Rate Of Neonatal Abstinence Syndrome 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.

Cost of Care for Newborns With Neonatal Abstinence Syndrome in a State Medicaid Program

Neonatal abstinence syndrome (NAS) is a medical condition among neonates experiencing substance withdrawal due to the mother's substance use during pregnancy. While previous studies suggest that the overall incidence and annual costs of NAS are increasing, to date, the long-term costs have yet to be demonstrated in Medicaid populations. To examine the demographic differences and long-term costs of care for neonates diagnosed with vs not diagnosed with NAS. This cohort study used claims data from the Alabama Medicaid Agency for neonates born to Medicaid-eligible mothers between January 1, 2010, and December 31, 2020. Data were analyzed in June 2022. A diagnosis of NAS within 30 days of birth. Rate of NAS by demographic and birth characteristics, long-term costs attributable to NAS status and demographic and birth characteristics, and distribution of this expenditure over the enrollment period. A total of 346 259 neonates with Medicaid eligibility were born during the study period (mean [SD] gestational age, 38.4 [2.2] weeks; 50.5%, male), 4027 (1.2%) of whom had an NAS diagnosis within 30 days of birth. A larger percentage of neonates with an NAS diagnosis were male (52.7%) than in the group without NAS (50.5%). Neonates with NAS also weighed less at birth (mean difference, -212.0 g; 95% CI, -231.1 to -192.8 g) and had older mothers (mean difference, 3.4 years; 95% CI, 2.6-4.2 years). An NAS diagnosis had an estimated additional cost of $17 921 (95% CI, $14 830-$21 012) over the enrollment period, and this cost was not evenly distributed over that period. In this cohort study of neonates born into the Alabama Medicaid population, those with an NAS diagnosis had a different demographic profile and a higher cost to state Medicaid agencies than those without NAS. These findings warrant further effort to reduce the occurrence of NAS.

Safety and Efficacy of Buprenorphine-Naloxone in Pregnancy: A Systematic Review of the Literature

The prevalence of opioid use among pregnant people has been increasing over the past few decades, with a parallel increase in the rate of neonatal abstinence syndrome. Opioid agonist treatment (OAT) including methadone and buprenorphine is the recommended management method for opioid use disorders during pregnancy. Methadone has been extensively studied during pregnancy; however, buprenorphine was introduced in the early 2000s with limited data on the use of different preparations during pregnancy. Buprenorphine-naloxone has been incorporated into routine practice; however, only a few studies have investigated the use of this medication during pregnancy. To determine the safety and efficacy of this medication, we conducted a systematic review of maternal and neonatal outcomes among buprenorphine-naloxone-exposed pregnancies. The primary outcomes of interest were birth parameters, congenital anomalies, and severity of neonatal abstinence syndrome. Secondary maternal outcomes included the OAT dose and substance use at delivery. Seven studies met the inclusion criteria. Buprenorphine-naloxone doses ranged between 8 and 20 mg, and there was an associated reduction of opioid use during pregnancy. There were no significant differences in gestational age at delivery, birth parameters, or prevalence of congenital anomalies between buprenorphine-naloxone-exposed neonates and those exposed to methadone, buprenorphine monotherapy, illicit opioids, or no opioids. In studies comparing buprenorphine-naloxone to methadone, there were reduced rates of neonatal abstinence syndrome requiring pharmacotherapy. These studies demonstrate that buprenorphine-naloxone is a safe and effective opioid agonist treatment for pregnant people with OUD. Further large-scale, prospective data collection is required to confirm these findings. Patients and clinicians may be reassured about the use of buprenorphine-naloxone during pregnancy.

Predictors of Length of Stay and Cost of Hospitalization of Neonatal Abstinence Syndrome in the United States.

