The prevalence of Neonatal Abstinence Syndrome (NAS) in Tennessee has increased more than tenfold in the past decade, and providers and lawmakers alike are taking note. A drug-withdrawal syndrome that most commonly occurs after in-utero exposure to opioids, NAS has been diagnosed in more than 600 Tennessee infants since Jan. 2016.
A Grim Outlook
"In my opinion, (NAS) is the most pitiful thing you'll ever see in medicine," said pediatrician James Batson, MD, board chairman of the Tennessee Medical Association. "Imagine a heroin addict going through withdrawals ... but in a newborn."
Dr. James Batson
Babies born with NAS often scratch themselves, cry excessively, tremble, experience profuse diarrhea and excruciatingly raw bottoms, and can sometimes seize or die. Acute symptoms can last hours or weeks, but babies can experience lifelong cognitive and psychological trauma.
"Kids born with NAS in 2003 are now teens, and we're afraid that they'll take that first try of a drug that's close to what they used to be on, and it will fire up their receptors," Batson cautioned. "Our suspicion is that they'll be very easily addicted."
One in five babies born with NAS will end up in state custody. In addition to the human toll, the problem is taking a financial toll, as well. In 2011, hospital costs to deliver a health baby on TennCare was $7,763, while those born with NAS cost $62,973.
The Rise of NAS
While NAS rates have seemingly plateaued over the past few years, numbers remain staggeringly high compared to the 1990s, when Tennessee hospitals saw less than 50 cases annually. Batson shared recent statistics from the Centers for Disease Control and Prevention that showed the number of babies with opioid withdrawal symptoms quadrupled between 1999 and 2013 across the United States.
Batson attributes the increase to a handful of notable events in the late '90s and early 2000s: A movement in medicine claimed that providers were under-treating pain because they were too afraid of addiction, and pharmaceutical companies began pushing long-term pain control as a "safe" option.
In 2001 Tennessee also enacted the Intractable Pain Act, a.k.a. the "Pain Patient's Bill of Rights." The law gave patients the option to treat their pain with opiate painkillers if other forms of treatment did not work and required doctors to inform the patient of providers who would prescribe opiates if he or she was unwilling to do so. State legislators repealed the law in 2015, at a time when the number of NAS births hit 1,600 annually.
The Surprising Face of Addiction
If your vision of a NAS birth mom is a back alley heroin user, think again. Michael D. Warren, MD, assistant commissioner of the Tennessee Department of Health, said nearly 72 percent of NAS cases in 2015 involved mothers using at least one substance provided by their healthcare provider.
"If you look broadly at national trends, we have a higher NAS rate compared to the rest of the country, but it's not surprising when you look at our rate of opioid dispensing," Warren explained. "The two problems are linked."
That means providers must constantly be thinking about how they screen for substance abuse. "We have to be systematic and screen everyone regardless of race, ethnicity or education," Warren said. "Addiction is pervasive."
He encouraged providers to consider physical therapy or over-the-counter pain relievers for non-malignant pain and to constantly check the state's drug database, designed to monitor the dispensing of controlled substances including opioids.
In 2012, a NAS subcabinet was formed with the help of officials from numerous state agencies. Unfortunately, they were relying on hospital discharge data with a 12 to 15 month lag when they needed to see problems - and improvements - in real time. However, in January 2013, Tennessee became the first state to make NAS a reportable condition and created a website to track real time NAS births.
Hospitals now provide data used to create weekly and monthly NAS surveillance that includes a year-to-date reporting summary, the maternal county of residence and source of exposure. The subcabinet also petitioned the FDA for black box warnings on extended and long-lasting opioids, with the goal of starting patient-provider conversations about risks, pregnancy and contraception.
"It allows providers to say to patients, 'This is really important,' and gives consumers that information as well," Warren said. "Sometimes perception is that if a doctor provides something it must be safe."
The group has also addressed the TennCare opioid authorization process and continues to look at systems of care. "Families of NAS infants frequently engage multiple state agencies, and each department is looking for ways to better serve families more efficiently," Warren said.
Under Tennessee's Safe Harbor Act, expectant mothers get priority for substance abuse treatment in hopes of keeping mother and baby together after childbirth. But for many women, danger still abounds after recovery. Addicted family members, unstable housing and unemployment are just some of the broader issues families face.
"How do we support the family after the baby is discharged?" Warren asked. "The baby may be medically okay, but there are social issues around addiction that don't go away."
Primary Care & Prevention
Getting in front of the problem means preventing substance abuse disorders in women of childbearing age and helping addicted women prevent unintended pregnancy. Among women who abuse opioids, 86 percent of pregnancies are unintended. "We're fortunate to have NICUs, but if all we do is treat babies who are sick, it's like catching water out of a hydrant," Warren said. "To address this, we have to move upstream and that involves preventing the disease before it happens."
Vanderbilt Study Finds Standardizing Care Improves NAS Outcomes
Standardizing hospital care policies across institutions for infants diagnosed with drug withdrawal symptoms at birth reduces their length of treatment and hospitalization, according to new collaborative research led by Vermont Oxford Network, Vanderbilt and the University of Michigan Health System. The researchers published their most recent findings April 15 in the journal Pediatrics, looking at the impact of standardizing care for infants born with NAS.
Dr. Stephen Patrick
"The rapid rise in the numbers of infants with NAS nationwide caught many hospitals off guard. Initially, we found that less than half of participating hospitals had policies to standardize care for affected infants," said lead author Stephen Patrick, MD, MPH, MS, assistant professor of Pediatrics and Health Policy in the Division of Neonatology at Monroe Carell Jr. Children's Hospital at Vanderbilt.
"Teams from 199 hospitals worked for more than two years to apply evidence-based and family-centered, potentially better practices in their hospitals. Their hard work resulted in improvements in outcomes for this vulnerable population," he continued.
The data from the 199 participating centers revealed that following a standardized protocol led to an overall reduction of one day in median length of treatment -- from 17 to 16 days. Length of hospitalization was reduced by two days -- from 21 to 19 days. A NAS toolkit served as a blueprint to guide centers through the process, which included developing and implementing a standard process for identification, evaluation, treatment and discharge of infants with NAS, as well as measuring and reporting rates of NAS and drug exposure.
Along with implementing evidence-based, potentially better practices at the 199 participating institutions, the collaborative supported participants with interactive webinars, real-time feedback of outcomes and sharing of improvement practices through electronic forums. Simple and inexpensive strategies included swaddling, soothing, skin-to-skin contact with mothers and breastfeeding to prevent escalation of withdrawal symptoms in the first few days after birth. The evidence of better outcomes, the study authors conclude, reinforces the need to continue to standardize the care provided to infants with NAS and to explore ways to make care more efficient and family centered.
Vanderbilt NAS Studies: