Neonatal Abstinence Syndrome Presentation to Drug Demand Reduction Advisory Committee March 13, 2014 Natalie Furdek, M.Ed., LPC Lead Program Specialist Mental Health and Substance Abuse Division Texas Department of State Health Services

Overview Neonatal Abstinence Syndrome (NAS) may be diagnosed in newborns when the mother is physically dependent (and therefore the newborn is born dependent) on substances of abuse at the time of birth. This diagnosis may result from any substance that produces a withdrawal syndrome, but primarily occurs when the mother is dependent upon opioids or opiates. The incidence of NAS has tripled in the United States over the past decade, largely due to the prescription painkiller epidemic.

NAS Clinical Symptoms Neurological Irritability Increased wakefulness High-pitched cry Tremor Increased muscle tone Hyperactive deep tendon reflexes Frequent yawning Sneezing Seizures Gastrointestinal Vomiting Diarrhea Dehydration Poor weight gain Poor feeding Uncoordinated and constant sucking Autonomic Diaphoresis (profuse sweating) Nasal stuffiness Fever Mottling Temperature instability Piloerection (goose bumps) Mild elevations in respiratory rate and blood pressure Mothers will need additional support with breastfeeding due to uncoordinated suck and breathing through nose

Treatment During Pregnancy The American Congress of Obstetrics and Gynecology (ACOG) and the American Society of Addiction Medicine (ASAM) recommend methadone or buprenorphine treatment for pregnant women who are dependent on heroin/analgesics. Withdrawal of the mother to an abstinent state is not recommended, as withdrawal from opioids and opiates may lead to serious complications with the pregnancy, including death of the fetus. Mothers treated with methadone or buprenorphine may have newborns that experience NAS; however, these mothers also have improved pregnancy outcomes and reduced risk behaviors.

NAS Treatment for Newborn Pharmacologic Morphine Phenobarbital Methadone Clonidine Tincture of Opium Buprenorphine Non-Pharmacologic Swaddling Vertical/elevator rocking Limiting sensory or environmental stimulation Skin to skin contact (Kangaroo Care) C positioning Clapping Pacifier use Breast milk feedings when appropriate can help reduce the need for pharmacological intervention Mothers will need additional support with breastfeeding due to uncoordinated suck and breathing through nose

NAS in Texas – statewide Data from the Texas Inpatient Public Use Data File (PUDF) indicate that the number of NAS cases (and associated charges) in Texas is rising. This data source includes hospital discharge data only; however it incorporates all funding sources associated with those data. Each year, approximately 75% of claims were to Medicaid (between 71.7% and 76.6%). It should be noted that preliminary Health and Human Services Commission (HHSC) Medicaid claims data indicate that many more newborns are diagnosed with NAS in an outpatient or clinic setting and the charges for those cases are not included below. Year Count Estimated Annual Charges Average Charge/Newborn Highest Charge For One Newborn 2007 536 $95,761,224 $178,659 $1,858,751 2008 616 $74,976,440 $121,715 $3,221,860 2009 678 $77,181,486 $113,837 $3,583,350 2010 713 $104,511,540 $146,580 $2,955,997 2011 852 $137,396,928 $161,264 $4,546,990

NAS in Texas – areas of concern The hospital discharge data also reveal that there are parts of Texas with unusually high numbers and charges (particularly Bexar, Dallas, and Harris Counties).   Locations of Highest Incidence: Locations of Highest Mean Charges: Year County 1 County 2 County 3 2007 % of cases Mean Charge Bexar (37.8%) $90,831 Dallas (12.1%) $50,178 Harris (10.0%) $101,319 Travis (5.0%) $216,354 Nueces (4.1%) $201.682 El Paso (1.2%) $131,839 2008 % of cases Mean Charge (37.6%) $85,833 (9.0%) $98,607 (8.7%) $87,031 (4.7%) $442,563 Collin (1.5%) $328,041 (2.0%) $321,974 2009 % of cases Mean Charge (36.3%) $100,122 (9.7%) $100,401 (9.1%) $87.279 (3.8%) $295,862 (5.8%) $266,599 Webb (1.5%) $265.517 2010 % of cases Mean Charge (32.2%) $104,987 (10.7%) $158,893 (9.2%) $107.031 (3.8%) $365,935 Ector (1.2%) $361,739 Denton (1.6%) $334,434 2011 % of cases Mean Charge (34.8%) $133,735 (9.3%) $135,570 (9.3%) $226,967 (3.3%) $319,004 (2.4%) $235,984 (9.3%) $226,967

What is being done now by DSHS? Substance abuse treatment services, including Opioid Substitution Therapy (OST): Pregnant women are given priority admission to treatment services that are funded by DSHS through state and federal funds.

What is being done now by DSHS? HHSC also funds treatment services through Medicaid but there is not a requirement to prioritize admissions for pregnant women due to the nature of the funding structure. The “San Antonio” Collaborative Model Collaboration between substance abuse treatment provider and hospital. Pre-delivery education provided to expectant mothers taking methadone and buprenorphine during pregnancy. Post-delivery support for caring for newborn experiencing NAS. 24-hour access to support from a specialized patient advocate.

What else can be done in Texas? Make NAS a “notifiable condition” and require reporting to DSHS on the substance the mother was using that caused the NAS. This will allow for more active surveillance of NAS and timelier implementation of interventions in the future. This is recommendation by the Association of State and Territorial Health Officials (ASTHO). Tennessee has implemented this system and now has access to more accurate data for targeting interventions. Currently, Texas has access to hospital discharge data and Medicaid billing data – neither of which can provide sufficient detail on the underlying substance.

What else can be done in Texas?

What else can be done in Texas?

What else can be done in Texas? Require Medicaid authorization for prescription opiates/opioids that would ensure women of child bearing age are counseled on the risks of use during pregnancy and are given the opportunity to receive contraception. Ensure that all licensed obstetricians and gynecologists serving Medicaid clients receive specific information concerning screening for substance abuse. treatment course recommendations for pregnant women using opiates/opioids. community resources for substance abuse treatment and intervention services and how to access them.

What else can be done in Texas? Advocate for black box warning on all opiate/opioid medications that warn of the risk of use during pregnancy. Coordinate with the Texas Department of Public Safety’s controlled substance program to help ensure physician compliance and target needed interventions.

Conclusion Addressing the problem of Neonatal Abstinence in Texas will require Cross-system collaboration (medical, behavioral health, regulatory, law enforcement). Access to timely surveillance data. Screening and prevention efforts with women of childbearing age. Timely and appropriate treatment services for pregnant women using opioids and opiates. Education for health care providers and supports for families to ensure newborns born with NAS receive appropriate care.

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