BackgroundThe incidence rate and economic burden of neonatal abstinence syndrome (NAS) are increasing in the United States (US). We explored the link between the length of stay (LOS) and hospitalization cost for neonatal abstinence syndrome in 2018.MethodsThis was a cross-sectional analysis of the 2018 national inpatient sample database. Newborn hospitalizations with neonatal abstinence syndrome and their accompanying comorbid conditions were identified using the International Classification of Diseases, 10th Edition diagnostic codes. Logistic regression was used to determine the impact of length of stay and the co-morbidities on inflation-adjusted hospital costs.ResultsThe incidence of neonatal abstinence syndrome was 7.1 per 1000 births (95% CI 6.8-7.3) in 2018. The majority had Medicaid (84.1%), with a neonatal abstinence syndrome incidence of 13.2 (95% CI: 12.8-13.6). In adjusted analysis, every one-day increase in length of stay increased the hospital cost by $1,685 (95% CI: 1,639-1,731). Neonatal abstinence syndrome hospitalizations with Medicaid had a longer length of stay by 1.8 days (95% CI: 0.5-3.1). Co-morbidities further increased the length of stay: seizures: 13.8 days; sepsis: 4.1 days; respiratory complications: 4.4 days; and feeding problems: 5.8 days. Those at urban teaching hospitals had a longer length of stay by 7.3 days (95% CI: 5.8-8.8). Co-morbidities increased hospital cost as follows: seizures: $71,380; sepsis: $12,837; respiratory complications: $8,268; feeding problems: $7,737. The cost of hospitalization at large bed-size hospitals and urban teaching was higher by $5,243 and $12,005, respectively.ConclusionThe incidence rate of neonatal abstinence syndrome remained high and was resource-intensive in 2018. Co-morbid conditions and hospitalization at urban teaching hospitals were major contributors to increased length of stay and hospital costs.

Outcomes associated with the use of medications for opioid use disorder during pregnancy.

To test the effect of the duration of medication for opioid use disorder (MOUD) use during pregnancy on maternal, perinatal and neonatal outcomes. Retrospective cohort analysis of claims, encounter and pharmacy data. Pennsylvania, USA. We analyzed 13 320 pregnancies among 10 741 women with opioid use disorder aged 15-44years enrolled in Pennsylvania Medicaid between 2009 and 2017. We examined five outcomes during pregnancy and for 12weeks postpartum: (1) overdose, (2) postpartum MOUD continuation, (3) preterm birth (<37weeks gestation), (4) term low birth weight (<2500g at ≥37weeks) and (5) neonatal abstinence syndrome (NAS). Our primary exposure was the duration (count of weeks) of any MOUD use, including methadone or buprenorphine, during pregnancy. Among 13 320 pregnancies, 306 (2.3%) were complicated by an overdose, 1753 (13.2%) resulted in a preterm birth and 6787 (50.9%) continued MOUD postpartum. Among infants, 874 (7.6%) were low birth weight at term and 7706 (57.9%) were diagnosed with NAS. As the duration of MOUD use increased, we found a statistically significant decrease in the rate of overdose and preterm birth, a statistically significant increase in the rate of postpartum MOUD continuation and NAS and a decline in term low birth weight. Specifically, for each additional week of MOUD, the adjusted odds of overdose decreased by 2% [adjusted odds ratio (aOR)=0.98; 95% confidence interval (CI)=0.97, 0.99], preterm birth decreased by 1% (aOR=0.99; 95% CI=0.99, 1.00), postpartum MOUD continuation increased by 95% (aOR=1.95; 95% CI=1.87, 2.04) and NAS increased by 41% (aOR=1.41; 95% CI=1.35, 1.47). The odds of term low birth weight did not change (aOR=1.00; 95% CI=0.99, 1.00), although the rate declined with a longer duration of MOUD use during pregnancy. Longer duration of medication for opioid use disorder use during pregnancy appears to be associated with improved maternal and perinatal outcomes.

