Neonatal Abstinence Syndrome in Tennessee Tara Sturdivant, MD East TN Regional Health Office

Objectives Describe the burden of NAS in Tennessee Identify state-level initiatives aimed at preventing NAS Identify East Region specific initiatives aimed at preventing NAS

Prenatal Drug Exposure Apparently “normal” Neonatal Abstinence Syndrome (NAS) Fetal Alcohol Syndrome Neurological abnormalities Prematurity Low birth weight Etc Infant with recognizable syndrome or signs “Drug Exposed” Tobacco Illicit Drugs Prescription Drugs Alcohol Etc… Pregnant women who use potentially harmful substances All pregnant women

NAS Hospitalizations in TN: 1999-2012 Data sources: Tennessee Department of Health; Office of Health Statistics; Hospital Discharge Data System (HDDS) and Birth Statistical System. Analysis includes inpatient hospitalizations with age less than 1 and any diagnosis of drug withdrawal syndrome of newborn (ICD-9-CM 779.5). HDDS records may contain up to 18 diagnoses. Infants were included if any of these diagnosis fields were coded 779.5.

Opioid Prescription Rates by County—TN, 2007-2011 2008 2009 2010 2011 Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.

2010 Controlled Substance Prescriptions 51 pills per every Tennessean over age 12 275.5 Million Hydrocodone Pills 22 pills per every Tennessean over age 12 116.6 Million Xanax Pills In 2010, the top three most prescribed controlled substances in Tennessee were: Hydrocodone, at 275.5 million pills, or 51 pills per every Tennessean over age of 12. Alprazolam, or Xanax, at 116.6 million pills or 22 pills per every Tennessean over age of 12 and Oxycodone, at 113.5 million, or 21 pills for every Tennessean over age of 12 21 pills per every Tennessean over age 12 113.5 Million Oxycodone Pills Data source: Tennessee Department of Health; Controlled Substance Monitoring Database.

Narcotics and Contraceptive Use: TennCare Women, CY2012* Demographics TennCare Women Women Prescribed Narcotics (>30 days supplied) Narcotic Users Rate per 1,000 Women Prescribed Contraceptives and Narcotics % of Women on Narcotics and Contraceptives Women Prescribed Narcotics without Contraceptives % of Women on Narcotics Not on Contraceptives All Women 296,687 42,082 141.8 7.538 18% 34,544 82% 15 - 20 84,398 2,054 24.3 987 48% 1,067 52% 21 - 24 44,620 3,897 87.3 1,432 37% 2,465 63% 25 - 29 53,333 8,689 162.9 2,199 25% 6,490 75% 30 - 34 48,912 10,442 213.5 1,699 16% 8,743 84% 35 - 39 37,483 9,319 248.6 805 9% 8,514 91% 40 - 44 27,940 7,681 274.9 416 5% 7,265 95% Data source: Division of Health Care Finance and Administration, Bureau of TennCare. *CY2012 data is provisional.

Unintended Pregnancy Among All Women & Opioid Abusers Data source: For general population: Tennessee Department of Health. Pregnancy Risk Assessment Monitoring System, 2009 Summary Report. Available at: http://hit.state.tn.us/Reports/HealthResearch/PregancyRisk2009.pdf . For opioid-abusing women: Heil SH et al. Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse Treatment. 2011. March; 40(2): 199-202.

TennCare Paid Live Births1 TennCare NAS Costs, CY2012* Metric TennCare Paid Live Births1 Non-NAS Infants NAS Infants Number of Births 42,171 41,435 736 Cost for infants in first year of life $352,516,166 $306,645,756 $45,870,410 Average cost per child $8,359 $7,401 $62,324 Average length of stay (days) 3.5 3.1 26.2 Data source: Division of Health Care Finance and Administration, Bureau of TennCare. *CY2012 data is provisional. 1. This sample contains only children that were directly matched to TennCare’s records based on Social Security Number.

