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      Increasing Incidence and Geographic Distribution of Neonatal Abstinence Syndrome: United States 2009-2012

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          Abstract

          Objective

          Neonatal abstinence syndrome (NAS), a postnatal opioid withdrawal syndrome, increased 3-fold from 2000 to 2009. Since 2009, opioid pain reliever prescriptions and complications increased markedly throughout the US. Understanding recent changes in NAS and its geographic variability would inform state and local governments in targeting public health responses.

          Study Design

          We utilized diagnostic and demographic data for hospital discharges from 2009 to 2012 from the Kids’ Inpatient Database and the Nationwide Inpatient Sample. NAS-associated diagnoses were identified utilizing ICD-9-CM codes. All analyses were conducted with nationally weighted data. Expenditure data were adjusted to 2012 US dollars. Between-year differences were determined utilizing least squares regression.

          Results

          From 2009 to 2012, NAS incidence increased nationally from 3.4 (95%CI: 3.2-3.6) to 5.8 (95%CI 5.5-6.1) per 1,000 hospital births, reaching a total of 21,732 infants with the diagnosis. Aggregate hospital charges for NAS increased from $732M to $1.5B (p<0.001), with 81% attributed to state Medicaid programs in 2012. NAS incidence varied by geographic Census division, with the highest incidence rate (per 1000 hospital births) of 16.2 (95%CI 12.4-18.9) in the East South Central Division (KY, TN, MS, AL) and the lowest in West South Central Division 2.6 (95%CI 2.3-2.9; [OK, TX, AR, LA]).

          Conclusion

          NAS incidence and hospital charges grew substantially during our study period. This costly public health problem merits a public health approach to alleviate harm to women and children. States, particularly in areas of the country most affected by the syndrome, must continue to pursue primary prevention strategies to limit the effects of opioid pain reliever misuse.

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          Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009.

          Stephen W Patrick, Robert E Schumacher, Brian Benneyworth … (2012)
          Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome primarily caused by maternal opiate use. No national estimates are available for the incidence of maternal opiate use at the time of delivery or NAS. To determine the national incidence of NAS and antepartum maternal opiate use and to characterize trends in national health care expenditures associated with NAS between 2000 and 2009. A retrospective, serial, cross-sectional analysis of a nationally representative sample of newborns with NAS. The Kids' Inpatient Database (KID) was used to identify newborns with NAS by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. The Nationwide Inpatient Sample (NIS) was used to identify mothers using diagnosis related groups for vaginal and cesarean deliveries. Clinical conditions were identified using ICD-9-CM diagnosis codes. NAS and maternal opiate use were described as an annual frequency per 1000 hospital births. Missing hospital charges (<5% of cases) were estimated using multiple imputation. Trends in health care utilization outcomes over time were evaluated using variance-weighted regression. All hospital charges were adjusted for inflation to 2009 US dollars. Incidence of NAS and maternal opiate use, and related hospital charges. The separate years (2000, 2003, 2006, and 2009) of national discharge data included 2920 to 9674 unweighted discharges with NAS and 987 to 4563 unweighted discharges for mothers diagnosed with antepartum opiate use, within data sets including 784,191 to 1.1 million discharges for children (KID) and 816,554 to 879,910 discharges for all ages of delivering mothers (NIS). Between 2000 and 2009, the incidence of NAS among newborns increased from 1.20 (95% CI, 1.04-1.37) to 3.39 (95% CI, 3.12-3.67) per 1000 hospital births per year (P for trend < .001). Antepartum maternal opiate use also increased from 1.19 (95% CI, 1.01-1.35) to 5.63 (95% CI, 4.40-6.71) per 1000 hospital births per year (P for trend < .001). In 2009, newborns with NAS were more likely than all other hospital births to have low birthweight (19.1%; SE, 0.5%; vs 7.0%; SE, 0.2%), have respiratory complications (30.9%; SE, 0.7%; vs 8.9%; SE, 0.1%), and be covered by Medicaid (78.1%; SE, 0.8%; vs 45.5%; SE, 0.7%; all P < .001). Mean hospital charges for discharges with NAS increased from $39,400 (95% CI, $33,400-$45,400) in 2000 to $53,400 (95% CI, $49,000-$57,700) in 2009 (P for trend < .001). By 2009, 77.6% of charges for NAS were attributed to state Medicaid programs. Between 2000 and 2009, a substantial increase in the incidence of NAS and maternal opiate use in the United States was observed, as well as hospital charges related to NAS.
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            Neonatal drug withdrawal.