950 Association between capacity for maternal opioid agonist therapy treatment and neonatal abstinence syndrome

To study the association between county capacity for maternal opioid agonist therapy (MOAT) and neonatal abstinence syndrome (NAS) rates in Missouri (MO). This is a retrospective cohort study examining the association between MO county NAS rates, county-level demographics, and MOAT capacity. County MOAT capacity was determined as follows: all providers listed on the Substance Abuse and Mental Health Services Administration website in December 2018 were called, and the number who accept pregnant patients was divided by the number of county births from 2014-2018. MOAT capacity was then categorized as 1) no capacity, 2) low capacity, or 3) high capacity. No capacity indicates no providers in the county prescribe OAT to pregnant women; the remaining counties were halved. Rates of NAS and opioid overdose among women aged 15-45 were provided by the MO Department of Health. County-level demographics were derived from the Area Health Resources Files. Multivariate negative binomial regression was performed to assess for associations between county demographics and NAS rates. Analyses were stratified by opioid overdose rates as a proxy for opioid use disorder prevalence. Overdose rate was divided into tertiles (low, middle, high) for stratification. The rate of NAS was 6.5 per 1,000 live births (Table1). There was a strong correlation between NAS and overdose rates (rho=0.64, p<0.0001). For counties with the highest overdose rates, rural status and higher levels of poverty, manufacturing jobs, and unemployment were associated with increased NAS rates. High capacity MOAT was associated with reduced rates of NAS in counties with low overdose rates. However, in counties with high overdose rates, increasing MOAT capacity was not associated with decreasing NAS rates. Increasing MOAT capacity may lead to reduced NAS in counties with low overdose rates, but it remains insufficient for counties with the highest overdose rates. Study findings suggest an unresolved, critical gap for MOAT treatment in areas with high opioid use disorder prevalence.

Do Maternal Pharmacogenetics Impact the Neonatal Abstinence Syndrome Following In Utero Exposure to Antidepressant Medications?

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the most commonly used medications for mood and anxiety disorders in women. Many women need to continue or initiate these medications during pregnancy, but there is concern about potential withdrawal effects in the newborn, referred to as neonatal abstinence syndrome (NAS). The reason why some infants remain asymptomatic while others are affected has not been elucidated. The objective of this study was to examine whether genetic differences in maternal drug metabolism influence the incidence of NAS. Women who took Selective serotonin reuptake inhibitors s/SNRIs during pregnancy were recruited from obstetrical clinics. DNA was extracted from saliva samples for genetic analyses of cytochrome P450 (CYP) enzyme polymorphisms. Delivery and NAS data were collected from electronic medical records. Ninety-five women participated. The overall NAS rate was 16.2%. Mild NAS was seen in 13.8% of neonates and severe NAS, in 2%. One-quarter (25%) of the neonates with mild withdrawal symptoms were born to mothers with polymorphisms associated with slower metabolism of their particular antidepressant, but this association was not statistically significant. Importantly, the overall rate of NAS in our study was lower than previously reported. Maternal CYP polymorphisms did not affect the rate of NAS in neonates exposed to SSRIs/SNRIs in utero. This study lends added assurance to patients requiring SSRIs or SNRIs during pregnancy.

Impact of Group Prenatal Care on Neonatal Outcomes in Women With Opioid Use Disorder [17O