Drug Dependent Newborns (Neonatal Abstinence Syndrome) Surveillance Summary For the Week of August 24 – August 30, 20141 Reporting Summary (Year-to-date) Cases Reported: 626 Male: 330 Female: 296 Unique Hospitals Reporting: 49 Maternal County of Residence (By Health Department Region) # Cases % Cases2 Davidson 31 5.0 East 179 28.6 Hamilton 7 1.1 Jackson/Madison 2 0.3 Knox 70 11.2 Mid-Cumberland 58 9.3 North East 89 14.2 Shelby 27 4.3 South Central 20 3.2 South East 10 1.6 Sullivan 43 6.9 Upper Cumberland 71 11.3 West 19 3.0 Total 626 100.0% Source of Maternal Substance (if known)2 # Cases3 % Cases Supervised replacement therapy 335 53.5 Supervised pain therapy 77 12.3 Therapy for psychiatric or neurological condition 41 6.6 Prescription substance obtained WITHOUT a prescription 259 41.4 Non-prescription substance 136 21.7 No known exposure but clinical signs consistent with NAS 2 0.3 No response 13 2.1 1. Summary reports are archived weekly at: http://health.tn.gov/MCH/NAS/NAS_Summary_Archive.shtml 2. Total percentage may not equal 100.0% due to rounding. 3. Multiple maternal substances may be reported; therefore the total number of cases in this table may not match the total number of cases reported.

NAS Reported Cases Exposure Sources (2013) Substance exposure unknown 3.5% Only substances prescribed to mother 41.7% 63.3% Only illicit or diverted substances 33.2% Mix of prescribed and non-prescribed substances 21.6%

2013 NAS Rate by Region Region NAS Cases Births* Rate (per 1,000 births) Davidson 35 9,889 3.5 East 268 7,795 34.4 Hamilton 17 4,139 4.1 Jackson/Madison 2 1,252 1.6 Knox 102 5,100 20.0 Mid-Cumberland 58 14,748 3.9 Northeast 138 3,321 41.6 Shelby 24 13,647 1.8 South Central 29 4,415 6.6 Southeast 12 3,663 3.3 Sullivan 86 1,571 54.7 Upper Cumberland 117 3,790 30.9 West 33 5,900 5.6 TOTAL 921 79,230 11.6 *Provisional count of births, 2013

The Levels of Prevention PRIMARY Prevention SECONDARY Prevention TERTIARY Prevention Definition An intervention implemented before there is evidence of a disease or injury An intervention implemented after a disease has begun, but before it is symptomatic. An intervention implemented after a disease or injury is established Intent Reduce or eliminate causative risk factors (risk reduction) Early identification (through screening) and treatment Prevent sequelae (stop bad things from getting worse) NAS Example Prevent addiction from occurring Prevent pregnancy Screen pregnant women for substance use during prenatal visits and refer for treatment Treat addicted women Treat babies with NAS Adapted from: Centers for Disease Control and Prevention. A Framework for Assessing the Effectiveness of Disease and Injury Prevention. MMWR. 1992; 41(RR-3); 001. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00016403.htm

Request for Black Box Warning

TennCare Prior Authorization Form Form available at: https://tnm.providerportal.sxc.com/rxclaim/TNM/TC%20PA%20Request%20Form%20(Long%20Acting%20Narcotics).pdf

Controlled Substance Monitoring Database Prescription Safety Act of 2012 TCA 53-10-300 Required prescribers to register “Shall check” provision CSMD Successes: 4.5M searches (240% increase from 2012) 50% decrease in doctor shopping Change in provider behavior: 71% have changed tx plan after viewing CSMD report 73% more likely to discuss substance abuse issues or concerns with a patient Report available at: http://health.tn.gov/statistics/Legislative_Reports_PDF/CSMD_AnnualReport_2014.pdf

Additional Legislative Actions Safe Harbor Act (TCA 33-10-104, 2013) Pregnant women get priority for treatment Child cannot be removed solely due to maternal substance use if treatment initiated by 20 weeks gestation HB1427/SB1631 (Signed by Governor 4/4/2014) Authorizes licensed practitioners to prescribe opioid antagonist to person at risk of overdose (or family member, friend or other person in position to assist) Immunity for prescribers and for people who administer antagonist

