Neonatal Abstinence Syndrome Cases Research Articles

Assessment of risk factors for Neonatal Abstinence Syndrome (NAS) using a Standardized Surveillance Case Definition in Clark County, NV

Background: Neonatal Abstinence Syndrome (NAS) is a withdrawal syndrome in neonates that can occur due to drug exposure during pregnancy. This study had two objectives: (1) Assess the implementation of the Council of State and Territorial Epidemiologists (CSTE) Tier 2 case definition for NAS surveillance in Clark County, Nevada and (2) Identify risk factors for NAS. Subjects and Method: This study utilized hospital discharge data. Claim-based records from non-federal acute care hospitals located in Clark County during 2016-2022 were analyzed. All newborn inpatient discharge records from January 1, 2016 to September 30, 2022 in Clark County, Nevada were selected. ICD-10-CM codes were utilized based on the CSTE Tier 2 case definition. Any neonate record that met the case definition, including any record with the diagnosis code P96.1, was considered a NAS confirmed case. Codes for suspect cases, maternal history of substance use, unspecified maternal medication, and transmitted noxious-substances were also assessed. A multiple logistic regression model using backward stepwise selection was developed to find risk factors related to NAS-confirmed births. Results: In Clark County, Nevada, the NAS incidence rate from January 2016 to September 2022 was 7.4 per 1,000 births. In 2022 alone, the rate of NAS was 8.9 per 1,000 births. Estimated rates of NAS were highest among neonates who were White at 13 per 1,000 births. Hospital J, the largest academic medical center in Southern Nevada, had the highest NAS confirmed case rate at 11.3 per 1000 newborn hospitalizations. Results from the multiple logistic regression model showed the odds of being born with NAS among neonates who identified as White were 5.0 (OR=5.17; 95% CI= 4.29 to 6.24; p <0.001) times more likely to have NAS compared to the Hispanic group. Conclusion: Given that 2022 had the highest rate of confirmed NAS cases there is a need to collect substance and diagnosis-specific data about prenatal substance use to identify unmet service care and disparities. Keywords: neonatal abstinence syndrome, opioids, substance dependence. Correspondence: Cassius Lockett. Southern Nevada Health District. 280 S Decatur Blvd, Las Vegas, NV 89107. lockett@snhd.org. 702-759-1691.

Assessment of the Standardized Surveillance Case Definition for Neonatal Abstinence Syndrome by the Council of State and Territorial Epidemiologists, 4 Jurisdictions, 2020-2021

Objectives: In 2019, the Council of State and Territorial Epidemiologists ratified a multitiered standardized surveillance case definition (SSCD) for neonatal abstinence syndrome (NAS) to minimize variability in definitions across states. This evaluation of the tier 1 NAS SSCD aimed to identify common challenges and opportunities for enhancement to support consistent implementation of the definition. Methods: This mixed-methods analysis consisted of 3 virtual focus groups in March 2021 with site principal investigators, medical record abstractors, and data analysts (1 focus group each) from 4 jurisdictions piloting the tier 1 NAS SSCD. We analyzed focus group transcripts to create a codebook. We collected written reports in February 2022 from the 4 jurisdictions, conducted thematic analysis of focus group transcripts and written reports to identify themes, and collected surveillance data on infants identified with NAS born from January 2020 through December 2021 from the pilot sites. We analyzed surveillance data to further inform identified themes. We examined agreement among tier 1 classifications assigned independently by each pilot site and the Centers for Disease Control and Prevention to cases of NAS. Results: Three major themes emerged in the data: challenges abstracting data on withdrawal signs from the medical record, difficulty determining the time frame of prenatal substance exposure, and challenges assigning case classifications. In a comparison of tier 1 classifications assigned by the Centers for Disease Control and Prevention and the sites, 82.1% of cases in the dataset were concordant. Conclusions: We identified several opportunities to modify the SSCD to promote consistency and ease implementation across jurisdictions. Promoting consistent implementation supports comparability of NAS incidence estimates across jurisdictions, evaluation of prevention efforts, and allocation of resources to support families.

