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Exploring Drug Dependent
Newborns In Appalachia: a
Conference of Experts
April 2-3, 2014
Johnson City, TN
Bruce Behringer
...
ARC	
  Region	
  
with	
  County	
  
Economic	
  
Status:	
  	
  
FY	
  2014	
  
ARC Programs
•  Research and advocacy
•  Public/private partnerships
•  Grantmaking for local initiatives
– Bottoms-up gra...
ARC Grantmaking
•  Job creation
– Business capital, food systems, entrepreneurs
•  Human capacity
– Education, workforce, ...
ARC Priority Setting
•  Strategic Plan
•  State Development Plans
•  Annual State Strategy Statements
•  OMB Performance T...
Appalachian Health Policy
Advisory Council
• Health career development pathways.
• Rural primary care provider base.
• Sta...
Appalachian Health Policy
Advisory Council
• Integration of treatment and coordination of
services.
• Health disparities ...
Major Health Research
•  An Analysis of Disparities in Health Status
and Access to Health Care in the
Appalachian Region (...
Substance Abuse in Appalachia:
2006 findings
•  Addiction = business (covert economy).
•  Substance use is culturally acce...
Substance Abuse in Appalachia:
2006 findings
•  Legal drugs and generational use of substances
are legitimized by:
–  hist...
Major Health Research
•  An Analysis of Mental Health and
Substance Abuse Disparities & Access to
Treatment Services in th...
NORC Study Outcomes
•  Meth vs. prescription opioids
•  Treatment access poor but better than
expected
•  Variability with...
Ongoing activities
•  Mini-grant competitions for coalitions
•  Other grantmaking interests:
•  Facilities
•  Integrated c...
NAS in Tennessee and Appalachia
•  Tennessee: greater NAS prevalence in
Appalachian counties than non-ARC
•  ARC co-funded...
www.arc.gov
Neonatal Abstinence Syndrome
Conference of Experts:
Exploring the Issue of Drug Dependent
Newborns in the Appalachian Regi...
Conference Design
•  Cooperative regional venture to assess regional Neonatal
Abstinence Syndrome (NAS) epidemic
•  Object...
Conference Agenda
•  The agenda
– The national picture
– Expert panels – Research, Practice, Partnerships and
State Policy...
Active participation by attendees as inputs
• Pre-conference questionnaire
• Idea collection sheets by panel:
– What we kn...
From the History Lesson…
Southern Appalachia was the target market
and became the epicenter of prescription
opiate abuse (...
To the Current Challenge
We believe that Appalachia is the epicenter of the latest
manifestation of the substance abuse ep...
Map	
  of	
  distribuBon	
  of	
  NAS	
  cases	
  
Data sources: Tennessee Department of Health; Office of Health Statisti...
Conference outcomes
•  Learn more about NAS problem in Appalachia region
including gaps in knowledge
•  Verify multistate ...
Common themes
•  Social and economic determinants are important.
•  Professional education with prescribers is
necessary.
...
Common themes
•  Too little is understood about long-term
impacts on child.
•  Intermediate impacts being discovered
(DCS ...
“We Believe” Statements
•  NAS is a growing epidemic in the Appalachian
region.
•  NAS is a symptom of larger issues.
•  N...
“We Believe” Statements
•  Poverty and social injustice are the primary
determinants of the NAS epidemic in
Appalachia.
• ...
Is Neonatal Abstinence
Syndrome a national problem?
Provide one statement to
document or describe the
situation in your
st...
Recommendations: Research Panel
•  Identify effective assessment tools for identifying
NAS
•  Promote universal protocols ...
Recommendations: Research Panel
•  Advocate for health care provider education about
addiction and recovery
•  Study effec...
Recommendations: Clinical Practice Panel
•  Advocate that all health related students learn
about drug addiction as prereq...
Recommendations: Clinical Practice Panel
•  Expand treatment sources and resources
•  Use multi-disciplinary and multipron...
Recommendations: Partnerships Panel
•  Identify community and family factors relevant to
recovery
•  Advocate for physicia...
Recommendations: Partnerships Panel
•  Create economics case for primary prevention of
NAS
•  Develop a provider and paren...
Tlr nas stockton behringer
Tlr nas stockton behringer
Tlr nas stockton behringer
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Thought Leaders Roundtable: Appalachian Neonatal Abstinence Syndrome Project - Bruce Behringer and Eric Stockton

