Transcript Preventing Neonatal Abstinence Syndrome: The Tennessee Story

Tennessee Efforts to Prevent
Neonatal Abstinence Syndrome
Kelly Luskin, MSN, WHNP-BC
Division of Family Health and Wellness
Objectives
• What is Neonatal Abstinence Syndrome
(NAS)?
• Briefly review etiology, diagnosis, and
treatment (NAS)
• Describe scope of NAS in TN and US
• Share TN efforts related to NAS
prevention
NAS Background
• Describes withdrawal symptoms in
neonates 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
• Tremors
• Hyperactivity
• Crying
• Gastrointestinal System:
• Poor feeding
• Poor weight gain
• Uncoordinated sucking
• Vomiting
• Diarrhea
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
• Depend on the half-life of the substance(s)
used, time last taken by mother, infant
metabolism, and gestational age and/or
birthweight
• Not all babies experience NAS
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
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
NAS Epidemiology (US)
• Over the past decade:
– 4.7-fold increase in maternal opioid use
– 2.8-fold increase in NAS incidence
– 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
US Prescription Drug Problem
Rates of prescription painkiller sales, deaths
and substance abuse treatment admissions (1999-2010)
Graphic Source: CDC. Vital Signs, November 2011. Prescription Painkiller Overdoses in the US. Available at:
http://www.cdc.gov/VitalSigns/pdf/2011-11-vitalsigns.pdf
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: http://www.cdc.gov/homeandrecreationalsafety/rxbrief/
TN’s Prescription Drug Problem
• In 2011, Tennessee ranked 2nd 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.
Opioid Prescription Rates
by County—TN, 2007
Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.
Opioid Prescription Rates
by County—TN, 2008
Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.
Opioid Prescription Rates
by County—TN, 2009
Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.
Opioid Prescription Rates
by County—TN, 2010
Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.
Opioid Prescription Rates
by County—TN, 2011
Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.
TN’s Prescription Drug Problem
51 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.
22 pills
per every
Tennessean
over age 12
21 pills
per every
Tennessean
over age 12
TN’s Prescription Drug Problem
• Increase in TN deaths due to prescription
drug overdose
– 422 in 2001
– 1,062 in 2011
• More than deaths from:
– Motor vehicle accidents, homicide, or suicide
• Opioids (methadone, oxycodone, and
hydrocodone) are by far the most-abused
prescription drugs
Relative Proportion of Patients With
Risk Factors Versus Death
Risk factor
% of All
Patients
% of Deaths
≥ 4 Prescribers
8.3
38
≥ 4 Pharmacies
2.7
24
High dosage use
1.9
24
Number of Prescribers & Dispensers with Database
Access and Actual Number Checking Data
Number of Queries by Quarter
2011 – Q2 2013
2011 - 1.5 M searches
2012 - 1.9 M searches
2013 - 1.9 M searches in 6 months
Total MME of Opioids
4/1/2012 - 3/31/2013
̴ 12% decrease
Number of Doctor Shoppers in CSMD
By Month, Jan 2012--- Mar 2013
̴ 40% decrease
from peak
Number
7
Rate
6
500
5
Number
400
4
300
3
200
2
100
1
0
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
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. Note that these are
discharge-level data and not unique patient data.
Rate per 1,000 Live Births
600
NAS Hospitalizations in TN:
1999-2010
TN NAS Hospitalizations (2010)
Data sources: Tennessee Department of Health; Office of Health Statistics; Hospital Discharge Data System (HDDS) and Birth Statistical System.
Numerator is number of inpatient hospitalizations with age less than one and any diagnosis of neonatal abstinence syndrome (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. Note that these are
discharge-level data and not unique patient data. Denominator is number of live births. For BSS data, county is mother’s county of residence.
Inpatient Hospitalization Rate for Any Diagnosis of Neonatal Abstinence Syndrome
Tennessee, 1999-2011
25
16.6
Rate per 1,000 Live Births
20
15
10
6.7
5
0
Tennessee
Sevier County
Data sources: Tennessee Department of Health; Division of Policy, Planning and Assessment; Office of Health Statistics; Hospital Discharge Data System (HDDS) and Birth Statistical System.
Analysis included inpatient hospitalizations with age less than 1 and any diagnosis of drug withdrawal syndrome of newborn (ICD-9-CM 779.5). HDDS records contain up to 18 diagnoses. Infants
were included if any of these diagnosis fields were coded 779.5. Note that these are discharge-level data and not unique patient data.