Minimizing the Consequences of Neonatal Abstinence Syndrome in the American Indian and Alaska Native Populations of California

The opioid epidemic has had a consequential impact on the health of the infant population as many are born with neonatal abstinence syndrome (NAS). Babies born with NAS suffer from many developmental and physical consequences following prenatal exposure to opioids. Specifically, the American Indian and Alaska Native (AI/AN) populations are disproportionately affected by this in California with significantly higher cases of NAS compared to other racial groups. This research focuses on the consequences of NAS as well as an assessment of the current programs in place to support the AI/AN population. Using a combination of extensive literature review as well as, evaluating sources for the government programs for aiding the AI/AN population with opioid addiction, it is concluded that the current programs are insufficient in providing culturally relevant approaches. Further implementation of more accessible and culturally centered programs for the AI/AN population to decrease the effects of the opioid epidemic are necessary.

Contribution of pharmaceutical drugs of dependence to the incidence of neonatal abstinence syndrome in Western Australia between 2003 and 2018.

Study objectiveThe aim of this study was to examine the incidence of neonatal abstinence syndrome (NAS) in Western Australia (WA) and estimate the contribution of pharmaceutical drugs of dependence (PDD) to NAS.DesignA population‐based birth cohort study.Data sourceNeonates were identified through the Midwives Notification Scheme. Linked medication dispensing and hospital records were used to identify exposure to PDD and NAS diagnosis.PatientsAll live born neonates born in WA between 2003 and 2018.MeasurementsThe incidence of NAS and percentage of NAS diagnoses associated with exposure to PDD.Main resultsDuring the study period, the incidence of NAS did not significantly change (annual percentage change (APC): 0.6, 95%CI: −1.3, 2.6), with 3.8 neonates per 1,000 live births diagnosed with NAS. PDD were dispensed to 41.4% of mothers of neonates with NAS, with PDD used to treat opioid use disorders the most commonly prescribed (35.2% of neonates with NAS), while opioid PDD used in the treatment of pain contributed to 5.2% of NAS cases. Non‐opioid PDD contributed to 1.7% of cases of NAS. The incidence of NAS associated with the use of opioids used to treat opioid use disorders (OUD) decreased over the study period (APC: −6.5, 95%CI: −9.5, −3.4), while NAS associated with opioids used to treat pain remained stable (APC: −2.7, 95%CI: −7.1, 1.9).ConclusionThe incidence of neonatal abstinence syndrome in WA remained stable from 2003 to 2018. Medications used to treat opioid use disorders were a substantial driver of NAS, although NAS associated with these medications has declined over time.

Incidence of Neonatal Abstinence Syndrome (NAS) in Castilla y Leon (Spain).

Introduction: Neonatal Abstinence Syndrome (NAS) is considered a Public Health problem that is defined as a group of symptoms that appear in the newborn due to withdrawal from intrauterine drug exposure. Objective: The aim of this study was to analyze the incidence of NAS in Castilla y León from 2000 to 2019. Methodology: Data of NAS cases in Castilla y León from 2000 to 2019 were obtained. NAS incidence per 1000 births was calculated and the correlation among data from different provinces and years was analyzed. Results: The cumulative incidence of NAS in Castilla y León per 1000 births between 2000-2019 was 0.91‰, with great interprovincial variability. The provinces of Zamora and Palencia stand out, with high incidence rates of NAS despite their low birth rates. The temporal trend points towards a decrease in incidence from 2000 to 2019. Opioids such as methadone, cannabis, benzodiazepines and poly-drug use are the most prevalent drugs causing NAS, and it has also been observed that methadone is being replaced by cannabis as the major cause of NAS cases at the University Hospital in Salamanca in recent years. Conclusions: The incidence of NAS in Castilla y León decreased in 2004 and remained constant until 2019, but it shows great interprovincial variability. It is necessary to implement a national NAS Registry to obtain comprehensive information regarding its incidence.

Racial Misclassification and Disparities in Neonatal Abstinence Syndrome Among American Indians and Alaska Natives.

