The incidence of neonatal abstinence syndrome (NAS) and the corresponding costs to Medicaid are unlikely to decline unless interventions focus on stopping opioid use by low-income mothers, said Tyler N.A. Winkelman, MD, of Hennepin County Medical Center, Minneapolis, and his associates.

NAS refers to a group of conditions experienced by infants exposed to opioids in utero as withdrawal shortly after birth. They may have tremors, irritability, poor feeding, respiratory distress, and seizures. As the opioid epidemic has worsened across the United States, the incidence of NAS has correspondingly surged.‍

Dr. Winkelman and his associates conducted a serial cross-sectional analysis that used 9,115,457 birth discharge records from the 2004-2014 National Inpatient Sample (NIS), which were representative of 43.6 million weighted births. Overall, 3,991,336 infants were covered by Medicaid, which were representative of 19.1 million weighted births. There were 35,629 (0.89%) infants with a diagnosis of NAS, which were representative of 173,384 weighted births. Medicaid was the primary payer for 74% (95% confidence interval, 68.9%-77.9%) of NAS-related births in 2004 and 82% (95% CI, 80.5%-83.5%) of NAS-related births in 2014.

Infants with NAS who were enrolled in Medicaid were significantly more likely to be male, live in a rural county, and have comorbidities reflective of the syndrome than were infants without NAS who were enrolled in Medicaid, the researchers wrote in Pediatrics .

During 2004-2014, the incidence of NAS in the United States increased more than fivefold, from 1.5 per 1,000 hospital births (95% CI, 1.2-1.9) to 8 per 1,000 hospital births (95% CI, 7.2-8.7), as the opioid epidemic worsened in the country.

Infants with NAS who were covered by Medicaid had a greater chance of being transferred to another hospital for care (9% vs. 7%; P = .02) and stay in the hospital longer (17 days vs. 15 days; P less than .001), compared with infants with NAS who were covered by private insurance.

NAS is costly. In the 2011-2014 era, mean hospital costs for a NAS infant covered by Medicaid were more than fivefold higher than for an infant without NAS ($19,340/birth vs. $3,700/birth; P less than .001). After adjustment for inflation, mean hospital costs for infants with NAS who were covered by Medicaid increased 26% between 2004-2006 and 2011-2014 ($15,350 vs. $19,340; P less than .001), the researchers reported. Annual hospital costs, which were adjusted for inflation to 2014 U.S. dollars, for all infants with NAS who were covered by Medicaid rose from $65.4 million in 2004 to $462 million in 2014.

“With the disproportionate impact of NAS on the Medicaid population, we suggest that NAS incidence rates are unlikely to improve without interventions targeted at low-income mothers and infants,” Dr. Winkelman and his associates concluded.

Nonpharmacologic interventions are available to help NAS infants. “Systematic implementation of policies that support rooming-in, breastfeeding, swaddling, on-demand feeding schedules, and minimization of sleep disruption may reduce symptoms of NAS and reduce the duration of, or even eliminate the need for, pharmacologic treatment of NAS,” the researchers said. “Pharmacologic treatment with buprenorphine, for example, has been shown to reduce hospital length of stay by 35%.‍”

Another intervention is medication-assisted treatment during pregnancy, which studies have shown “improves outcomes and reduces costs associated with NAS, compared with attempted abstinence,” Dr. Winkelman and his associates said. It does not necessarily reduce NAS incidence, but “it may prevent prolonged hospital stays due to preterm birth, reduce NICU [neonatal intensive care unit] admissions, decrease the severity of NAS symptoms, and improve birth outcomes for some infants.”

The researchers also endorsed screening, referral, and treatment for substance abuse and mental health disorders among reproductive age women, including adolescents, because these are risk factors for opioid abuse.

One author was supported by an award from the National Institute on Drug Abuse. None of the other authors had relevant financial disclosures.

SOURCE: Winkelman TNA et al. Pediatrics. 2018;141(4):e20173520 .


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