Additional Legislative Actions HB1295/SB1391 (2014) Mother can be prosecuted for misdemeanor if mother illegally uses narcotic drug and child born “addicted or harmed” Addiction recovery program is affirmative defense Two year sunset

Drug Drop-Off/Take Back TDH partnered with Department of Environment & Conservation to place 92 drop-off boxes across Tennessee Funded in part with CDC Core Violence and Injury Grant funds (TDH) Local “Take Back Days” 23 locations in 2013 Department of Mental Health and Substance Abuse Services Partnership w/ county substance abuse coalitions

SBIRT Pilot Screening, Brief Intervention, and Referral to Treatment (SBIRT) Partnership with Department of Mental Health and Substance Abuse Services SAMHSA Center for Substance Abuse Treatment, State SBIRT Grant Putnam County HD Pilot Family Planning and Primary Care patients Partnership with local mental health provider to facilitate referrals Billable through TennCare

Collaborative Research Projects 5 grants awarded to collaborative research partnerships Address key NAS research questions Answerable: With TN data and expertise Within one year Funded with MCH Block Grant funds and Medicaid Infant Mortality/Women’s Health grant

Additional Activities TDH: Pilot w/ Families Free (Johnson City) Recovery support and wraparound services for mothers delivering NAS infants Funded with mix of MCH Block Grant and Medicaid Infant Mortality/Women’s Health grant DCS: Hospital Liaison (Connie Gardner) Coordinate efforts between hospital and regional DCS staff TIPQC: Reducing NAS Length of Stay Perinatal Quality Collaborative Kickoff in February 2013 with 15 hospitals

LARC Clinics Long-Acting Reversible Contraceptives (LARCs) Progestin-only or non-hormonal implants Nexplanon Mirena Paragard Placeable/Removable during in-office procedure

LARC Clinics Selected two counties (Cocke and Sevier) having 25.8% of the total East Region NAS cases as pilot sites and began implementation in January, 2014 Followed the PDCA (PLAN-DO-CHECK-ACT) continuous improvement cycle after each phase of the implementation to ensure success as other counties begin to replicate and implement the program Securing “buy-in” from local staff Data collection and reporting Process evaluation Revisions for continuous program improvement

LARC Clinics for Inmates Educational presentation and pamphlet developed for inmates risk of NAS associated with using narcotics during pregnancy how to minimize risk of pregnancy through use of LARCs Standardized clinic documentation tools developed Initial Exam and LARC clinics were conducted in the health department to provide services while participants were still incarcerated Collaborated with UT Family Physicians to provide experience for residents to place LARCs

Partnership with Recovery Courts Met with Recovery (Drug) Court Judge personally familiar with NAS and supportive of interventions Incorporating Family Planning and NAS education into sentencing for all defendants who appear before his bench Judge facilitated participation by local Sheriffs and jail staff who transport inmates

Sessions Court Partnership Sessions Court Judges agree to incorporate Family Planning and NAS education into sentencing for all who appear on misdemeanor drug charges

Methadone Clinic Partnership Focus groups of female clinic patients reported difficulty accessing contraception Public Health Nurse staffs off-site family planning clinic at two methadone clinics in Knox County Provides long acting progestin-only contraceptive injection by protocol for clinic patients Plan to incorporate contraception into all treatment plans by methadone clinic was challenged by DMHSA based on concerns about scope of practice regulations

Pain Clinic Detailing Medical Director and Epidemiologist visit each registered pain clinic Review Epidemiology of NAS TennCare data regarding contraceptive use among female long term opiate users TDH Chronic Pain Management Guidelines Medical malpractice statutory limitations women who deliver infants diagnosed with NAS = one year infants diagnosed with NAS = age of majority plus one year

Pain Clinic Detailing, cont. Assess clinic’s screening practices Female clients’ current contraceptive practices Pregnancy status Provide pain clinic with TDH’s protocol for administering Depo-Provera, as well as pricing information

Successes? Still measuring scope of problem NAS only became reportable in 2013 Associated data reporting catching up Local initiatives should target problem Local input in design Focus groups Local judiciary and law enforcement Community health programs Practice-based solutions Outcomes to be determined still…