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Exploring Drug Dependent Newborns In Appalachia: a Conference of Experts April 2-3, 2014 Johnson City, TN Bruce Behringer Deputy Commissioner Tennessee Department of Health Eric Stockton Health Program Manager Appalachian Regional Commission

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Thought Leaders Roundtable: Appalachian Neonatal Abstinence Syndrome Project - Bruce Behringer and Eric Stockton

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Exploring Drug Dependent Newborns In Appalachia: a

Conference of Experts April 2-3, 2014

Johnson City, TN

Bruce Behringer Deputy Commissioner

Tennessee Department of Health

Eric Stockton Health Program Manager

Appalachian Regional Commission

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ARC  Region  with  County  Economic  Status:    FY  2014  

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ARC Programs •  Research and advocacy •  Public/private partnerships •  Grantmaking for local initiatives

– Bottoms-up grantmaking – Guided by regional strategy – Local development districts and states =

gatekeepers

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ARC Grantmaking •  Job creation

– Business capital, food systems, entrepreneurs •  Human capacity

– Education, workforce, health, leadership •  Physical infrastructure

– Water, sewer, industrial sites – Clinics and hospitals – Highway network & intermodal transport

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ARC Priority Setting •  Strategic Plan •  State Development Plans •  Annual State Strategy Statements •  OMB Performance Targets •  Distressed Area mandate •  Advisory groups

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Appalachian Health Policy Advisory Council

• Health career development pathways. • Rural primary care provider base. • State and community-based HPDP.

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Appalachian Health Policy Advisory Council

• Integration of treatment and coordination of services.

• Health disparities economic disparities

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Major Health Research

•  An Analysis of Disparities in Health Status and Access to Health Care in the Appalachian Region (Halverson: 2004)

•  (Published at www.arc.gov)

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Substance Abuse in Appalachia: 2006 findings

•  Addiction = business (covert economy). •  Substance use is culturally accepted. •  Widespread incidence and prevalence of

addiction and additive behaviors. •  Lack of health services infrastructure reduced

capacity for people and communities

From “A Community-Based Approach to Substance Abuse Including Methamphetamine in Appalachia,” Johnson City, TN, 2006

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Substance Abuse in Appalachia: 2006 findings

•  Legal drugs and generational use of substances are legitimized by: –  historical medical practice –  the media

•  Appalachian life contributes a unique set of life and community stressors: –  poverty and disenfranchisement

•  From “A Community-Based Approach to Substance Abuse Including Methamphetamine in Appalachia,” Johnson City, TN, 2006

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Major Health Research •  An Analysis of Mental Health and

Substance Abuse Disparities & Access to Treatment Services in the Appalachian Region (August 2008)

•  National Opinion Research Center (NORC) at the University of Chicago, and East Tennessee State University

•  (Published at www.arc.gov)

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NORC Study Outcomes •  Meth vs. prescription opioids •  Treatment access poor but better than

expected •  Variability within region •  Place-based study of regional conditions •  National researchers (NORC) helped

legitimize findings

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Ongoing activities •  Mini-grant competitions for coalitions •  Other grantmaking interests:

•  Facilities •  Integrated care demonstrations •  (Not ongoing operations) •  Workforce development •  Business opportunity? •  Links to economic development

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NAS in Tennessee and Appalachia •  Tennessee: greater NAS prevalence in

Appalachian counties than non-ARC •  ARC co-funded multi-state project

– Other states’ experience? – What is known…or unknown? –  Is this an Appalachian issue?

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www.arc.gov

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Neonatal Abstinence Syndrome Conference of Experts:

Exploring the Issue of Drug Dependent Newborns in the Appalachian Region

Tennessee Department of Health Johnson City, TN

April 2-3, 2014 Supported by a conference grant

from the Appalachian Regional Commission

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Conference Design •  Cooperative regional venture to assess regional Neonatal

Abstinence Syndrome (NAS) epidemic •  Objectives

–  Summarize what is known about the epidemiology of NAS in Appalachia

–  Generate a set of questions and potential inquiries that would address that which is unknown

–  Identify existing and ideas for proposed collaborations and cooperative ventures

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Conference Agenda •  The agenda

–  The national picture –  Expert panels – Research, Practice, Partnerships and State Policy – Federal and national organizations reflections –  Closing thoughts on a public health epidemic

•  The thirty-eight attendees were “experts” from eight Appalachian states representing multiple stakeholder interests

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Active participation by attendees as inputs • Pre-conference questionnaire •  Idea collection sheets by panel:

– What we know (findings); – What we don’t know (gaps); – Recommendations (key elements needed for change)

•  Notes from facilitated audience discussion with panels •  “We Believe” statements from all participants

Approach: Active participation will

inform conference report

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From the History Lesson…

Southern Appalachia was the target market and became the epicenter of prescription

opiate abuse (Oxycontin) fifteen years ago, and now has become a part of the regional

culture sowing the seed of death and destruction of people, families communities

and a proud culture.