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  1. 1. Exploring Drug Dependent Newborns In Appalachia: a Conference of Experts April 2-3, 2014 Johnson City, TN Bruce Behringer Deputy Commissioner Tennessee Department of Health Eric Stockton Health Program Manager Appalachian Regional Commission
  2. 2. ARC  Region   with  County   Economic   Status:     FY  2014  
  3. 3. ARC Programs •  Research and advocacy •  Public/private partnerships •  Grantmaking for local initiatives – Bottoms-up grantmaking – Guided by regional strategy – Local development districts and states = gatekeepers
  4. 4. ARC Grantmaking •  Job creation – Business capital, food systems, entrepreneurs •  Human capacity – Education, workforce, health, leadership •  Physical infrastructure – Water, sewer, industrial sites – Clinics and hospitals – Highway network & intermodal transport
  5. 5. ARC Priority Setting •  Strategic Plan •  State Development Plans •  Annual State Strategy Statements •  OMB Performance Targets •  Distressed Area mandate •  Advisory groups
  6. 6. Appalachian Health Policy Advisory Council • Health career development pathways. • Rural primary care provider base. • State and community-based HPDP.
  7. 7. Appalachian Health Policy Advisory Council • Integration of treatment and coordination of services. • Health disparities economic disparities
  8. 8. Major Health Research •  An Analysis of Disparities in Health Status and Access to Health Care in the Appalachian Region (Halverson: 2004) •  (Published at www.arc.gov)
  9. 9. Substance Abuse in Appalachia: 2006 findings •  Addiction = business (covert economy). •  Substance use is culturally accepted. •  Widespread incidence and prevalence of addiction and additive behaviors. •  Lack of health services infrastructure  reduced capacity for people and communities From “A Community-Based Approach to Substance Abuse Including Methamphetamine in Appalachia,” Johnson City, TN, 2006
  10. 10. Substance Abuse in Appalachia: 2006 findings •  Legal drugs and generational use of substances are legitimized by: –  historical medical practice –  the media •  Appalachian life contributes a unique set of life and community stressors: –  poverty and disenfranchisement •  From “A Community-Based Approach to Substance Abuse Including Methamphetamine in Appalachia,” Johnson City, TN, 2006
  11. 11. Major Health Research •  An Analysis of Mental Health and Substance Abuse Disparities & Access to Treatment Services in the Appalachian Region (August 2008) •  National Opinion Research Center (NORC) at the University of Chicago, and East Tennessee State University •  (Published at www.arc.gov)
  12. 12. NORC Study Outcomes •  Meth vs. prescription opioids •  Treatment access poor but better than expected •  Variability within region •  Place-based study of regional conditions •  National researchers (NORC) helped legitimize findings
  13. 13. Ongoing activities •  Mini-grant competitions for coalitions •  Other grantmaking interests: •  Facilities •  Integrated care demonstrations •  (Not ongoing operations) •  Workforce development •  Business opportunity? •  Links to economic development
  14. 14. NAS in Tennessee and Appalachia •  Tennessee: greater NAS prevalence in Appalachian counties than non-ARC •  ARC co-funded multi-state project – Other states’ experience? – What is known…or unknown? – Is this an Appalachian issue?
  15. 15. www.arc.gov
  16. 16. Neonatal Abstinence Syndrome Conference of Experts: Exploring the Issue of Drug Dependent Newborns in the Appalachian Region Tennessee Department of Health Johnson City, TN April 2-3, 2014 Supported by a conference grant from the Appalachian Regional Commission
  17. 17. Conference Design •  Cooperative regional venture to assess regional Neonatal Abstinence Syndrome (NAS) epidemic •  Objectives –  Summarize what is known about the epidemiology of NAS in Appalachia –  Generate a set of questions and potential inquiries that would address that which is unknown –  Identify existing and ideas for proposed collaborations and cooperative ventures
  18. 18. Conference Agenda •  The agenda – The national picture – Expert panels – Research, Practice, Partnerships and State Policy – Federal and national organizations reflections – Closing thoughts on a public health epidemic • The thirty-eight attendees were “experts” from eight Appalachian states representing multiple stakeholder interests
  19. 19. Active participation by attendees as inputs • Pre-conference questionnaire • Idea collection sheets by panel: – What we know (findings); – What we don’t know (gaps); – Recommendations (key elements needed for change) • Notes from facilitated audience discussion with panels • “We Believe” statements from all participants Approach: Active participation will inform conference report
  20. 20. From the History Lesson… Southern Appalachia was the target market and became the epicenter of prescription opiate abuse (Oxycontin) fifteen years ago, and now has become a part of the regional culture sowing the seed of death and destruction of people, families communities and a proud culture.
  21. 21. To the Current Challenge We believe that Appalachia is the epicenter of the latest manifestation of the substance abuse epidemic because vehicle transmission (NAS) is a lagging indicator. Appalachia, the canary in our coalmines of the current substance abuse epidemic, spoke loudly when our people stated dying, but not loud enough to warn the country and stop the epidemic. This time we can work together, be a louder voice to turn back and stop NAS, emphasizing prevention and destigmatization recognizing the tri-level approach of prevention, treatment and control. “Place matters” and in Appalachia we can make it matter for the nation.
  22. 22. Map  of  distribuBon  of  NAS  cases   Data sources: Tennessee Department of Health; Office of Health Statistics; Hospital Discharge Data System (HDDS) and Birth Statistical System. Numerator is number of inpatient hospitalizations with age less than one 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. Note that these are discharge- level data and not unique patient data. Data suppressed for counties with fewer than 100 births.
  23. 23. Conference outcomes •  Learn more about NAS problem in Appalachia region including gaps in knowledge •  Verify multistate place-based problem •  Recognize and validate multiple perspectives about multiple dimensions requiring systems approaches •  Share implementation ideas and personal networking •  Collect ideas and recommendations to future ARC consideration •  Develop common themes across states
  24. 24. Common themes •  Social and economic determinants are important. •  Professional education with prescribers is necessary. •  Compassion, not arrest, will lead to improved outcomes. •  NAS is just becoming recognized as a real financial issue. •  Too little consensus on protocols: case definition, prenatal treatment of mothers, hospital level of care for infants.
  25. 25. Common themes •  Too little is understood about long-term impacts on child. •  Intermediate impacts being discovered (DCS placements). •  Treatment resources are lacking, and prevention strategies are undeveloped. •  Policy pressures mounting to punish mothers as “the moral thing”.
  26. 26. “We Believe” Statements •  NAS is a growing epidemic in the Appalachian region. •  NAS is a symptom of larger issues. •  NAS is preventable! Primary prevention is a must! •  NAS is an expected and treatable condition. •  NAS is the “wakeup call” and opportunity to change perceptions and stigma surrounding substance abuse and lack of education among providers and citizens.
  27. 27. “We Believe” Statements •  Poverty and social injustice are the primary determinants of the NAS epidemic in Appalachia. •  NAS is: multi-dimensional, affects multiple systems; not only a constellation of symptoms, but a family and society unit issue
  28. 28. Is Neonatal Abstinence Syndrome a national problem? Provide one statement to document or describe the situation in your state or region
  29. 29. Recommendations: Research Panel •  Identify effective assessment tools for identifying NAS •  Promote universal protocols around drug screening for OB-GYNs and hospitals •  Identify elements of successful treatment •  Fund long term studies to follow children through childhood •  Identify structural factors that drive long lengths of stay: Study new hospital treatment options Neonatal Abstinence Syndrome Conference of Experts: Exploring the Issue of Drug Dependent Newborns in the Appalachian Region, April 2014
  30. 30. Recommendations: Research Panel •  Advocate for health care provider education about addiction and recovery •  Study effectiveness of primary prevention strategies (injury prevention, related tobacco use, changing prescribing polices for women of childbearing age) •  Describe locally successful community programs Neonatal Abstinence Syndrome Conference of Experts: Exploring the Issue of Drug Dependent Newborns in the Appalachian Region, April 2014
  31. 31. Recommendations: Clinical Practice Panel •  Advocate that all health related students learn about drug addiction as prerequisite and eliminate provider bias and decrease stigma •  Improve standardized protocols for discharge and post hospital care •  Institute universal biochemical drug testing early in pregnancy •  Promote early prenatal engagement and education about what to expect: Patients to be informed about risk of NAS who receive Medication Assisted Therapy
  32. 32. Recommendations: Clinical Practice Panel •  Expand treatment sources and resources •  Use multi-disciplinary and multipronged approaches •  Co-locate primary health care and behavioral health •  Advocate for non-judgmental, non punitive approaches
  33. 33. Recommendations: Partnerships Panel •  Identify community and family factors relevant to recovery •  Advocate for physician engagement in public NAS education •  Gain support for buprenorphine and suboxone oversight •  Focus on underlying social determinants of heath (e.g., promote job training and placement). •  Improve family planning and substance abuse education in prisons and general population.
  34. 34. Recommendations: Partnerships Panel •  Create economics case for primary prevention of NAS •  Develop a provider and parent navigation guide for working with Children’s Services. •  Conduct evaluation that promotes resources for sustained effective partnership programs and coalitions •  Be about health, not health care.
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