Preventing Neonatal Abstinence Syndrome (NAS)

1. Preventing Neonatal Abstinence
Syndrome (NAS)
Presenters:
• Sheri Lawal, MPH, CHES, Senior Associate, The Pew Charitable Trusts
• Michael D. Warren, MD, MPH, Assistant Commissioner, Tennessee
Department of Health
• Deborah Huddleston, Media Relations and Project Director, Metro
(Knoxville) Drug Coalition
• Karen Pershing, MPH, CPS II, Executive Director, Metro (Knoxville) Drug
Coalition
Prevention Track
Moderator: Carla S. Saunders, NNP-BC, Advance Practice Coordinator, Pediatrix
Medical Group, Neonatal Nurse Practitioner, East Tennessee Children’s Hospital,
and Member, Rx and Heroin Summit National Advisory Board

2. Disclosures
Deborah Huddleston; Sheri Lawal, MPH, CHES;
Karen Pershing, MPH, CPS II; Michael D. Warren,
MD, MPH; and Carla S. Saunders, NNP-BC, have
disclosed no relevant, real, or apparent personal
or professional financial relationships with
proprietary entities that produce healthcare
goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
1. Describe how Tennessee is collecting NAS data
and using it to inform primary prevention
projects.
2. Identify NAS primary prevention opportunities
for state and local health departments.
3. Explain the Born Drug-Free Tennessee program
for raising awareness of NAS and educating
expectant mothers.
4. Provide accurate and appropriate counsel as
part of the treatment team.

5. Neonatal Abstinence Syndrome
Physical withdrawal in newborns with in-utero drug exposure
*Does not matter if drug it is prescribed, diverted, misused, or illicit*
Multiple symptoms including:
irritability and high-pitched cry, poor sleep, poor feeds, increase tone/tremors,
hypersensitivity, autonomic instability/tachypnea, sneezing, yawning, fever,
sweating, vomiting, cramping, diarrhea, excessive sucking, skin breakdown
Incidence has increased to 5.8 cases per 1000 inpatient births
~ 1 baby every 25minutes
The total US hospital charges for infants with NAS
is > $1.25 billion
100% Preventable

6. Partnering with Health Departments
to Prevent Neonatal Abstinence
Syndrome
Sheri Lawal, MPH, CHES
Research Analyst

7. Disclaimer
• The Pew Charitable Trusts did not review or
endorse the findings or conclusions in this
presentation.

8. Outline
• Trends in Opioid Use Among Women
• Health Departments’ Role in Preventing NAS
• Prevention Strategies

9. Trends in Opioid Use Among Women
• Between 2000 and 2009, the incidence of NAS
grew by nearly 300%, from 1.20 per 1,000
hospital births per year in 2000 to 3.39 in 20091
• Compared to men, women are more likely to:2
– Have chronic pain
– Be prescribed prescription opioids
– Be given higher doses
– Use them for longer time periods
– May become dependent on prescription opioids
more quickly
– May be more likely to engage in “doctor shopping”
1 Patrick SW, Schumacher RE, Bennyworth BD, Krans EE, McAllister JM & Davis MM. (2012). Neonatal Abstinence Syndrome and Associated Health
Care Expenditures: United States, 2000-2009. Journal of the American Medical Association, 307(18): 1934-40.
2 Centers for Disease Control and Prevention (2013). Vital Signs: Prescription Painkiller Overdoses: A Growing Epidemic, Especially Among Women.
Accessed at: http://www.cdc.gov/vitalsigns/pdf/2013-07-vitalsigns.pdf

10. Trends in Opioid Use Among Women
• Since 1999, the percent increase in
prescription opioid overdose deaths was
more than 400% among women3
– In 1999, 1,287 women died from
prescription opioid overdose
– In 2010, 6,631 women died from
prescription opioid overdose
– Between 1999 and 2010, 47,935 women
died from prescription opioid overdose
3 Centers for Disease Control and Prevention (2013). Vital Signs: Overdoses of Prescription Opioid Pain Relievers and
Other Drugs Among Women – United States, 1999 – 2010. Accessed at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6226a3.htm?s_cid=mm6226a3_w

11. Health Departments are Vital to the
Prevention of NAS
• Public health departments protect the
community, respond in times of crisis, and are
instrumental in leading or participating in:4
– Surveillance
– Building Partnerships
– Treatment and Recovery
– Education
– Legislation
– Funding and Research
4 National Association of County and City Health Officials. (2015). Statement of Policy: Responding to America’s
Prescription Drug Abuse and Overdose Epidemic. Accessed at: http://www.naccho.org/uploads/downloadable-
resources/Policy-and-Advocacy/14-04-Rx-Drug-Epidemic.pdf.

