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Neonatal Abstinence Syndrome in Tennessee

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.

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Neonatal Abstinence Syndrome in Tennessee

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  1. Neonatal Abstinence Syndromein 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 Infantwithrecognizable 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 779.5.

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

  6. 2010 Controlled Substance Prescriptions 51 pillsper every Tennessean over age 12 275.5 Million Hydrocodone Pills 22 pillsper every Tennessean over age 12 116.6 Million Xanax Pills 21 pillsper 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* Data source: Division of Health Care Finance and Administration, Bureau of TennCare. *CY2012 data is provisional.

  8. Unintended PregnancyAmong 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.

  9. TennCare NAS Costs, CY2012* 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 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.

  11. NAS Reported CasesExposure 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 *Provisional count of births, 2013

  13. The Levels of Prevention 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

  14. Request for Black Box Warning

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

  16. Controlled SubstanceMonitoring 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

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

  24. 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

  25. 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

  26. 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

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

  28. 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

  29. 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

  30. 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

  31. 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…

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