Tennessee Efforts to Prevent Neonatal Abstinence Syndrome Kelly Luskin, MSN, WHNP-BC Division of Family Health and Wellness

Tennessee Efforts to PreventNeonatal Abstinence Syndrome

Kelly Luskin, MSN, WHNP-BCDivision 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 • Hyperactivity• Tremors • Crying

• 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• 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

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

Rates of prescription painkiller sales, deathsand substance abuse treatment admissions (1999-2010)

http://www.cdc.gov/VitalSigns/pdf/2011-11-vitalsigns.pdf

TN’s Prescription Drug Problem

Data source: CDC, Policy Impact Brief: Prescription Painkiller Overdoses. Available at: http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

Prescription Painkillers Sold By State, 2010

TN: 2nd highest in country for kilograms of prescription painkillers sold per 10,000 people

http://www.cdc.gov/homeandrecreationalsafety/rxbrief/


• 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 Ratesby County—TN, 2007

Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.

Opioid Prescription Rates by County—TN, 2008









51 pillsper every Tennessean over age 12



275.5 Million Hydrocodone Pills

116.6 Million Xanax Pills

113.5 Million Oxycodone Pills



• 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

Risk factor % of All Patients % of Deaths

≥ 4 Prescribers 8.3 38

≥ 4 Pharmacies 2.7 24

High dosage use 1.9 24

Relative Proportion of Patients With Risk Factors Versus Death

Number of Prescribers & Dispensers with Database Access and Actual Number Checking Data

Number of Queries by Quarter2011 – Q2 2013

2011 - 1.5 M searches2012 - 1.9 M searches2013 - 1.9 M searches in 6 months

Total MME of Opioids 4/1/2012 - 3/31/2013

F 12% decrease

Number of Doctor Shoppers in CSMD By Month, Jan 2012--- Mar 2013

F 40% decreasefrom peak

NAS Hospitalizations in TN:1999-2010

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

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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.

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.

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Inpatient Hospitalization Rate for Any Diagnosis of Neonatal Abstinence SyndromeTennessee, 1999-2011

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.

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-9-CM 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.

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Inpatient Hospitalization Rate for Deliveries with Any Maternal Substance AbuseTennessee, 1999-2011

Narcotics and Contraceptive Use:TennCare Women, CY2011

DemographicsTennCare 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 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

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.

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%

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 PreventionPRIMARYPrevention

SECONDARYPrevention

TERTIARYPrevention

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. 1992; 41(RR-3); 001. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00016403.htm

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

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 long-

acting 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


• 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


• Reporting hospitals/providers submit electronic report

• Reporting Elements– Case Information– Diagnostic Information– Source of Maternal Exposure

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 310

50100150200250300350400450500 476

490

Cumulative Cases NAS Reported

2013 Cases Estimated 2011

Week

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ases

Drug Dependent Newborns (Neonatal Abstinence Syndrome) Surveillance Summary For the Week of August 4-10, 2013(Week 32)1

Source of Maternal Substance (if known)2

# 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%

Reporting Summary (Year-to-date)Cases Reported: 490

Male: 279Female: 211

Unique Hospitals Reporting: 47

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%

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.

http://health.tn.gov/MCH/NAS/NAS_Summary_Archive.shtml


• Through Week 32 (August 4-10, 2013)

– 490 cases• 279 male, 211 female

– 47 unique reporting hospitals

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 310

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Cumulative Cases NAS Reported

2013 Cases Estimated 2011

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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%

63% of cases in East and Northeast TN

24% of cases in Middle TN and Plateau

Sevier County ~5% of cases in

TN and 18% of cases in

East Region


Source of Maternal Substance (if known)#

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%

*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

%Only substances reported were prescribed

207 42.2%Only substances reported were not prescribed (illicit or diverted)

164 33.5%Both prescribed and non-prescribed substance(s) reported

99 20.2%No substance reported or no known history of substance use

20 4.1%

TOTAL 490 100.0

NAS—Maternal Source of Exposure(Analysis for East Region—as of August 10, 2013)

State East Sevier0%

10%

20%

30%

40%

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70%

80%

90%

100%

UnknownNOT PRESCRIBED substances onlyBoth prescribed and non-prescribed substancesPrescribed substances only

n = 127n = 490 n = 23


• 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


• 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


• 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

http://health.tn.gov/MCH/NAS/



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]

mailto:[email protected]

mailto:[email protected]

Documents

Tennessee Efforts to Prevent Neonatal Abstinence Syndrome Kelly Luskin, MSN, WHNP-BC Division of Family Health and Wellness