Transcript Preventing Neonatal Abstinence Syndrome: The Tennessee Story

Tiny Victims of a Massive Problem:
Neonatal Abstinence Syndrome
and Tennessee’s
Prescription Drug Epidemic
Michael D. Warren, MD MPH FAAP
Division of Family Health and Wellness
Sheri Smith, RN
Nursing Director, Critical Care Services
Disclosures
• We have no relevant financial disclosures.
• We will not be discussing any unapproved
or off-label uses of therapeutic agents of
products.
Objectives
• Review signs, symptoms, and treatment
related to Neonatal Abstinence Syndrome.
• Describe the scope of the NAS epidemic
and the larger prescription drug problem in
Tennessee.
• Identify state-level initiatives to prevent
NAS.
• Discuss collaboration between state and
community partners on this topic.
Neonatal Abstinence Syndrome:
Signs, Symptoms, and Treatment
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
• 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
NAS Outcomes
• Prenatal drug exposure associated with increased
risks:
–
–
–
–
–
Cesarean delivery (OR 1.5-1.9)
Pre-term birth (OR 3.7-4.6)
Low birth weight (OR 4.1-5.2)
Feeding problems (OR 8.2-10.3)
Respiratory distress syndrome (OR 3.4-5.3)
• Prenatal opioid use associated with increased risk
of:
– Spina bifida (OR 1.3-3.2)
– Gastroschisis (OR 1.1-2.9)
– Any heart defect (OR 1.1-1.7)
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. 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
Neonatal Abstinence Syndrome:
Scope of the Problem in US & TN
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:
1999-2011
Number
Rate
700
9.0
8.0
600
500
Number
6.0
400
5.0
300
4.0
3.0
200
2.0
100
1.0
0
0.0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
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
7.0
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.
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
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/
Opioid Prescription Rates
by County—TN, 2007-2011
2007
2008
2009
2010
2011
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
– 1,062 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
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
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
US Prescription Drug Problem
Graphic Source: CDC. QuickStats: Number of Deaths From Poisoning, Drug Poisoning, and Drug Poisoning Involving Opioid Analgesics—United
States, 1999–2010. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6212a7.htm
Narcotics and Contraceptive Use:
TennCare Women, CY2012*
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
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
General Population
49.9%
Opioid-Abusing Women
86.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90% 100%
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.
TennCare NAS Costs, CY2012*
TennCare Paid
Live Births1
TennCare
non-LBWT
Births
TennCare Live
LBWT Births2
NAS
Infants
42,171
37,576
4,595
736
$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
Metric
Number of Births
Cost for Infant in first year
of life
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).
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.
Neonatal Abstinence Syndrome:
State-Level Efforts
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 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
TennCare Prior Authorization Form
Form available at: https://tnm.providerportal.sxc.com/rxclaim/TNM/TC%20PA%20Request%20Form%20(Long%20Acting%20Narcotics).pdf
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
Drug Dependent Newborns (Neonatal Abstinence Syndrome)
Surveillance Summary For the Week of November 10-November 16, 2013
(Week 46)1
Cumulative Cases NAS Reported
Reporting Summary (Year-to-date)
Cases Reported: 752
Male: 441
Female: 311
Unique Hospitals Reporting: 50
#
Cases
Estimated 2011
800
731
752
700
%
Cases
Davidson
33
4.4%
East
204
27.1%
Hamilton
13
1.7%
Jackson/Madison
2
0.3%
Knox
86
11.4%
Mid-Cumberland
49
6.5%
North East
116
15.4%
Shelby
15
2.0%
South Central
23
3.1%
South East
11
1.5%
Sullivan
79
10.5%
Upper Cumberland
98
13.0%
West
23
Total
752
Number of Cases
Maternal County of
Residence
(By Health Department
Region)
2013 Cases
600
500
400
300
200
100
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Week
#
Cases2
%
Cases
Supervised replacement therapy
344
45.7%
Supervised pain therapy
147
19.5%
Therapy for psychiatric or neurological condition
58
7.7%
Prescription substance obtained WITHOUT a prescription
294
39.1%
Non-prescription substance
214
28.5%
3.1%
No known exposure but clinical signs consistent with NAS
11
1.5%
100%
No response
19
2.5%
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
Maternal County of Residence
(By HD Region)
64% of
cases in
East and
Northeast
TN
# Cases
% Cases
Davidson
33
4.4%
East
204
27.1%
Hamilton
13
1.7%
Jackson/Madison
2
0.3%
Knox
86
11.4%
Mid-Cumberland
49
6.5%
North East
116
15.4%
Shelby
15
2.0%
South Central
23
3.1%
South East
11
1.5%
Sullivan
79
10.5%
Upper Cumberland
98
13.0%
West
23
3.1%
Total
752
100%
24% of
cases in
Middle TN
and
Plateau
NAS—Reportable Disease
Maternal Source of Exposure
Substance exposure
unknown
4.0%
Only illicit or
diverted
substances
33.4%
Only substances
prescribed to mother
41.7%
Mix of prescribed
and nonprescribed
substances
20.9%
Data source: Tennessee Department of Health, Neonatal Abstinence Syndrome Reporting Data. Data through 10/26/2013.
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.
Controlled Substance
Monitoring Database
•
Established in 2006
–
Monitor prescribing of controlled
substances—drugs illegal to use except with
prescription
– Drug Enforcement Agency (DEA)
Schedule II–V
– Provider participation was previously
voluntary
Controlled Substance
Monitoring Database
•
Prescription Safety Act of 2012
–
All prescribers required to register by 1/1/13
– Starting 4/1/2013, prescribers required to
check the database before prescribing any
opioid or benzodiazepine as a new course
of treatment and at least annually when said
controlled substance remains part of the
treatment
– Dispensers must report at least every 7 days
to CSMD
Controlled Substance
Monitoring Database
Provider
Opioid
Prescription
TNCSMP
database
Tennessee
Pharmacy
Controlled Substance
Monitoring Database
Controlled Substance
Monitoring Database
Top 10 Prescriptions reported to CSMD, 2012
Buprenorphine
products
3%
Diazepam
4%
Lorazepam
5%
Morphine
products
3%
Clonazepam
6%
Hydrocodone
36%
Tramadol
6%
Zolpidem
10%
Oxycodone
products
12%
Alprazolam
15%
Controlled Substance
Monitoring Database
Risk Factor
Cases
N=592
Controls
N=11,840
AORs
95%
Confidence
Interval
Number (%)
Number (%)
Provider
shopping
227 (38)
513 (4)
5.1
3.2-8.1
Pharmacy
shopping
145 (24)
196 (2)
4.5
2.5-8.1
High dosage
use
140 (24)
172 (1)
13.2
8.6-20.8
Source: Dr. Jane Baumblatt, TN Department of Health. Case control analysis of TN Controlled Substance Monitoring Database. 2013.
Neonatal Abstinence Syndrome:
Opportunities for Prevention and
Collaboration
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 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—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
– Tennessee Department of Health
– [email protected]
• Sheri Smith, RN
– Nursing Director, Critical Care Services
– East TN Children’s Hospital
– [email protected]