12. Surveillance at the Local and State Levels
Epidemiology and
Surveillance Services
Size of Population Served
All LHDs <25,000 25,000-
49,999
50,000-
99,999
100,000-
499,999
500,000+
Injury Surveillance 27% 21% 24% 30% 34% 48%
Maternal and Child Health 61% 53% 62% 66% 71% 78%
5 National Association of County and City Health Officials (2014). 2014 National Profile of Local Health Departments.
Accessed at: http://nacchoprofilestudy.org/wp-content/uploads/2014/02/2013_National_Profile021014.pdf
6 Safe States Alliance (2013). State of the States. Accessed at: http://www.safestates.org/?page=SOTS.
Local Health Departments5
State Health Departments6
• 64% of state IVP (injury and violence prevention) programs report having access to
vital records, BRFSS, HDD, YRBSS, and child death review data
• 95% of state IVP programs indicate that they produce some type of report using
injury and violence surveillance data

13. Health Department Surveillance in Action
• Health departments
– Participate in local surveillance committees
(e.g., local poison review committees)4
• Identify overdose trends, risk factors, and points
of intervention
– Contribute to state Health Burden of Injury
reports
– Utilize data to monitor the local and state
incidence of NAS, prescribing trends, and
illicit drug trends
4 National Association of County and City Health Officials. (2015). Statement of Policy: Responding to America’s
Prescription Drug Abuse and Overdose Epidemic. Accessed at: http://www.naccho.org/uploads/downloadable-
resources/Policy-and-Advocacy/14-04-Rx-Drug-Epidemic.pdf.

14. 71% 71% 66%
54%
43% 40%
11%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Local Health Departments Use of Surveillance Data for
Injury Prevention, by Activity7
Injury Prevention
7 National Association of County and City Health Officials. (2013). Injury and Violence Prevention: A Local Health
Department Perspective: Examination of Local Health Department Capacity and Infrastructure for Injury and Violence
Prevention.
Health Department Surveillance in Action

15. 64%
58% 55%
34% 33%
0%
10%
20%
30%
40%
50%
60%
70%
Share data
with
community
members
Share data
with other
government
agencies
Identify
appropriate
secondary
data sources
Collect
original data
Analyze data
Local Health Departments With Very High or High
Capacity for Injury Prevention Surveillance Activities7
Injury Prevention
7 National Association of County and City Health Officials. (2013). Injury and Violence Prevention: A Local Health
Department Perspective: Examination of Local Health Department Capacity and Infrastructure for Injury and Violence
Prevention.
Health Department Surveillance in Action

16. Building Partnerships
• Health departments collaborate with federal,
state, local, and tribal partners to coordinate
solutions that mitigate prescription opioid
misuse:4
– Work with law enforcement, healthcare providers,
professional licensing boards, and other stakeholders
to develop and provide recommendations for
legislation that prevents inappropriate prescribing
practices.
– Work with police departments on drug take-back days
and drug drop-off kiosks
4 National Association of County and City Health Officials. (2015). Statement of Policy: Responding to America’s
Prescription Drug Abuse and Overdose Epidemic. Accessed at: http://www.naccho.org/uploads/downloadable-
resources/Policy-and-Advocacy/14-04-Rx-Drug-Epidemic.pdf.

17. Building Partnerships
Local Health Departments
• Of those LHDs engaged in
injury prevention, most
collaborate with:7
– Other local government (82%)
– Local non-government (81%)
– Other LHD divisions (77%)
– State government and non-
government (65%)
– National government and
non-government (30%)
State Health Departments
• Of all state IVP programs:
– ALL have some sort of
partnership with local Vital
Statistics, with 88%
characterizing the partnership
as “strong”
7 National Association of County and City Health Officials. (2013). Injury and Violence Prevention: A Local Health
Department Perspective: Examination of Local Health Department Capacity and Infrastructure for Injury and Violence
Prevention.