Inpatient Hospitalization Rate for Deliveries with Any Maternal Substance Abuse
Tennessee, 1999-2011
60
40.5
Rate per 1,000 Liveborn Deliveries
50
40
30
20.6
20
10
0
Tennessee
Sevier County
Data sources: Tennessee Department of Health; Division of Policy, Planning and Assessment; Office of Health Statistics; Hospital Discharge Data System (HDDS). Analysis included inpatient
hospitalizations for liveborn delivery (identified using ICD-9-CM codes V270, V272, V273, V275, and V276) among females aged 15-44 years. Maternal substance abuse was defined using ICD-9CM codes beginning with 304 (drug dependence) and codes beginning with 305.2-305.9 (nondependent drug abuse), which include use of opioids, sedatives, hypnotics, anxiolytics, cocaine,
cannabis, amphetamines, and hallucinogens. HDDS records contain up to 18 diagnoses – women were classified as substance abusers if any of these diagnosis fields were coded with one of the
above listed diagnoses. Note that these are discharge-level data and not unique patient data.
Narcotics and Contraceptive Use:
TennCare Women, CY2011
Women
% of Women on
Prescribed
Narcotics
Narcotics
Not on
without
Contraceptives
Contraceptives
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
All Women
299,989
45,774
152.6
8,400
18%
37,374
82%
15 - 20
88,668
3,450
38.9
1,663
48%
1,787
52%
21 - 24
44,877
5,244
116.9
1,758
34%
3,486
66%
25 - 29
53,583
9,883
184.4
2,368
24%
7,515
76%
30 - 34
48,173
10,504
218.0
1,501
14%
9,003
86%
35 - 39
37,194
9,398
252.7
746
8%
8,652
92%
40 - 44
27,494
7,295
265.3
364
5%
6,931
95%
Data source: Division of Health Care Finance and Administration, Bureau of TennCare.
TennCare Infants in DCS Custody
Within 1 Year of Birth, CY2011
Infants born in CY 2011 NAS infants
Total # of Infants
55,578
528
Total # infants in DCS
767
120
% in DCS
1.4%
22.7%
Data source: Division of Health Care Finance and Administration, Bureau of TennCare.
This sample contains only children that were directly matched to TennCare’s records based on Social Security Number.
NAS Efforts in TN
• Spring 2012
• “Prescription Safety Act” required prescribers
to register with Controlled Substances
Monitoring Database (CSMD)
• Growing awareness of increasing NAS
incidence among neonatal providers
• Initial discussions between public health (TN
Department of Health) and Medicaid
(TennCare)
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
NAS Subcabinet Working Group
• Working principles:
• Multi-pronged approach
• Best strategy is primary prevention but clearly
must address secondary and tertiary
prevention
• Each department progresses independently,
keep group informed of efforts
• Supportive rather than punitive approach
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
Screen pregnant
women for substance
use during prenatal
visits and refer for
treatment
Treat addicted
women
Prevent pregnancy
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
NAS—Primary Prevention
• Prevent addiction from occurring
– Letter to FDA encouraging black box warning
– Provider education
• Letter to providers to increase awareness
• Possibly add to “responsible prescribing” CME
– TennCare limitations on opioid availability
• Requirement for counseling as part of prior
authorization
• Limitations on available quantity
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
NAS—Primary Prevention
• Prevent pregnancy from occurring
– Provider education
• Counseling by providers at initial prescription
• Promotion of contraceptives, particularly longacting reversible contraceptives (LARCs)
– Work with non-traditional partners to promote
counseling re: addition during pregnancy and
contraceptives
• A&D
• Pain clinics
• Drug courts
NAS—Secondary Prevention
• Identify pregnant women who may be
opioid addicted
– Identify reproductive-aged women via CSMD
whose fill patterns suggest risk of
dependence
– Referral to TennCare managed care
organization case management programs
– Screen pregnant women for drug use
• Consent of patient
• Supportive rather than punitive approach
NAS—Tertiary Prevention
• Minimize complications for women who
are addicted (and their neonates)
– Can addicted pregnant women be weaned?
– What are best strategies for treating NAS
infants?