Maternal substance misuse can result in neonatal abstinence syndrome (NAS), a drug withdrawal process in newborns exposed in utero to drugs. This study aimed to examine the effect of racial misclassification of American Indians and Alaska Natives (AI/AN) on rates of NAS in two hospital discharge datasets in the Pacific Northwest. We conducted probabilistic record linkages between the Northwest Tribal Registry and Oregon and Washington hospital discharge datasets to correct racial misclassification of AI/AN people. We assessed outcomes using International Classification of Disease, Ninth Revision/Tenth Revision, Clinical Modification (ICD-9-CM or ICD-10-CM) diagnosis codes. Linkage increased ascertainment of NAS cases among AI/AN by 8.8% in Oregon and by 18.1% in Washington. AI/AN newborns were 1.5 and 3.9 times more likely to be diagnosed with NAS than NHW newborns in Oregon and Washington, respectively. The results showed that newborns residing in rural Washington were 1.4 times more likely to be diagnosed with NAS than those living in urban areas. Correct racial classification is an important factor in improving data quality for AI/AN populations and establishing accurate surveillance to help address the disproportionate burden of neonatal abstinence syndrome among AI/AN. The results highlight the need for programing efforts tailored by insurance status and rurality for pregnant women using substances.

Incidence of Neonatal Abstinence Syndrome Epidemic and Associated Predictors in Nevada: A Statewide Audit, 2016-2018.

Neonatal abstinence syndrome (NAS) is a postnatal withdrawal syndrome among neonates born to mothers with drug dependence disorders. NAS poses a significant public health challenge nationally, with a six-fold increase in incidence (1.2 to 6.7 per 1000 hospital births/year) from 2000–2016. Besides national data, it is critical to quantify NAS at the state-level to identify target areas for prevention. The objectives of this study were to ascertain statewide burden, including county and regional distribution of NAS in Nevada during 2016–2018, and to investigate potential factors associated with NAS. This study utilized hospital administrative data, and a total of 100,845 inpatient pediatric discharges were examined to identify NAS cases. Statistical analyses included estimation of crude incidence rates per 1000 hospital births and multilevel logistic regression modeling. NAS incidence in Nevada decreased slightly from 8.6 to 7.7 per 1000 hospital births between 2016 and 2018, but the overall incidence of 8 was substantially higher than earlier estimates (4.8/1000 hospital births) reported for 2013. Incidence was disproportionately higher among white newborns (12, 95% CI 11.0,13.0) and Medicaid enrollees (13.2, 95% CI 11.0,15.0). Southern Nevada had the highest incidence rate of 8.2 per 1000 hospital births. Nearly 75% of NAS cases were residents of Clark County. Incidence rates of NAS parallel the growing opioid prescription rates in Nevada and highlight the need for adopting opioid control prescribing practices to combat this drug epidemic. These findings might help in designing and evaluating state- and system-level interventions introduced to combat the opioid epidemic.

The interaction of neonatal abstinence syndrome and opioid use disorder treatment availability for women insured by medicaid.

This paper will discuss the process of mapping opioid use disorder (OUD) treatment resources for pregnant women and discuss the intersection between treatment resources and rates of neonatal abstinence syndrome (NAS). A resource manual was developed through a systematic process with stakeholders across Illinois. Resources were mapped by county and overlaid with county rates of NAS, using hospital discharge data. Across Illinois, 89 treatment resources were identified for pregnant women insured by Medicaid. Resources were concentrated in 36% of Illinois' counties. Counties with limited treatment resources generally had high rates of NAS. Sixty-six percent of NAS cases among rural Illinois residents had no OUD treatment resources in their county. Rural counties had less access to medication-assisted treatment (MAT), the standard of care for treatment of OUD, compared with other counties across the state. Efforts to increase OUD treatment options for pregnant women insured by Medicaid should concentrate on geographic areas with limited access and high need.

Assessing the relationship between neonatal abstinence syndrome and birth defects in Delaware.

Neonatal abstinence syndrome (NAS) is a withdrawal syndrome in newborns and is frequently caused by maternal opioid use during pregnancy. Our study examines whether NAS is associated with birth defects in Delaware. We conducted a retrospective analysis of linked Delaware birth certificate data (BCD), hospital discharge data (HDD), and birth defects registry (BDR) data to examine the association between NAS and birth defects for all hospital births to Delaware residents from 2010 to 2017. Birth defects data were abstracted from medical records from Delaware's BDR. We used International Classification of Diseases Ninth and Tenth Revision Clinical Modification (ICD-9-CM/ICD-10-CM) 779.5 and P96.1 codes to determine NAS using HDD and excluded iatrogenic cases of NAS. We estimated crude and adjusted odds ratio with 95% confidence intervals (CIs). During 2010-2017, there were 2,784 cases of birth defects and 1,651 cases of NAS in Delaware. Among infants with a diagnosis of NAS, 56 also had a birth defect (3.4%), similar to 2,728 birth defects among 79,636 infants without a diagnosis of NAS (3.4%). We found no statistically significant association between an NAS diagnosis and birth defects (adjusted odds ratios = 1.0; 95% CI: 0.8-1.3). Our multiyear state-wide study using linked BCD, HDD, and BDR data for Delaware did not show a statistically significant association between infants diagnosed with NAS and birth defects, overall.