INTRODUCTION: Opioid use disorder (OUD) is a growing problem that incurs several obstetric risks. The objective of this study was to determine the impact of group prenatal care (PNC) compared to conventional individual PNC on neonatal outcomes in women with OUD. METHODS: This was a retrospective cohort study evaluating a practice change to group PNC from individual PNC in pregnant patients with OUD at the Indiana University Maternal Recovery Program (MRP). IRB committee approval was obtained. Data were collected from pregnant patients at the MRP diagnosed with OUD, with initiation of care &lt;32 weeks gestation, and receiving buprenorphine therapy. Our primary outcomes were the rate of neonatal abstinence syndrome (NAS) treatment requirement and NAS severity. Outcomes were compared between group and individual PNC patients using Student t-tests for continuous variables and chi-square tests for discrete variables. RESULTS: 252 OUD patients presented for PNC at the MRP from September 2015 to August 2017. 104 OUD patients presented for PNC from September 2017 to October 2018, following a practice change to group PNC. Among those meeting inclusion and exclusion criteria (n=304), 76 underwent group PNC and 228 underwent individual PNC. The two groups were similar in maternal demographics, substance use history, delivery characteristics, and antenatal buprenorphine dosing. There was a significant difference in the rate of NAS treatment requirement between the two groups of 40.8% for group PNC, compared to 54.8% for individual PNC (P=.0353). CONCLUSION: Women receiving group PNC for OUD may benefit from improved neonatal outcomes, specifically a decreased rate of NAS treatment requirement.

High Prevalence of Buprenorphine in Prenatal Drug Screens in an Appalachian City.

To define the magnitude of buprenorphine presence in the urine drug screens of pregnant women and to assess the presence of illicit buprenorphine use versus the presence of prescribed buprenorphine use. Initial prenatal drug screen results for all pregnant patients in our practice for a 1-year period were analyzed and tabulated. Buprenorphine was found in the urine drug screens of 16% of pregnant patients. The presence of buprenorphine was by far the highest for any substance associated with neonatal abstinence syndrome (NAS). We estimate that the exposure to buprenorphine of approximately one-third of individuals in our population is associated with illicit buprenorphine use. The high rate of NAS in our region is primarily associated with both illicit and prescribed buprenorphine rather than other substances. Buprenorphine usage at the time that prenatal care is initiated, rather than opiate use at the onset of prenatal care, is the underlying factor that must be addressed if our region is to successfully combat our high rates of NAS.

Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016

This cross-sectional study examines the national incidence rate of neonatal abstinence syndrome using data from the 2016 Healthcare Cost and Utilization Project Kids’ Inpatient Database.

Association Among County-level Economic Factors, Clinician Supply, Metropolitan or Rural Location, and Neonatal Abstinence Syndrome

(JAMA. 2019;321(4):385–393) Opioid use in the United States increased between 1999 and 2014, including opioid analgesics, heroin, and fentanyl. Opioid overdose deaths also increased during this time. From 2000 to 2014, the rate of neonatal abstinence syndrome (NAS) in the United States increased from 1.2 per 1000 hospital births to 80 per 1000 hospital births. The increases in both opioid overdose deaths and the rate of NAS disproportionately affected impoverished rural communities. Opioid-related complications for adults have been associated with poor access to health care, lack of economic opportunity, and diminished social capital, but links between these economic factors and opioid-related outcomes for infants have not yet been evaluated. This study aimed to examine the associations between long-term unemployment, clinician supply, and rates of NAS, while evaluating how these affect rural versus urban communities.

Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study.

To compare maternal and fetal outcomes among dyads prescribed buprenorphine and naloxone or buprenorphine during pregnancy. Retrospective cohort study of patients with opioid use disorder obtaining care in a comprehensive, perinatal program. Patients utilized medication for opioid use disorder: a buprenorphine and naloxone combination product or buprenorphine monotherapy. The primary outcome was neonatal abstinence syndrome requiring treatment. Maternal secondary outcomes included: negative urine drug screen at delivery, obstetrical care attendance, primary cesarean delivery, and preterm delivery. Neonatal secondary outcomes included neonatal biometry, admission to neonatal intensive care, appropriate findings on cord toxicology, and length of stay. Univariate analyses included Chi square, Fisher exact, t-, or Mann-Whitney tests, as appropriate. Multivariate binary logistic regressions examined the association of type of buprenorphine product with diagnosis of neonatal abstinence syndrome requiring treatment and adjusted for variables significantly different in between-group comparisons and correlates of treatments and the primary outcome. The rate of neonatal abstinence syndrome was significantly higher (P = 0.007) among infants exposed in utero to buprenorphine versus buprenorphine and naloxone: 59/108 (54.6%) versus 30/85 (35.3%), respectively. The combined product, relative to the monoproduct, was associated with lower odds of neonatal abstinence syndrome: odds ratio (OR) = 0.453 (95% confidence interval [CI] 0.253-0.813; P = 0.008). Adjusting for dose of buprenorphine product at delivery, year of expected delivery, type of prescriber, diagnosis of hepatitis C, and preterm delivery negated these results: adjusted OR = 0.627 (95% CI 0.309-1.275). Secondary outcomes were similar. Compared with buprenorphine monotherapy, the combined buprenorphine and naloxone product was an acceptable alternative pharmacologic treatment for opioid use disorder during pregnancy.