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To the Current Challenge We believe that Appalachia is the epicenter of the latest manifestation of the substance abuse epidemic because

vehicle transmission (NAS) is a lagging indicator. Appalachia, the canary in our coalmines of the current

substance abuse epidemic, spoke loudly when our people stated dying, but not loud enough to warn the country and stop the epidemic. This time we can work together, be a

louder voice to turn back and stop NAS, emphasizing prevention and destigmatization recognizing the tri-level approach of prevention, treatment and control. “Place

matters” and in Appalachia we can make it matter for the nation.

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Map  of  distribuBon  of  NAS  cases  

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 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. Data suppressed for counties with fewer than 100 births.

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Conference outcomes •  Learn more about NAS problem in Appalachia region

including gaps in knowledge •  Verify multistate place-based problem •  Recognize and validate multiple perspectives about

multiple dimensions requiring systems approaches •  Share implementation ideas and personal networking •  Collect ideas and recommendations to future ARC

consideration •  Develop common themes across states

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Common themes •  Social and economic determinants are important. •  Professional education with prescribers is

necessary. •  Compassion, not arrest, will lead to improved

outcomes. •  NAS is just becoming recognized as a real

financial issue. •  Too little consensus on protocols: case definition,

prenatal treatment of mothers, hospital level of care for infants.

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Common themes •  Too little is understood about long-term

impacts on child. •  Intermediate impacts being discovered

(DCS placements). •  Treatment resources are lacking, and

prevention strategies are undeveloped. •  Policy pressures mounting to punish

mothers as “the moral thing”.

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“We Believe” Statements •  NAS is a growing epidemic in the Appalachian

region. •  NAS is a symptom of larger issues. •  NAS is preventable! Primary prevention is a

must! •  NAS is an expected and treatable condition. •  NAS is the “wakeup call” and opportunity to

change perceptions and stigma surrounding substance abuse and lack of education among providers and citizens.

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“We Believe” Statements •  Poverty and social injustice are the primary

determinants of the NAS epidemic in Appalachia.

•  NAS is: multi-dimensional, affects multiple systems; not only a constellation of symptoms, but a family and society unit issue

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Is Neonatal Abstinence Syndrome a national problem?

Provide one statement to document or describe the

situation in your state or region

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Recommendations: Research Panel •  Identify effective assessment tools for identifying

NAS •  Promote universal protocols around drug

screening for OB-GYNs and hospitals •  Identify elements of successful treatment •  Fund long term studies to follow children through

childhood •  Identify structural factors that drive long lengths of

stay: Study new hospital treatment options

Neonatal Abstinence Syndrome Conference of Experts: Exploring the Issue of Drug Dependent Newborns in the Appalachian Region, April 2014

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Recommendations: Research Panel •  Advocate for health care provider education about

addiction and recovery •  Study effectiveness of primary prevention

strategies (injury prevention, related tobacco use, changing prescribing polices for women of childbearing age)

•  Describe locally successful community programs

Neonatal Abstinence Syndrome Conference of Experts: Exploring the Issue of Drug Dependent Newborns in the Appalachian Region, April 2014

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Recommendations: Clinical Practice Panel •  Advocate that all health related students learn

about drug addiction as prerequisite and eliminate provider bias and decrease stigma

•  Improve standardized protocols for discharge and post hospital care

•  Institute universal biochemical drug testing early in pregnancy

•  Promote early prenatal engagement and education about what to expect: Patients to be informed about risk of NAS who receive Medication Assisted Therapy

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Recommendations: Clinical Practice Panel •  Expand treatment sources and resources •  Use multi-disciplinary and multipronged

approaches •  Co-locate primary health care and behavioral

health •  Advocate for non-judgmental, non punitive

approaches

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Recommendations: Partnerships Panel •  Identify community and family factors relevant to

recovery •  Advocate for physician engagement in public NAS

education •  Gain support for buprenorphine and suboxone

oversight •  Focus on underlying social determinants of heath

(e.g., promote job training and placement). •  Improve family planning and substance abuse

education in prisons and general population.

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Recommendations: Partnerships Panel •  Create economics case for primary prevention of

NAS •  Develop a provider and parent navigation guide

for working with Children’s Services. •  Conduct evaluation that promotes resources for

sustained effective partnership programs and coalitions

•  Be about health, not health care.