Identification of Substance-Exposed Newborns and Neonatal Abstinence Syndrome Using ICD-10-CM - 15 Hospitals, Massachusetts, 2017.

Opioid use disorder and neonatal abstinence syndrome (NAS) increased in Massachusetts from 1999 to 2013 (1,2). In response, in 2016, the state passed a law requiring birth hospitals to report the number of newborns who were exposed to controlled substances to the Massachusetts Department of Public Health (MDPH)* by mandating monthly reporting of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes related to maternal dependence on opioids (F11.20) or benzodiazepines (F13.20) and to newborns affected by maternal use of drugs of addiction (P04.49) or experiencing withdrawal symptoms from maternal drugs of addiction (P96.1) separately.† MDPH uses these same codes for monthly, real-time crude estimates of NAS and uses P96.1 alone for official NAS state reporting.§ MDPH requested CDC's assistance in evaluating the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of either maternal or newborn codes to identify substance-exposed newborns, and of newborn exposure codes (both exposure [P04.49] or withdrawal [P96.1]) and the newborn code for withdrawal alone (P96.1) to identify infants with NAS cases related to three exposure scenarios: 1) opioids, 2) opioids or benzodiazepines, and 3) any controlled substance. Confirmed diagnoses of substance exposure and NAS abstracted from linked clinical records for 1,123 infants born in 2017 and their birth mothers were considered the diagnostic standard and were compared against hospital-reported ICD-10-CM codes. For identifying substance-exposed newborns across the three exposure scenarios, the newborn exposure codes had higher sensitivity (range=31%-61%) than did maternal drug dependence codes (range=16%-41%), but both sets of codes had high PPV (≥74%). For identifying NAS, for all exposure scenarios, the sensitivity for either newborn code (P04.49 or P96.1) was ≥92% and the PPV was ≥64%; for P96.1 alone the sensitivity was ≥79% and the PPV was ≥92% for all scenarios. Whereas ICD-10-CM codes are effective for NAS surveillance in Massachusetts, they should be applied cautiously for substance-exposed newborn surveillance. Surveillance for substance-exposed newborns using ICD-10-CM codes might be improved by increasing the use of validated substance-use screening tools and standardized facility protocols and improving communication between patients and maternal health and infant health care providers.

Assessing the Burden of Neonatal Abstinence Syndrome: Validation of ICD-9-CM Data, Florida, 2010-2011.

On October 1, 2015, the United States transitioned from using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM. Continuing to monitor the burden of neonatal abstinence syndrome (NAS) after the transition presently requires use of data dependent on ICD-9-CM coding to enable trend analyses. Little has been published on the validation of using ICD-9-CM codes to identify NAS cases. To assess the validity of hospital discharge data (HDD) from selected Florida hospitals for passive NAS surveillance, based on ICD-9-CM codes, which are used to quantify baseline prevalence of NAS. We reviewed infant and maternal data for all births at 3 Florida hospitals from 2010 to 2011. Potential NAS cases included infants with ICD-9-CM discharge codes 779.5 and/or 760.72 in linked administrative data (ie, HDD linked to vital records) or in unlinked HDD and infants identified through review of neonatal intensive care unit admission logs or inpatient pharmacy records. Confirmed infant cases met 3 clinician-proposed criteria. Sensitivity and positive predictive value were calculated to assess validity for the 2 ICD-9-CM codes, individually and combined. Of 157 confirmed cases, 134 with 779.5 and/or 760.72 codes were captured in linked HDD (sensitivity = 85.4%) and 151 in unlinked HDD (sensitivity = 96.2%). Positive predictive value was 74.9% for linked HDD and 75.5% for unlinked HDD. For either HDD types, the single 779.5 code had the highest positive predictive value (86%), lowest number of false positives, and good to excellent sensitivity. Passive surveillance using ICD-9-CM code 779.5 in either linked or unlinked HDD identified NAS cases with reasonable validity. Our work supports the use of ICD-9-CM code 779.5 to assess the baseline prevalence of NAS through 2015.