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.

Use of naltrexone in treating opioid use disorder in pregnancy

The mainstay of the management of opioid use disorder in pregnancy is with methadone or buprenorphine medication-assisted treatment. Methadone and buprenorphine are opioid agonist drugs. Naltrexone, an opioid antagonist, is also a medication-assisted treatment option; however, to date, only a few retrospective studies have reported its use in pregnancy. Our study objective was to evaluate prospectively obstetric and newborn outcomes and the maternal/fetal effects of the use of naltrexone as a medication-assisted treatment in pregnant patients with opioid use disorder. We performed a prospective cohort study collecting data on all pregnant women who were treated with naltrexone medication-assisted treatment compared with pregnant women who were treated with methadone or buprenorphine medication-assisted treatment. Based on a sample size calculation, it was determined that for a power of 90, a minimum of 160 study participants (80 in each group) was needed with an alpha of .01 and an expected 60% rate of newborn infants who were treated for neonatal abstinence syndrome in the methadone or buprenorphine medication-assisted treatment group compared with a 30% rate in the naltrexone medication-assisted treatment group. In a random subset of 20 maternal/newborn dyads, blood levels for naltrexone and 6-beta-naltrexol (an active metabolite) were analyzed at delivery. A total of 230 patients were studied: 121 patients with naltrexone medication-assisted treatment compared with 109 patients with methadone or buprenorphine medication-assisted treatment. No differences between groups were seen regarding demographics, the use of comedications/drugs, or obstetric outcomes. For newborn outcomes, the rate of neonatal abstinence syndrome in neonates >34 weeks gestation was significantly lower in the naltrexone medication-assisted treatment group (10/119 [8.4%] vs 79/105 [75.2%]; P<.0001). Multivariate analysis demonstrated that the only significant factor for the rate of neonatal abstinence syndrome was the form of medication-assisted treatment. Of 87 patients who received naltrexone up to delivery, no neonates experienced symptoms of neonatal abstinence syndrome. No maternal relapses occurred in the 7-day no-treatment window before the initiation of naltrexone therapy. No cases of spontaneous abortion or stillbirth occurred in either group. In 64 patients who started naltrexone therapy at ≥24 weeks gestation, no changes were seen in the fetal heart monitor tracing with drug initiation. The incidence of birth anomalies was no different between the groups. Umbilical cord blood and maternal levels for naltrexone and 6-beta-naltrexol matched; no levels were elevated, and values were undetected if naltrexone was discontinued >60 hours before delivery. These study data demonstrate that, in pregnant women who choose to completely detoxify off opioid drugs during gestation, naltrexone, as a continued form of medication-assisted treatment, is a viable option for some pregnant patients who experience opioid use disorder. Naltrexone crosses the placenta, and maternal and fetal levels are concordant. Because naltrexone clears quickly from the maternal circulation, this rapid clearance needs to be addressed with patients. This is important because maternal relapse could occur in a short time-period if the oral drug is discontinued without the knowledge of their healthcare providers. Nonetheless, the drug is well-tolerated by both mother and fetus, and newborn infants do not experience symptoms of neonatal abstinence syndrome if naltrexone medication-assisted treatment is maintained to delivery.

