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

2. 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

3. 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

4. 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

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

6. 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 million pills, or 51 pills per every Tennessean over age of 12.
Alprazolam, or Xanax, at million pills or 22 pills per every Tennessean over age of 12 and
Oxycodone, at 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.

7. 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%
84,398
2,054
24.3
987
48%
1,067
52%
44,620
3,897
87.3
1,432
37%
2,465
63%
53,333
8,689
162.9
2,199
25%
6,490
75%
48,912
10,442
213.5
1,699
16%
8,743
84%
37,483
9,319
248.6
805 9%
8,514
91%
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.

8. 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: For opioid-abusing women: Heil SH et al. Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse Treatment March; 40(2):

9. 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.

10. 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:
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.

11. 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%

12. 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

13. 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 ; 41(RR-3); Available at:

14. Request for Black Box Warning

16. TennCare Prior Authorization Form
Form available at:

17. Controlled Substance Monitoring Database
Prescription Safety Act of 2012
TCA
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:

18. Additional Legislative Actions
Safe Harbor Act (TCA , 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

19. 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

20. 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

21. 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

22. 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

23. 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

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

25. 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

26. 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

27. 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

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

29. 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

30. 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

31. 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

32. 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…