Prevalence of Maternal-Risk Factors Related to Neonatal Abstinence Syndrome in a Commercial Claims Database: 2011-2015.

Despite the rising incidence of neonatal abstinence syndrome (NAS), data evaluating trends in maternal risk factors associated with NAS have not been available for recent years, a period characterized by declining opioid prescriptions. The objective of this study was to examine the prevalence of opioid- and non-opioid-related factors associated with NAS, and by mutually exclusive subgroups of deliveries without prescription-opioid use, with prescription-opioid use, and with opioid-use disorder (OUD). A cohort of pregnancies resulting in live births in a commercial claims data base in 2011-2015 was identified. Examples of maternal risk factors of interest included antepartum prescription-drug use (e.g., opioids, selective serotonin reuptake inhibitors [SSRIs], antipsychotics) and nonprescription-related factors (e.g., smoking, OUD). A total of 659 cases of NAS among 621,940 deliveries was identified. Among NAS deliveries, prescription opioids were the most commonly used drug-class (39.0%). Adjusted relative risk (RR) for NAS was 5.43 (95% confidence interval [CI] 4.25-6.95), followed by SSRIs (20.9%; RR 3.16, CI 2.43-4.11); OUD was noted in 36.3% of the deliveries (RR 40.74, CI 22.64-73.32). In the subgroup of deliveries without a prescription opioid (33% of overall NAS deliveries), the absolute incidence of NAS was low (0.3 cases/1000 deliveries), and SSRIs were the most commonly used medication class (32.7%; RR 10.21, CI 7.28-14.31). In the subgroup of deliveries with an opioid prescription, the absolute incidence of NAS was 7.7/1000 (29% of all overall NAS deliveries), and 22.7% of these deliveries were exposed to one other psychotropic agent in addition to the opioid, most commonly an SSRI (18.0%). In the subgroup of deliveries with a diagnosis of OUD, the NAS incidence was high (214.3/1000 [36% of all NAS cases]). A third of NAS deliveries did not have evidence of prescription opioids. Other psychotropic medications, especially SSRIs, were strong predictors of NAS in this stratum but had no relevance among deliveries with OUD, suggesting varying etiologies and the need for tailored preventive approaches to reduce NAS effectively.

Surveillance, Epidemiology, and Estimated Burden of Neonatal Abstinence Syndrome, Tennessee, 2013-2016.

Between 2003 and 2013, the rate of neonatal abstinence syndrome (NAS)-a postnatal drug withdrawal syndrome-in Tennessee increased approximately 10-fold. NAS surveillance is relatively new, and underestimation associated with surveillance has not been described. We compared data from the Tennessee NAS public health surveillance system (TNSS) with a second source of NAS data, hospital discharge data system (HDDS), and estimated the true number of infants with NAS using capture-recapture methods. We obtained NAS data on cases of NAS among Tennessee infants from TNSS and HDDS from January 1, 2013, through December 31, 2016. We matched cases of NAS identified in TNSS to cases identified in HDDS. We estimated the true number of infants with NAS by using the Lincoln-Peterson estimator capture-recapture methodology. During the study period, 4070 infants with NAS were reported to TNSS, and 5321 infants with NAS were identified in HDDS; 2757 were in both data sets. Using capture-recapture methods, the total estimated number of infants with NAS during the study period was 7855 (annual mean = 1972; estimated range = 1531-2427), which was 93% more than in TNSS and 48% more than in HDDS. Drugs used for the medication-assisted treatment of substance use disorder were the most commonly reported substances associated with NAS (n = 2389, 59%). TNSS underestimated the total burden of NAS based on the capture-recapture estimate. Case-based public health surveillance is important for monitoring the burden of and risk factors for NAS and helping guide public health interventions.

Increased Severity of Neonatal Abstinence Syndrome Associated With Concomitant Antenatal Opioid and Benzodiazepine Exposure.