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
• Collaborated with state perinatal quality
collaborative (TIPQC) to define reporting
elements
– Align required reporting elements with same
data elements reported in hospital QI projects
NAS—Reportable Disease
• 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 August 4-10, 2013
(Week 32)1
Cumulative Cases NAS Reported
Maternal County of
Residence
(By Health Department
Region)
#
Cases
%
Cases
Davidson
23
4.7%
East
127
25.9%
Hamilton
9
1.8%
Jackson/Madison
1
0.2%
Knox
59
12.0%
Mid-Cumberland
31
6.3%
North East
72
14.7%
Shelby
10
2.0%
South Central
18
3.7%
South East
7
1.4%
Sullivan
53
10.8%
Upper Cumberland
65
13.3%
West
15
3.1%
Total
490
100%
Number of Cases
2013 Cases
Reporting Summary (Year-to-date)
Cases Reported: 490
Male: 279
Female: 211
Unique Hospitals Reporting: 47
Estimated 2011
490
476
500
450
400
350
300
250
200
150
100
50
0
1
3
5
7
9
11 13 15 17 19 21 23 25 27 29 31 33 35
Week
#
Cases2
%
Cases
Supervised replacement therapy
215
43.9%
Supervised pain therapy
102
20.8%
Therapy for psychiatric or neurological condition
40
8.2%
Prescription substance obtained WITHOUT a prescription
193
39.4%
Non-prescription substance
138
28.2%
No known exposure but clinical signs consistent with NAS
9
1.8%
No response
11
2.2%
Source of Maternal Substance (if known)2
1. Summary reports are archived weekly at: http://health.tn.gov/MCH/NAS/NAS_Summary_Archive.shtml
2. Multiple maternal substances may be reported; therefore the total number of cases in this table may not match the total number of cases reported.
NAS—Reportable Disease
• Through Week 32 (August 4-10, 2013)
– 490 cases
• 279 male, 211 female
– 47 unique reporting hospitals
NAS—Reportable Disease
Cumulative Cases NAS Reported
2013 Cases
500
Estimated 2011
490
476
450
Number of Cases
400
350
300
250
200
150
100
50
0
1 2 3 4 5 6 7 8 9 1011121314151617181920212223242526272829303132333435
Week
NAS—Reportable Disease
Sevier
County ~5%
of cases in
TN and 18%
of cases in
East Region
63% of
cases in
East and
Northeast
TN
Maternal County of Residence
(By HD Region)
% Cases
Davidson
4.7%
East
25.9%
Hamilton
1.8%
Jackson/Madison
0.2%
Knox
12.0%
Mid-Cumberland
6.3%
North East
14.7%
Shelby
2.0%
South Central
3.7%
South East
1.4%
Sullivan
10.8%
Upper Cumberland
13.3%
West
3.1%
Total
100%
24% of
cases in
Middle TN
and
Plateau
NAS—Reportable Disease
#
Cases*
%
Cases
Supervised replacement therapy
215
43.9%
Supervised pain therapy
102
20.8%
Therapy for psychiatric or neurological condition
40
8.2%
Prescription substance obtained WITHOUT a prescription
193
39.4%
Non-prescription substance
138
28.2%
No known exposure but clinical signs consistent with NAS
9
1.8%
No response
11
2.2%
Source of Maternal Substance (if known)
*Multiple maternal substances may be reported; therefore the total number of cases in this table may not match the total number of cases
reported.
NAS—Maternal Source of Exposure
(Analysis by Exclusive Category as of 8/10/2013)
Maternal Source of Exposure
State
#
State
%
207
42.2%
164
33.5%
99
20.2%
20
4.1%
490
100.0
Only substances reported were prescribed
Only substances reported were not prescribed
(illicit or diverted)
Both prescribed and non-prescribed
substance(s) reported
No substance reported or no known history of
substance use
TOTAL
NAS—Maternal Source of Exposure
(Analysis for East Region—as of August 10, 2013)
100%
n = 490
n = 127
n = 23
90%
80%
70%
Unknown
60%
NOT PRESCRIBED
substances only
Both prescribed and nonprescribed substances
Prescribed substances only
50%
40%
30%
20%
10%
0%
State
East
Sevier
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
– [email protected]
• Kelly Luskin, MSN, WHNP-BC
– Women’s Health Nurse Consultant, Division of
Family Health and Wellness
– [email protected]