            Mark Hudak, Rosemarie C Tan (2012)
            Maternal use of certain drugs during pregnancy can result in transient neonatal signs consistent with withdrawal or acute toxicity or cause sustained signs consistent with a lasting drug effect. In addition, hospitalized infants who are treated with opioids or benzodiazepines to provide analgesia or sedation may be at risk for manifesting signs of withdrawal. This statement updates information about the clinical presentation of infants exposed to intrauterine drugs and the therapeutic options for treatment of withdrawal and is expanded to include evidence-based approaches to the management of the hospitalized infant who requires weaning from analgesics or sedatives.
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              Vital signs: overdoses of prescription opioid pain relievers---United States, 1999--2008.

              (2011)
              Overdose deaths involving opioid pain relievers (OPR), also known as opioid analgesics, have increased and now exceed deaths involving heroin and cocaine combined. This report describes the use and abuse of OPR by state. CDC analyzed rates of fatal OPR overdoses, nonmedical use, sales, and treatment admissions. In 2008, drug overdoses in the United States caused 36,450 deaths. OPR were involved in 14,800 deaths (73.8%) of the 20,044 prescription drug overdose deaths. Death rates varied fivefold by state. States with lower death rates had lower rates of nonmedical use of OPR and OPR sales. During 1999--2008, overdose death rates, sales, and substance abuse treatment admissions related to OPR all increased substantially. The epidemic of overdoses of OPR has continued to worsen. Wide variation among states in the nonmedical use of OPR and overdose rates cannot be explained by underlying demographic differences in state populations but is related to wide variations in OPR prescribing. Health-care providers should only use OPRs in carefully screened and monitored patients when non-OPR treatments are insufficient to manage pain. Insurers and prescription drug monitoring programs can identify and take action to reduce both inappropriate and illegal prescribing. Third-party payers can limit reimbursement in ways that reduce inappropriate prescribing, discourage efforts to obtain OPR from multiple health-care providers, and improve clinical care. Changes in state laws that focus on the prescribing practices of health-care providers might reduce prescription drug abuse and overdoses while still allowing safe and effective pain treatment.
              Article 0 comments Cited 166 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-journal-id): 8501884
                Journal ID (pubmed-jr-id): 5061
                Journal ID (nlm-ta): J Perinatol
                Journal ID (iso-abbrev): J Perinatol
                Title: Journal of perinatology : official journal of the California Perinatal Association
                ISSN (Print): 0743-8346
                ISSN (Electronic): 1476-5543
                Publication date Nihms-submitted: 25 March 2015
                Publication date (Electronic): 30 April 2015
                Publication date (Print): August 2015
                Publication date PMC-release: 01 February 2016
                Volume: 35
                Issue: 8
                Pages: 650-655
                Affiliations
                [1 ]Department of Pediatrics, Vanderbilt University, Nashville, TN
                [2 ]Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, TN
                [3 ]Vanderbilt Center for Health Services Research, Nashville, TN
                [4 ]Department of Health Policy, Vanderbilt University, Nashville, TN
                [5 ]Child Health Evaluation and Research (CHEAR) Unit, Department of Pediatrics and Communicable Diseases, University of Michigan Health System, Ann Arbor, MI
                [6 ]Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI
                [7 ]Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
                [8 ]Department of Biomedical Informatics, Vanderbilt University, Nashville, TN
                Author notes
                Correspondence to: Stephen W. Patrick, MD, MPH, MS, Monroe Carell Jr Children’s Hospital At Vanderbilt, Mildred Stahlman Division of Neonatology, 11111 Doctor’s Office Tower, 2200 Children’s Way, Nashville, TN 37232-9544, Telephone: 615-343-8898, Facsimile: 615-343-1763, stephen.patrick@ 123456vanderbilt.edu
                Article
                Manuscript ID: NIHMS672061
                DOI: 10.1038/jp.2015.36
                PMC ID: 4520760
                PubMed ID: 25927272
                SO-VID: 1ce9b1c2-ff53-4b8a-984b-08493987398a
                License:

                Users may view, print, copy, and download text and data-mine the content in such documents, for the purposes of academic research, subject always to the full Conditions of use: http://www.nature.com/authors/editorial_policies/license.html#terms

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                Categories
                Subject: Article

                ScienceOpen disciplines: Pediatrics
                Keywords: neonatal abstinence syndrome,neonatal drug withdrawal syndrome,neonatal opioid withdrawal syndrome,opioid pain reliever
                Data availability:
                ScienceOpen disciplines: Pediatrics
                Keywords: neonatal abstinence syndrome, neonatal drug withdrawal syndrome, neonatal opioid withdrawal syndrome, opioid pain reliever

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