Neonatal Abstinence Syndrome

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1 Neonatal Abstinence Syndrome Effective Prevention Strategies Division of Prevention and Health Promotion Injury Prevention Program

2 Objectives Characterize PDA as a public health problem Detail the impact of PDA on neonates Identify prevention strategies and discuss how these can be applied to this population

3 Drugs

4 Winslow's Soothing Syrup for infants Active Ingredient: Morphine Source: Kolodny, Andrew, M.D Children s Safety Network: Overview of the Opioid Addiction Epidemic. Retrieved from:

5 Greater use of opioids Pain Patient Groups Professional Societies The Joint Commission The Federation of State Medical Boards Source: Kolodny, Andrew, M.D Children s Safety Network: Overview of the Opioid Addiction Epidemic. Retrieved from:

6 Dr. Thomas Frieden Director, Centers for Disease Control and Prevention When I was in medical school I was told if you give opiates to a patient who s in pain, they will not get addicted. Completely wrong..a generation of us grew up being trained that these drugs aren t risky. In fact, they are risky. REPORT: PBS NEWSHOUR AIR DATE: April 30, 2013 Pain and Consequences for Those Taking Too Much Pain Medicine

7 Misuse, Abuse, Diversion Misuse: When a schedule II V substance is taken by an individual for a non-medical reason. Abuse: When an individual repeatedly takes a schedule II V substance for a non-medical reason. Diversion: When a schedule II V substance is acquired and/or taken by an individual for whom the medication was not prescribed. Source: Cabinet for Health and Family Services

8 Why is this a problem? Precisely calculated Adverse health effects Misconceptions of Safety Overdose

9 Source: Commonly Abused Drugs

10 Source: Rx Drug Abuse

11 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

12 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

13 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

14 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

15 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

16 Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

17

18 Virginia Deaths Drug/Poisoning Death rate 9.6 per 100,000 Motor Vehicle Traffic Death rate 9.4 per 100,000 Source: Office of Chief Medical Examiner, Western District, 2011 Data

19 SOURCE: Drug Abuse Warning Network, Women and PDA

20 Factors Women s body size and body fat affect the metabolism rate of prescription drugs Women report more chronic pain Women are prescribed more painkillers and are given higher doses for longer periods of time than men Women may become addicted sooner than men Women are more likely to engage in doctor shopping Centers for Disease Control and Prevention (2013) Press Release: Deaths from Prescription Painkiller Overdoses Rise Sharply Among Women: National Vital Statistics System ( ) and the Drug Abuse Warning Network public use file (

21 Neonatal Abstinence Syndrome Group of problems that can occur in newborns exposed to prescription painkillers or other drugs while in utero Source: Patrick, S. W. et al. JAMA 2012;307:

22 Neonatal Abstinence Syndrome Central Nervous System Gastrointestinal Autonomic/Metabolic Source: Patrick, S. W. et al. JAMA 2012;307:

23 Long -Term Effects Brain development Increased Risk for SIDS Sleep Neurodevelopmental delays Behavior regulation Sensory processing Cognitive/Learning delays Psychosocial implications Source: Source: Patrick, S. W. et al. JAMA 2012;307:

24 Neonatal Abstinence Syndrome Data: Virginia,

25 Neonatal Abstinence Syndrome: Virginia Data Source NAS data were compiled from inpatient hospitalization data set maintained by Virginia Health Information (VHI) Data source includes discharges from all nonfederal, acute care hospitals in Virginia ICD-9-CM diagnosis code of in any of 18 diagnosis fields Only included infants <1 year of age Cases reflect only Virginia residents

26 Number of Cases Neonatal Abstinence Syndrome Cases: Virginia, Year Data Source: Virginia Health Information,

27 Number of Cases Neonatal Abstinence Syndrome Cases by Region: Virginia, Central Eastern Northern Northwestern Southwestern Data Source: Virginia Health Information, Data from Northwestern region in 1999 suppressed due to small numbers.

28 Rate per 1000 Live Births Neonatal Abstinence Syndrome Rate: Virginia, Year Data Source: Virginia Health Information,

29 Rate per 1000 Live Births Neonatal Abstinence Syndrome Rate by Region: Virginia, Central Eastern Northern Northwestern Southwestern Data Source: Virginia Health Information,

30 Payment Source for Neonatal Abstinence Syndrome Births: Virginia, % 1.6% 25.6% 65.8% Medicaid Private/HMO Self-pay Other Data Source: Virginia Health Information,

31 Total Charges in Millions of Dollars Total Charges for Neonatal Abstinence Syndrome Births, All Payers and Medicaid: Virginia, All Payers Medicaid Only Data Source: Virginia Health Information, Costs associated with NAS births only.

32 Length of Stay in Days Median Length of Stay for Neonatal Abstinence Syndrome Births: Virginia, Year Data Source: Virginia Health Information,

33 Why the increase? Opioid prescribing practices? Increased case detection and reporting? Changes in Virginia reporting law? Unknown factors?

34 Possible Connections NAS rate increased 3x ( ) Maternal opiate use increased 5x ( ) Opiate sales and related death increased 4x ( ) Source: Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: United States, JAMA Advance online publication Available online at:

35 NAS Prevention Primary Prevention- Prevention of prescription drug abuse, family planning counseling, effective monitoring, education Secondary- Prenatal referrals for positive screens and reporting Tertiary - Acute management and reporting Adapted from: Centers for Disease Control and Prevention MMWR. (1992).

36 Primary Prevention American Congress of Obstetrics and Gynecology: Substance abuse is one of the most important risks encountered in contemporary obstetrics. Therefore, all patients should be questioned thoroughly about substance abuse at the time of their first prenatal visit. (ACOG, 1994)

37 Primary Prevention Healthcare Provider Trainings Prescription Monitoring Program Responsible Opioid Dispensing Policies Resources

38 Primary Prevention NAS Outreach and Education Lockbox safe storage education for vulnerable populations (Homeless population, DV Shelters) Schools, Home Visiting Programs awareness

39 Secondary Prevention B of the Code of Virginia requires health care providers to report findings made within six weeks of birth to the Department of Social Services NAS is not currently a reportable public health condition in Virginia

40 Tertiary Prevention Postnatal monitoring Increased injury risk -SUID/Suffocation -Abusive Head Trauma

41 Opportunities for Virginia Build and nurture collaborative screening, monitoring, and treatment models, frameworks, and coalition networks Share data sources, methodologies, and outcome results to strengthen program development Improve health outcomes for women of child bearing age and their neonates through evidenced based prevention strategies

42 In Summary: Prescription drug abuse is a growing epidemic, and a concern for women of childbearing age Maternal prescription drug abuse can lead to Neonatal Abstinence Syndrome Primary prevention techniques can be impactful in reducing NAS

43 Contact JoAnn Wells, RDH Injury Prevention Outreach Coordinator, Virginia Department of Health Division of Prevention and Health Promotion Injury Prevention Program (804) Anne M. Zehner, MPH Epidemiologist, Virginia Department of Health Division of Policy and Evaluation Phone: 804/

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