Polysubstance use is common among opioid-using women, yet its association with pharmacotherapy for neonatal abstinence syndrome (NAS) remains unclear. We hypothesized that benzodiazepine exposure would increase risk of an infant developing pharmacologically treated NAS. We conducted a retrospective cohort study of maternal-infant dyads enrolled in Tennessee Medicaid, using individual-level data linkage of vital records and administrative (ie, outpatient, inpatient, and prescription) data from 2009 to 2011. These data underwent chart review from 2013 to 2016 to obtain clinically relevant exposure data (eg, toxicology testing). The association of antenatal exposures with pharmacologically treated NAS was evaluated by using multivariable logistic regression, controlling for maternal and infant factors and clustered by hospital. Among 112 029 maternal-infant dyads, we confirmed 822 cases of NAS, of which 598 (72.7%) were cases of pharmacologically treated NAS. Infants who developed pharmacologically treated NAS were more likely to have been exposed to antenatal benzodiazepines compared with infants with confirmed NAS not treated pharmacologically (40.9% vs 30.8%; P = .008). In adjusted analyses, benzodiazepine exposure was associated with greater risk of developing pharmacologically treated NAS (odds ratio: 1.51; 95% confidence interval: 1.04-2.21). Alternatively, exposure to tobacco, marijuana, cocaine, gabapentin, and selective serotonin reuptake inhibitors were not associated with increased risk of developing pharmacologically treated NAS. Among a population of infants with intrauterine polysubstance exposure, benzodiazepine exposure was an independent predictor of an infant developing pharmacologically treated NAS. Obtaining history of antenatal benzodiazepine exposure among opioid-exposed infants may allow for risk stratification and development of personalized care plans.

Expanding Contraceptive Access for Women With Substance Use Disorders: Partnerships Between Public Health Departments and County Jails.

Law enforcement has been the primary strategy for addressing the opioid epidemic. As a result, the incarceration rate for women in county jails has increased more than 800% since 1980, and most women inmates struggle with substance use disorders. There is a large unmet need for contraception among women in county jails. The East Region of the Tennessee Department of Health partnered with county correctional facilities to provide comprehensive family planning education and voluntary long-acting reversible contraception (LARC) to women in 15 jails. Incarcerated women were invited to attend a comprehensive family planning education session conducted in the jail by health department nurses. The sessions included information on neonatal abstinence syndrome. The nurses explained that the women could receive intrauterine devices, implants, and injectable progesterone while incarcerated and come to the health department for all contraceptive methods upon release. Between January 2014 and June 2017, nurses conducted 182 education sessions, and 794 women received a LARC. Method placement occurred in the jails or at the local health department. No adverse effects were known to have occurred. We collected pilot data to explore the accuracy and the comprehensiveness of the family planning education session and whether the incarcerated women experienced the program as voluntary. All 18 women inmates interviewed reported experiencing the program as voluntary. Using published and administrative data, we roughly estimated that the program prevented between 270 and 460 unintended pregnancies and between 40 and 52 cases of neonatal abstinence syndrome in the first year after the women received a method. This represents a cost savings to Medicaid of $1.4 million. The partnership demonstrated the feasibility of providing voluntary comprehensive family planning education and access to highly effective contraception for women inmates who, as a group, face a host of political, socioeconomic, and personal barriers to reproductive health care.

