Painkiller Overdoses. Available at:
22Opioid Prescription Rates by County—TN, 2007-2011 2008200920102011Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.
23TN’s Prescription Drug Problem 51 pills per every Tennessean over age 12275.5 Million Hydrocodone Pills22 pills per every Tennessean over age 12116.6 Million Xanax PillsThe 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 1221 pills per every Tennessean over age 12113.5 Million Oxycodone PillsData source: Tennessee Department of Health; Controlled Substance Monitoring Database.
24TN’s Prescription Drug Problem Increase 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
25NAS Hospitalizations by County—TN, 2010-2012 20112012
26Narcotics 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 NarcoticsNot on ContraceptivesAll Women296,68742,082141.87.53818%34,54482%84,3982,05424.398748%1,06752%44,6203,89787.31,43237%2,46563%53,3338,689162.92,19925%6,49075%48,91210,442213.51,69916%8,74384%37,4839,319248.68059%8,51491%27,9407,681274.94165%7,26595%Data source: Division of Health Care Finance and Administration, Bureau of TennCare. *CY2012 data is provisional.
27Unintended 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):
28Unintended 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 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: . For opioid-abusing women: Heil SH et al. Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse Treatment March; 40(2):
29TennCare NAS Costs, CY2012* Metric TennCare Paid Live Births1 TennCare 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)3.52.015.826.2Data 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).
30TennCare Infants in DCS Custody Within 1 Year of Birth, CY2012* Infants born in CY 2012NAS infantsTotal # of Infants54,984736Total # infants in DCS906179% in DCS1.6%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.
32NAS Subcabinet Working Group Convened in late Spring 2012Committed to meeting every 3-4 weeksCabinet-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
33The Levels of Prevention 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 occurringPrevent pregnancyScreen pregnant women for substance use during prenatal visits and refer for treatmentTreat addicted womenTreat babies with NASAdapted from: Centers for Disease Control and Prevention. A Framework for Assessing the Effectiveness of Disease and Injury Prevention. MMWR ; 41(RR-3); Available at:
36TennCare Prior Authorization Form Form available at: https://tnm.providerportal.sxc.com/rxclaim/TNM/TC%20PA%20Request%20Form%20(Long%20Acting%20Narcotics).pdf
37Controlled Substance Monitoring Database Prescription Safety Act of 2012TCARequired prescribers to register“Shall 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 report73% more likely to discuss substance abuse issues or concerns with a patientReport available at:
38Additional Legislative Actions Safe Harbor Act (TCA , 2013)Pregnant women get priority for treatmentChild cannot be removed solely due to maternal substance use if treatment initiated by 20 weeks gestationHB1427/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
39Additional 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 defenseTwo year sunset
40Drug Drop-Off/Take Back TDH 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 Days”23 locations in 2013Department of Mental Health and Substance Abuse ServicesPartnership w/ county substance abuse coalitions
41SBIRT 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
42Collaborative Research Projects 5 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/Women’s Health grant
43Funded Research Proposals Development of a predictive model for NASVanderbilt, with collaboration of East TN Children’s Hospital, TDH, and United HealthcareBarriers to contraception in women attending substance abuse programsKnox County Health Dept., with collaboration of UT Dept. of Public Health, Knoxville MIST programOptimal management of the pregnant woman taking opioidsCherokee Health Systems, with collaboration of UT Dept. of Public Health, and the High Risk Obstetrical Consultants Group in Knoxville
44Funded Research Proposals Understanding and improving provider knowledge and behaviorETSU, with collaboration of the Appalachian Research NetworkUnderstanding optimal management of the infant with NASVanderbilt, with collaboration of East TN Children’s Hospital
45Additional Activities Knox County Health Department and East TN Regional Health OfficePartnership with methadone clinics—provide Depo-Provera and referral to Family Planning Clinic for long-acting reversible contraceptiveEast TN Regional Health OfficePrimary Prevention Initiative (PPI) ProjectPartnership with jails in Sevier and Cocke countiesVoluntary provision of long-acting reversible contraceptives to female inmates of childbearing age19 women have received LARCs thus far
46Additional Activities TDH: 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/Women’s 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
47NAS—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
48NAS—Reportable Disease Add NAS to state’s Reportable Disease listEffective January 1, 2013Reporting hospitals/providers submit electronic reportReporting ElementsCase InformationDiagnostic InformationSource of Maternal Exposure
49Drug Dependent Newborns (Neonatal Abstinence Syndrome) Surveillance Summary For the Week of October 5 – October 11, 20141Reporting Summary (Year-to-date)Cases Reported: 747Male: 400Female: 347Unique Hospitals Reporting: 49Maternal County of Residence(By Health Department Region)#Cases% Cases2Davidson395.22East21128.25Hamilton111.47Jackson/Madison20.27Knox8010.71Mid-Cumberland668.84North East10313.79Shelby293.88South Central263.48South East182.41Sullivan557.36Upper Cumberland8511.38West222.95Total747100.0Source of Maternal Substance (if known)2# Cases3% CasesSupervised replacement therapy39452.7Supervised pain therapy10313.8Therapy for psychiatric or neurological condition496.6Prescription substance obtained WITHOUT a prescription30340.6Non-prescription substance16221.7No known exposure but clinical signs consistent with NAS20.3No response141.91. 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.
50Source of Exposure 2013 NAS Surveillance Mutually Exclusive Sources of ExposureSourceCasesPercent, %Prescription Drugs Only38441.7Illicit/Diverted Drugs Only30533.2Prescription and Illicit Drugs19921.6Unknown323.5*Percentages may not equal 100% as women may be exposed to drugs from more than one class
51NAS Incidence by Region, 2013 Maternal County of Residence(By HD Region)# Cases% CasesDavidson353.8%East26829.1%Hamilton171.8%Jackson/Madison20.2%Knox10211.1%Mid-Cumberland586.3%North East13815.0%Shelby242.6%South Central293.1%South East121.3%Sullivan869.3%Upper Cumberland11712.7%West333.6%Total921100%65% of cases in East and Northeast TN23% of cases in Middle TN and Plateau
53NAS Reported Cases Exposure Sources (2013) Substance exposure unknown3.5%Only substances prescribed to mother41.7%Mix of prescribed and non-prescribed substances21.6%Only illicit or diverted substances33.2%
54NAS Reported Cases Exposure Sources (2013) by Region *The distribution of exposure source is statistically significant by region; P<
55NAS—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.
56NAS—What Can You Do? Connect family with: Primary care medical home TennCare or other insuranceTN Early Intervention Services (TEIS)Help Us Grow Successfully (HUGS)Children’s Special Services (CSS)Family PlanningWIC
57NAS—What Can You Do?Promote long-acting reversible contraceptives (LARCs)Intrauterine devicesSubdermal implantCollaborate with local prescription drug “drop-off” effortsFor prescribers: Register for and use CSMD
58NAS—What Can You Do?Decide whether referral to Department of Children’s Services is appropriateState law requires all persons to make a report when they suspect abuse, neglect or exploitation of children
59NAS Resources NAS Main Page Weekly Surveillance Summary Archive Weekly Surveillance Summary Archive
60Contact InformationMichael D. Warren, MD MPH FAAPDirector, Division of Family Health and Wellness