A longitudinal analysis of temporal and spatial incidence of neonatal abstinence syndrome in Ontario: 2003-2016.

This study describes the incidence of neonatal abstinence syndrome (NAS) in Ontario, Canada by year and health region from 2003 to 2016. The incidence of NAS diagnoses per 1,000 live births was calculated for the 36 local public health agency regions in Ontario from 2003 to 2016 using retrospective hospital admissions data. Infants with a diagnosis of NAS were identified using ICD-10 code P961. Local public health agency level data were aggregated and analyzed by geographic region and by Statistics Canada 2015 Peer Groups. The incidence of NAS in Ontario increased from 0.99 per 1,000 live births in 2003 to 5.94 per 1,000 live births in 2016. There were major differences in NAS incidence by geography, North Western Ontario had the greatest incidence across all years. Health regions with a rural and population center mix or mostly rural population had greater incidence rate of NAS compared to health regions with high density population centers. The incidence of NAS has dramatically increased across Ontario in the last decade. Actions should be taken to combat the continued increase in NAS rates, especially in health regions with disproportionately high incidence of NAS.

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

Association Among County-Level Economic Factors, Clinician Supply, Metropolitan or Rural Location, and Neonatal Abstinence Syndrome

Neonatal abstinence syndrome (NAS) has increased over the last 2 decades, but limited data exist on its association with economic conditions or clinician supply. To determine the association among long-term unemployment, clinician supply (as assessed by primary care and mental health clinician shortage areas), and rates of NAS and evaluate how associations differ based on rurality. Ecological time-series analysis of a retrospective, repeated cross-sectional study using outcome data from all 580 counties in Florida, Kentucky, Massachusetts, Michigan, New York, North Carolina, Tennessee, and Washington from 2009 to 2015 and economic data from 2000 to 2015. Negative binomial models were used with year and county-level fixed effects. Interactions were tested and stratified analyses were conducted by metropolitan counties, rural counties adjacent to metropolitan counties, and rural remote counties. County-level 10-year unemployment rate and mental health and primary care clinician supply obtained from the Health Resources and Services Administration Area Health Resources Files. Rates of NAS, excluding iatrogenic withdrawal, obtained from state inpatient databases. The sample included observations from 580 counties over 7 years (1803 county-years from metropolitan counties, 1268 county-years from rural counties adjacent to metropolitan counties, and 927 county-years from rural remote counties). During the study period, there were 6 302 497 births and 47 224 diagnoses of NAS. The median rate of NAS was 7.1 per 1000 hospital births (interquartile range [IQR], 2.2-15.8), the 10-year unemployment rate was 7.6% (IQR, 6.4%-9.0%), and 83.9% of county-years were partial or complete mental health shortage areas. In the adjusted analyses, mental health shortage areas had higher NAS rates (unadjusted rate in shortage areas of 14.0 per 1000 births vs unadjusted rate in nonshortage areas of 10.6 per 1000 births; adjusted incidence rate ratio [IRR], 1.17 [95% CI, 1.07-1.27]), occurring primarily in metropolitan counties (adjusted IRR, 1.28 [95% CI, 1.16-1.40]; P = .02 for test of equivalence between metropolitan counties and rural counties adjacent to metropolitan counties). There was no significant association between primary care shortage areas and rates of NAS. The 10-year unemployment rate was associated with higher rates of NAS (unadjusted rate in highest unemployment quartile of 20.1 per 1000 births vs 7.8 per 1000 births in lowest unemployment quartile; adjusted IRR, 1.11 [95% CI, 1.00-1.23]) occurring primarily in rural remote counties (adjusted IRR, 1.34 [95% CI, 1.05-1.70]; P = .04 for test of equivalence between metropolitan counties and rural remote counties). In this ecological analysis of counties in 8 US states, there was a significant association among higher long-term unemployment, higher mental health clinician shortage areas, and higher county-level rates of neonatal abstinence syndrome.