18. Treatment and Recovery
• Health departments:4
– Work with healthcare systems to increase
screenings for substance abuse to identify patients
in need of treatment and link them to care
– Educate medical providers and pharmacy personnel
to eliminate over-prescribing practices and
promote use of PDMPs
– Train emergency medical responders, police
officers, and community members on how to use
Naloxone. In some jurisdictions, local health
departments provide the medications.
4 National Association of County and City Health Officials. (2015). Statement of Policy: Responding to America’s
Prescription Drug Abuse and Overdose Epidemic. Accessed at: http://www.naccho.org/uploads/downloadable-
resources/Policy-and-Advocacy/14-04-Rx-Drug-Epidemic.pdf.

19. Education
• Healthcare providers: prevention
strategies, screening and monitoring
for substance abuse and mental
health problems, and appropriate
prescribing behaviors4
• First responders, patients, family
members, and other caregivers: how
to recognize signs of overdose and to
administer naloxone or similar drug
• General public: risks associated with
prescription opioid use, misuse, and
abuse
4 National Association of County and City Health Officials. (2015). Statement of Policy: Responding to America’s
Prescription Drug Abuse and Overdose Epidemic. Accessed at: http://www.naccho.org/uploads/downloadable-
resources/Policy-and-Advocacy/14-04-Rx-Drug-Epidemic.pdf.

20. Legislation
Local Health Departments7
• 72% of LHDs engaged in injury
and violence prevention
participate in local policy
activities
• 52% work to increase public
awareness of existing policies
• 50% conduct or participate in
community organizing
• 44% meet with policy- and
decision-makers
State Health Departments6
• 73% of state IVP programs have a
mechanism/protocol for
communicating injury prevention
issues to policymakers
• 71% participate in boards and/or
commissions
• 71% work to increase public
awareness of laws
• 63% recommend health
department positions on bills
• 61% work to encourage adoption
of organizational policies
• 61% evaluate, assess, and
monitor the impact of laws
6 Safe States Alliance (2013). State of the States. Accessed at: http://www.safestates.org/?page=SOTS.
7 National Association of County and City Health Officials. (2013). Injury and Violence Prevention: A Local Health
Department Perspective: Examination of Local Health Department Capacity and Infrastructure for Injury and Violence
Prevention.

21. Funding and Research
• Local health departments receive in-kind and
monetary support for injury prevention,
mostly through state government (42%) and
local government (34%)7
• On average, states received $2,786,408 each
for injury and violence prevention6
– Lowest state total: $54,933
– Highest state total: $22,798,724
6 Safe States Alliance (2013). State of the States. Accessed at: http://www.safestates.org/?page=SOTS.
7 National Association of County and City Health Officials. (2013). Injury and Violence Prevention: A Local Health
Department Perspective: Examination of Local Health Department Capacity and Infrastructure for Injury and Violence
Prevention.

22. Conclusions
• Health departments…
– Track and investigate public health threats, such as the
incidence of NAS
– Mobilize stakeholders to ensure safe prescribing
practices, develop policy recommendations, and
provide education
– Lead innovative and evidence-based efforts that
prevent prescription opioid misuse and abuse
– Inform the public about health problems and how to
stay safe
– Link people who need health care or treatment with
services

23. Contact Information
Sheri Lawal, MPH, CHES
slawal@pewtrusts.org
202-540-6734

24. Preventing Neonatal
Abstinence Syndrome (NAS)
Michael D. Warren, MD MPH FAAP
Assistant Commissioner
Division of Family Health and
Wellness

25. Disclosure
• Michael Warren, MD MPH, has disclosed no relevant,
real or apparent personal or professional financial
relationships with proprietary entities that produce health
care goods and services.

26. What We Knew in 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.
0
2
4
6
8
10
12
14
0
100
200
300
400
500
600
700
800
900
1000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Rateper1,000LiveBirths
NumberofHospitalizations
NAS Hospitalizations in Tennessee, 1999-2012
Number Rate

27. What We Knew in 2012…
• Hospital discharge data through 2010
– Showed sharp increase in NAS cases
• Feedback from hospitals (particularly in
East TN)
– “Busting at the seams” with NAS babies
• Increase in drug overdose deaths
• We have a problem

28. What We Didn’t Know in 2012…
• 2011 or 2012 case numbers
– State rules re: release of hospital discharge
data
• Source of prenatal exposure
– Not easily identifiable via administrative
claims