Neonatal Abstinence Syndrome Linked to Unemployment, Mental Health Shortages

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessNeonatal Abstinence Syndrome Linked to Unemployment, Mental Health ShortagesTerri D’ArrigoTerri D’ArrigoSearch for more papers by this authorPublished Online:5 Apr 2019https://doi.org/10.1176/appi.pn.2019.3a39AbstractFrom 2009 to 2015, the median rate of neonatal abstinence syndrome in the United States jumped from 3.2 per 1,000 hospital births to 14.5 per 1,000 hospital births.U.S. counties with higher 10-year unemployment rates and greater shortages of mental health professionals have the highest rates of neonatal abstinence syndrome (NAS), a study published in JAMA has found. Neonatal abstinence syndrome occurs when newborns experience withdrawal from drugs they were exposed to in the womb.Stephen W. Patrick, M.D., M.P.H., M.S., an assistant professor of pediatrics and health policy in the Department of Pediatrics at Vanderbilt University School of Medicine, and colleagues studied outcome data from more than 6.3 million births in eight states from 2009 to 2015. These states were Florida, Kentucky, Massachusetts, Michigan, New York, North Carolina, Tennessee, and Washington. They also analyzed economic data from these states from 2000 to 2015, including unemployment rates, designation as a health professional shortage area, and designation as a mental health clinician shortage area.The researchers found that between 2009 and 2015 the overall median rate of neonatal abstinence syndrome rose from 3.2 per 1,000 hospital births to 14.5 per 1,000 hospital births. However, neonatal abstinence syndrome clustered in areas with high 10-year unemployment rates, such as rural Appalachia, southeastern Massachusetts, northern Michigan, and southwestern Washington. Per 1,000 hospital births, there were 20.1 cases of neonatal abstinence syndrome in counties in the highest quartile of unemployment compared with 7.8 cases of neonatal abstinence syndrome in counties in the lowest quartile of unemployment.Study co-author Bradley D. Stein, M.D., Ph.D., a senior physician policy researcher at RAND Corporation, noted how long-term unemployment chips away at social support, particularly in rural areas.“If friends and family are unable to find jobs, they often move away, so [those who remain] don’t have social support that can protect against drug use,” Stein told Psychiatric News.Stein called for economic development and other social support programs that can reinvigorate rural communities where jobs have disappeared.“Oftentimes we don’t think of these things as health interventions, but those types of investments may pay off in the improved health of a community. We can’t ignore that the opioid crisis occurs in a social context. Health care infrastructure and societal factors both matter,” Stein said.Although the researchers did not find a link between neonatal abstinence syndrome rates and shortages of primary care professionals, they did find an association between mental health clinician shortages and neonatal abstinence syndrome. For every 1,000 hospital births, there were 14 cases of NAS in counties with a shortage of mental health clinicians, compared with 10.6 in counties without shortages. Here, the county-to-county differences in NAS rates were most pronounced in urban areas.“While we saw the impact of insufficient mental health providers in urban areas, it also likely matters in rural communities,” Stein explained. “But there may be so few rural communities that have adequate mental health providers that we were unable to detect a statistical difference [from county to county] there.”The increase in neonatal abstinence syndrome rates across the board signals a gap in the care of pregnant women that psychiatrists can help fill, said Stein.“Psychiatrists who are treating pregnant women for anxiety, depression, or another mental health condition should realize that these women are at higher risk for using and misusing opioids. The risk is low, but it’s there, and it should become part of routine assessment and practice.”This study was supported by funding from the National Institute for Healthcare Management Foundation, the National Institute on Drug Abuse, and RAND Health Care. ■“Association Among County-Level Economic Factors, Clinician Supply, Metropolitan or Rural Location, and Neonatal Abstinence Syndrome” can be accessed here. ISSUES NewArchived

Leveraging Existing Birth Defects Surveillance Infrastructure to Build Neonatal Abstinence Syndrome Surveillance Systems - Illinois, New Mexico, and Vermont, 2015-2016.

Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome that can occur following prenatal exposure to opioids (1). NAS surveillance in the United States is based largely on diagnosis codes in hospital discharge data, without validation of these codes or case confirmation. During 2004-2014, reported NAS incidence increased from 1.5 to 8.0 per 1,000 U.S. hospital births (2), based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes identified in hospital discharge data, without case confirmation. However, little is known about how well these codes identify NAS or how the October 1, 2015, transition from ICD-9-CM to the tenth revision of ICD-CM (ICD-10-CM) codes affected estimated NAS incidence. This report describes a pilot project in Illinois, New Mexico, and Vermont to use birth defects surveillance infrastructure to obtain state-level, population-based estimates of NAS incidence among births in 2015 (all three states) and 2016 (Illinois) using hospital discharge records and other sources (varied by state) with case confirmation, and to evaluate the validity of NAS diagnosis codes used by each state. Wide variation in NAS incidence was observed across the three states. In 2015, NAS incidence for Illinois, New Mexico, and Vermont was 3.0, 7.5, and 30.8 per 1,000 births, respectively. Among evaluated diagnosis codes, those with the highest positive predictive values (PPVs) for identifying confirmed cases of NAS, based on a uniform case definition, were drug withdrawal syndrome in a newborn (ICD-9-CM code 779.5; state range=58.6%-80.2%) and drug withdrawal, infant of dependent mother (ICD-10-CM code P96.1; state range=58.5%-80.2%). The methods used to assess NAS incidence in this pilot project might help inform other states' NAS surveillance efforts.

Positive Predictive Value of Administrative Data for Neonatal Abstinence Syndrome.