Clinical Opinion Letters Regarding Breastfeeding and Neonatal Abstinence Syndrome for Child Apprehension Family Court Proceedings.

The accelerating reach of opioid use disorder in North America includes increasing prevalence among pregnant people. In Canada, the rate of Neonatal Abstinence Syndrome (NAS) rose 27% between 2012-2013 and 2016-2017, and it is estimated that 0.51% of all infants now experience NAS after delivery. Pregnant people are a priority population for access to opioid replacement therapy programs. Participation in such programs demonstrates significant commitment to self-care among pregnant people and concern for fetal and infant wellbeing. Participation in opioid replacement therapy often results in family surveillance by Child Protection Services and infant apprehension. Children of Indigenous descent are held in foster care at high and disproportionate rates.The Convention on the Rights of the Child principle of Best Interests of the Child governs family law and child access decisions. The value of breastfeeding for all children and in particular for children recovering from NAS can be a consideration in the Best Interest of the Child. Clinicians with expertise in lactation may support the breastfeeding dyad to remain together by preparing Clinical Opinion Letters for the court. This Insights into Policy presents a how-to description of the content of clinical opinion letters in such cases, including context and process considerations, client background, breastfeeding science, and factors specific to neonatal abstinence syndrome.

Capturing the statewide incidence of neonatal abstinence syndrome in real time: the West Virginia experience.

Neonatal abstinence syndrome (NAS) is one of the consequences at birth affecting the newborn after discontinuation of prenatal drug exposure to mainly opioids. The objective of this study was to determine the extent of the problem in the state of West Virginia (WV) using a real-time statewide surveillance system. Project WATCH is a surveillance tool that since 1998 collects data on all infants born in the state of WV. NAS surveillance item was added to the tool in October 2016. This study examined all births (N = 23,667) in WV from October to December 2017. The data from six WV birthing facilities were audited for 1 month to evaluate how well this tool was capturing NAS data using κ-statistics. The 2017 annual incidence rate of NAS was 51.3 per 1000 live births per year for all births and 50.6 per 1000 live births per year for WV residents only. The κ-coefficient between the hospital medical records and Project WATCH data was 0.74 (95% confidence interval: 0.66-0.82) for NAS. The study provides justification to develop effective systems of care for the mother-infant dyad affected by substance use, especially targeting pregnant women in rural communities.

Opioid Withdrawal During Pregnancy May Reduce Rates of Neonatal Abstinence Syndrome (NAS) [27E

INTRODUCTION: The incidence of Neonatal Abstinence Syndrome (NAS) has risen dramatically in the United States (U.S) during the past decade paralleling the increase in pregnant patients with opioid dependence. Current U.S. Drug Enforcement Agency (DEA) policy does not support opioid withdrawal during pregnancy. DEA policy and the paucity of Licensed Narcotic Treatment Programs in the U.S. that accept Medicaid payment has led to limited options for opioid-dependent patients who request voluntary withdrawal during pregnancy. METHODS: This pilot study was designed to assess safety and efficacy of voluntary withdrawal using methadone. The study is a prospective cohort comparing patients who enrolled in methadone withdrawal to a cohort of patients who chose to remain in methadone maintenance. RESULTS: 31 pregnant patients were identified with opioid dependency at our institution from 2014 to present (ICDM 10). 15 patients were in the withdrawal program and 16 chose to remain in maintenance. 4 of those in the withdrawal program remain pregnant. One was lost to follow up. The rate of NAS in the methadone maintenance cohort was 33% (5/15). The rate of NAS in the successful withdrawal group was 0% (6/6). The rate of NAS in the failed withdrawal group was 100% (3/3). There was one pregnancy loss in each group. There was a spontaneous abortion in the maintenance group and one perinatal death at 26 weeks in the withdrawal group. CONCLUSION: Successful, supervised opioid withdrawal during pregnancy may reduce rates of Neonatal Abstinence Syndrome as compared to opioid maintenance.