29. NAS—Reportable Disease
• Add NAS to state’s Reportable Disease list
– Effective January 1, 2013
• Reporting hospitals/providers submit
electronic report
• Reporting Elements
– Case Information
– Diagnostic Information
– Source of Maternal Exposure

30. Drug Dependent Newborns (Neonatal Abstinence Syndrome)
Surveillance Summary For the Week of June 14 – June 20, 20151
Source of Maternal Substance (if known)2
#
Cases3
%
Cases
Supervised replacement therapy 259 61.4
Supervised pain therapy 40 9.5
Therapy for psychiatric or neurological condition 31 7.4
Prescription substance obtained WITHOUT a prescription 147 34.8
Non-prescription substance 102 24.2
No known exposure but clinical signs consistent with NAS 3 0.7
No response 7 1.7
Reporting Summary (Year-to-date)
Cases Reported: 422
Male: 237
Female: 185
Unique Hospitals Reporting: 38
Maternal County of
Residence
(By Health Department
Region)
#
Cases
%
Cases2
Davidson 25 5.9
East 92 21.8
Hamilton 11 2.6
Jackson/Madison 0 0
Knox 53 12.6
Mid-Cumberland 44 10.4
North East 64 15.2
Shelby 13 3.1
South Central 23 5.5
South East 9 2.1
Sullivan 37 8.8
Upper Cumberland 42 10.0
West 9 2.1
Total 422 100.1
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.
404422
0
50
100
150
200
250
300
350
400
450
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
NumberofCases
Week
Cumulative Cases NAS Reported
2015 Cases 2014 Cases

31. NAS—Reportable Disease
Cases by Exposure Source, 2015
Only
illicit/diverted
substances
25.9%
Only
substances
prescribed to
mother
46.5%
Substance
exposure
unknown 5.5%
Mix of
prescription
and illicit
substances
22.1%

32. NAS—Reportable Disease
Exposure Source by Region, 2015
40.5
32.3 31.2
36.5 34.1
37.9
28.6
11.5
22.9
26.2
15.5 16.9
24.3
12.9
24.7
25.0
20.5
16.5
22.9
26.9
25.2
33.6
11.2
20.8
32.4
54.8
41.9
34.6
43.2
37.9
40.0
61.5 44.2
36.1
65.2
59.7
0
10
20
30
40
50
60
70
80
90
100
Percent,%
Unknown (%)
Prescription Drugs Only
(%)
Prescription and Illicit
Drugs (%)
Illicit Drugs Only (%)

33. 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

34. Narcotics and Contraceptive Use:
TennCare Women, CY2014
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 320,327 38,210 119 5,625 15% 32,585 85%
15-20 85,174 1,333 16 541 41% 792 59%
21-24 48,169 2,787 58 814 29% 1,973 71%
25-29 59,165 6,998 118 1,561 22% 5,437 78%
30-34 53,614 9,483 177 1,459 15% 8,024 85%
35-39 42,963 9,281 216 804 9% 8,477 91%
40-44 31,241 8,328 267 446 5% 7,882 95%
Data source: Division of Health Care Finance and Administration, Bureau of TennCare. CY2014 data.
Available at: http://www.tn.gov/assets/entities/tenncare/attachments/TennCareNASData2014.pdf

35. Opportunities for Preventing NAS:
Primary Prevention Initiative
• Primary Prevention Initiative (PPI):
– Department-wide initiative
– Vision by State Health Officer
– Focus upstream
– Engage community partners to address local
issues

36. Opportunities for Preventing NAS:
Primary Prevention Initiative
• East TN PPI Project:
– Started in Cocke and Sevier counties
– Partnership with local jails
– Health education sessions
• Focus on NAS prevention
• Information on effective contraception
– Partnerships with jails to refer inmates to local
health department for family planning

37. Opportunities for Preventing NAS:
Primary Prevention Initiative
• East TN PPI Project:
– All services are voluntary
– Any patient referred to health department for
family planning services is offered a variety
of acceptable and effective contraceptive
methods

38. Opportunities for Preventing NAS:
Primary Prevention Initiative
• Selected results from East TN PPI project:
– 442 referrals in 2014-15
• 88% with history of drug use
• 30% reported drug use during pregnancy
• 19% had delivered infant with NAS
• 73% reported no contraceptive method
– Among referred patients:
• 94% received a contraceptive method (N=406)
• 84% chose a voluntary reversible long-acting
contraceptive (N=361)