Neonatal abstinence syndrome (NAS) is a postnatal withdrawal syndrome experienced by some infants with opioid exposure. Hospital administrative data are commonly used for research and surveillance but have not been validated for NAS. Our objectives for this study were to validate the diagnostic codes for NAS and to develop an algorithm to optimize identification. Tennessee Medicaid claims from 2009 to 2011 (primary sample) and 2016 (secondary sample; post-International Classification of Diseases, 10th Revision, Clinical Modification [ICD-10-CM]) were obtained. Cases of NAS were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification code (2009-2011) 779.5 and ICD-10-CM code (2016) P96.1. Medical record review cases were then conducted by 2 physicians using a standardized algorithm, and positive predictive value (PPV) was calculated. Algorithms were developed for optimizing the identification of NAS in administrative data. In our primary sample of 112 029 mother-infant dyads, 950 potential NAS cases were identified from Medicaid claims data and reviewed. Among reviewed records, 863 were confirmed as having NAS (including 628 [66.1%] cases identified as NAS requiring pharmacotherapy, 224 [23.5%] as NAS not requiring pharmacotherapy, and 11 [1.2%] as iatrogenic NAS), and 87 (9.2%) did not meet clinical criteria for NAS. The PPV of the International Classification of Diseases, Ninth Revision, Clinical Modification code for NAS in clinically confirmed NAS was 91% (95% confidence interval: 88.8%-92.5%). Similarly, the PPV for the ICD-10-CM code in the secondary sample was 98.2% (95% confidence interval: 95.4%-99.2%). Algorithms using elements from the Medicaid claims and from length of stay improved PPV. In a large population-based cohort of Medicaid participants, hospital administrative data had a high PPV in identifying cases of clinically diagnosed NAS.

Neonatal Head Circumference in Newborns With Neonatal Abstinence Syndrome.

To compare head circumference (HC) in neonates treated for neonatal abstinence syndrome (NAS) with control neonates without antenatal opioid exposure. Our prospective cohort study ran from April 1, 2014, through December 31, 2016. Newborns treated for NAS delivered from well-dated pregnancies ≥34 weeks' gestation were compared with newborns who were nonopioid exposed and matched for race, parity, mode of delivery, and gestational age. All mothers underwent serial antenatal urine drug testing. A minimum of 754 study participants were needed (377 in each group) to demonstrate an increase in the proportion of newborns with HCs less than or equal to the 10th percentile from 10% in controls to a minimum of 20% in NAS newborns with 90% power. A total of 858 neonates were enrolled (429 NAS cases and 429 controls). Mean HC for cases was 33.04 cm (±1.9 cm) compared with 33.99 cm (±2.0 cm) for controls (P < .0001). Among the 429 NAS cases, the mothers of 372 (87%) were on opioid medication-assisted treatment. For NAS cases, 30.1% (95% confidence interval: 25.8%-34.7%) had an HC less than or equal to the 10th percentile (129 of 429 neonates), and 8.2% (95% confidence interval: 5.8%-11.2%) had an HC less than or equal to the third percentile (35 of 429 neonates). Multivariate analysis was used and determined that only chronic opioid use during gestation resulting in a neonate who was NAS treated was a significant risk factor for the observed smaller HC. Chronic opioid use during pregnancy sufficient to cause NAS was associated with smaller HCs at birth. Most mothers were on opioid agonist medication-assisted treatment, which is currently the recommended treatment option during pregnancy.

Novel Withdrawal Symptoms of a Neonate Prenatally Exposed to a Fentanyl Analog

Neonatal abstinence syndrome (NAS) is a withdrawal syndrome observed in neonates exposed to drugs in utero, typically opioids, which is associated with symptoms affecting the central and autonomic nervous systems and the gastrointestinal system. West Virginia, particularly the southeastern region of the state, has remarkably higher rates of NAS than similar communities. Our facility is increasingly faced with complex cases of NAS caused by in utero exposure to multiple substances. We present a case report of a neonate born to a 25-year-old mother enrolled in a medication-assisted treatment program for substance use disorder who was noncompliant in prenatal care, using multiple substances throughout the pregnancy, including gabapentin and fentanyl. After birth, the neonate began to exhibit unusual withdrawal symptoms including arching, tongue thrusting, and irregular eye movements, which are typically associated with in utero gabapentin exposure. The parents denied consent to treat with gabapentin, the suggested management for these symptoms; thus, a treatment protocol for methadone and clonidine were followed. This case exemplifies the medical and social complexities involved in treating polysubstance exposure-associated NAS.