39. Opportunities for Preventing NAS:
Primary Prevention Initiative
• Project has been replicated in 24 counties
• Key Lessons Learned:
– Community partners are interested in
reducing burden of NAS
– Inmates are receptive to health education and
to referrals to public health services
– Need to emphasize that services are
voluntary and offer a variety of acceptable and
effective contraceptive methods

40. Summary
• Public health surveillance for NAS allows
real-time tracking of incidence and
description of exposure sources
• Local partnerships can move prevention
efforts upstream

41. For More Information
• Weekly NAS Surveillance Archive
– http://www.tn.gov/health/article/nas-summary-
archive
• Monthly and Annual NAS Reports
– http://www.tn.gov/health/article/nas-update-
archive

42. Acknowledgements
• TDH Commissioner
– John J. Dreyzehner, MD, MPH, FACOEM
• TDH NAS Surveillance
– Angela M. Miller, PhD, MSPH
• East TN Regional Health Office Staff
– Danni Lambert, RN
– Janet Ridley, RN, BSN, MSN
– Brittany S. Isabell, MPH

43. Born Drug-Free Tennessee:
NAS in Your State
Deborah Huddleston, BS
Karen Pershing, MPH, CPS II
March 29, 2016

44. Disclosure
“I, Karen Pershing, MPH, CPS II have no real or apparent
personal or professional financial relationships with
proprietary entities that produce health care goods and
services.”
“I, Deborah Huddleston, BS, have no real or apparent
personal or professional financial relationships with
proprietary entities that produce health care goods and
services.”

45. Objectives
• Describe how Tennessee is collecting NAS data
and using it to inform primary prevention
projects.
• Identify NAS primary prevention opportunities
for state and local health departments.
• Explain the Born Drug-Free Tennessee program
for raising awareness of NAS and educating
expectant mothers.
• Provide accurate and appropriate counsel as part
of the treatment team.

46. Coalition Response
• What is a community coalition?
• Who’s involved?
• Purpose
• Status of Coalitions in Tennessee-52

47. SAMHSA’S Strategic Prevention
Framework

48. Moving to “Action”
Provide Information
• Born Drug-Free Tennessee campaign
• Print and television media outreach
• Health education curriculum includes NAS
Enhance Skills/Training and Education
• Pain clinic provider education
• Treatment provider education
• SBIRT training for OB’s/PC’s
• Educate medical providers on discussing pregnancy
prevention when prescribing

49. “Action” Continued
Provide Support/Build Capacity
• Connect with local HD FP program
• Work with judges and jails on educating
incarcerated women
Change Incentives/Disincentives
• Increase access to gender-specific trauma
informed treatment
• Decreased access to opiate narcotics
• Establish Family Recovery Courts

50. “Action” Continued
Reduce Barriers or Enhance Access
• Expand Access to LARC
Change Physical Design of Environment
• Reduce number of pill mills
Modify Policies and Systems Change
• Collect local information on criminalization law
• Strengthen pain management clinic regulations
• Expansion of treatment coverage

51. Born Drug-Free Tennessee Launch

52. Knoxville Media Reach
• Knoxville population:
444,622
• TV households in the
Knoxville DMA*:
503,410
• Media Reach: 17
counties
*Direct Marketing Association

53. Media Outreach

54. Media Outreach Continued
Campaign Launch YTD
• Over 65,000 visits to
borndrugfreetn.com
• 78% of women visitors
were of child-bearing
age
• 24% visitors viewed
“Find Out More” section
 Facebook: 863 page likes
*23,972 organic post reach
 Twitter: 168 followers

55. Questions?

56. Preventing Neonatal Abstinence
Syndrome (NAS)
Presenters:
• Sheri Lawal, MPH, CHES, Senior Associate, The Pew Charitable Trusts
• Michael D. Warren, MD, MPH, Assistant Commissioner, Tennessee
Department of Health
• Deborah Huddleston, Media Relations and Project Director, Metro
(Knoxville) Drug Coalition
• Karen Pershing, MPH, CPS II, Executive Director, Metro (Knoxville) Drug
Coalition
Prevention Track
Moderator: Carla S. Saunders, NNP-BC, Advance Practice Coordinator, Pediatrix
Medical Group, Neonatal Nurse Practitioner, East Tennessee Children’s Hospital,
and Member, Rx and Heroin Summit National Advisory Board