Medical Costs of Addicted Newborns: Neonatal Abstinence Syndrome
R. Mihaly
I. Introduction
Drug use by pregnant mothers can cause babies to be born addicted. This condition of the baby is referred to as Neonatal Abstinence Syndrome (NAS). There is both prenatal and postnatal NAS. Generally, NAS refers to the condition and constellation of drug withdrawal symptoms exhibited by babies born dependent on drugs. (Dutta & Sachdev, 2007). NAS occurs when the newborn is immediately cutoff at birth from opioids and other drugs, sometimes in combination. The frequency and costs of NAS are rapidly increasing, so much so that NAS might be considered an epidemic.
NAS most commonly results from antepartum opiate use, both illegal and prescription. Other drugs have also been implicated (Patrick et al., 2012). Some degree of withdrawal symptoms associated with NAS have been found in 60% to 80% of newborns exposed to heroin or methadone in utero (Doberczak, Kandall, & Wilets, 1991). Newborns born to mothers with opioid disorders have approximately a 50% chance of developing NAS (Petz & Anand, 2015).
Babies with NAS are known to have an increased incidence of an array of symptoms such as seizures, respiratory disorders, feeding difficulties, and low birthweight (Patrick et al., 2012). NAS leads to an ever-increasing period of hospitalization for supportive care and sometimes opioid-replacement therapy averaging 16 days (Petz & Anand, 2015) to 19 days (Tolia et. al., 2013)
Substance abuse and its effects on others are very costly, Medical treatments of babies suffering with NAS regularly reach beyond $150,000 per child (Petz & Anand, 2015).
II. Scale
It is estimated 400,000 to 440,000 infants, a baby born between every 75 seconds, may be affected to some extent by prenatal alcohol or illicit drug exposure (Verklan & Walden, 2014). But an infant born somewhere between every 39 minutes (Patrick et al., 2012), and every hour (Murphy-Oikonen, 2013) in the United States suffers from NAS.
Between 1979 and 1987, the number of drug-affected newborns increased by >300% (Dutta & Sachdev, 2007). Then the annual rate of NAS-diagnosed newborns in the United States increased another 300% between 2000 and 2009 (Patrick et al., 2012). Then the incidence of NAS then doubled between 2009 and 2012 (Patrick, Davis, Lehman, & Cooper, 2015). Assuming no increase between 1987 and 2000, the increase in babies suffering from NAS from 1979 to 2012 exceeds 1,800%.
In 2009, mothers at time of delivery were diagnosed as dependent on or using opiates at a rate of 5.63 per 1000 hospital births (Patrick et al., 2012). Newborns suffering from NAS were 3.39 per 1000 hospital births (Patrick et al., 2012). Maternal opiate use is increasing at a more rapid rate than the incidence of NAS, likely because not all opiate-exposed newborns exhibit signs of withdrawal (Doberczak et. al., 1991). By 2012, the national NAS incidence had increased to 5.8 per 1000 hospital births (Patrick, Davis et. al., 2015).
The prevalence of maternal opioid drug use at the time of delivery is much higher in some states. For example, in California it is approximately 10 per 1,000 births, or one percent (Peltz & Drover, 2012). Closer to home, in West Virginia, the numbers are staggering. The 2007-2013 WV Health Care Authority, analyzed uniform billing data of 119,605 newborn admissions with 1,974 NAS diagnoses. Between 2007 and 2013, NAS increased from 7.74 to 31.56 per 1,000 live births (Stabler et. al., 2016). In 2013, in the southeastern region of West Virginia, almost 5% of babies were born suffering from NAS, 48.76 per 1,000 live births (Stabler et. al., 2016).
NAS is becoming more common among babies in both developed and developing countries (Kocherlakota, 2014). The incidence of NAS among newborns in Western Australia from 1980 to 2005 increased from 0.097 to a high of 4.2 per 1,000 live births (O'donnell et al., 2009).
III. Costs
Although NAS treatments are of relatively short duration, the treatment is typically very costly. In 2000, mean hospital charges for newborns diagnosed with NAS was $39,400. By 2009 this had increased to $53,400. (Patrick et al., 2012) (Verklan & Walden, 2014). Last year, the typical overall cost of care for a newborn child suffering from NAS was found to be $159,000 to $238,000 beyond that of a typical newborn (Petz & Anand, 2015).
The medical expenses of birthing mothers using opiates are paid by Medicaid 60% of the time. The costs of treating babies suffering from NAS are more often, and increasingly, paid by Medicaid. In 2009, 77.6%-78.1% of charges for NAS sufferers were paid by state Medicaid programs (Patrick et al., 2012). By 2012, 81% of babies suffering from NAS were paid by state Medicaid programs (Patrick, Davis et. al., 2015).
From 2009 to 2012, aggregate hospital charges for NAS increased from $732 million to $1.5 billion (Patrick, Davis, Lehman, & Cooper, 2015). (Patrick, Davis et. al., 2015).
IV. Opiate Causation
Prenatal exposure to opiates such as heroin, morphine, methadone, codeine, oxycodone, and buprenorphine, can cause NAS. Opioid use in pregnancy, and NAS, is correlated with increased incidence of low birthweight, third trimester bleeding, toxemia, mortality, irritability, feeding difficulties, hypertonia, emesis, seizures, postnatal growth deficiency, microcephaly, neurobehavioral problems, and sudden infant death syndrome, central nervous system hyperirritability (high-pitched cry, increased muscle tone, tremors, restlessness, convulsions), gastrointestinal dysfunctions (poor feeding, weak suction reflex, regurgitation, vomit, loose or watery stools), fever, sweating, respiratory distress, and apnea (Bersani, 2013) (Forray, 2016) (Patrick et al., 2012).
The consequences of prenatal opium use are confounded by coexisting substance use. For example, cigarettes are smoked by opiate-using pregnant women, in 77% to 95% of cases (Forray, 2016). Moreover, Substance-abusing women frequently experience inadequate prenatal care, poor nutrition, chronic medical problems, poverty, and domestic violence (Forray, 2016).
V. Prescription Opiate Causation
Illicit drug use is unfortunately common among young, pregnant females. In the year prior to pregnancy, 36.5% of teenagers used illegal drugs, typically marijuana. 16.2%-16.5% of pregnant teens use illicit drugs during pregnancy (Chandler, 1997). 7.4% of pregnant women aged 18 to 25 years have been shown to use (Substance Abuse and Mental Health Administration, 2010). As women mature, illicit drug use drops substantially, such that the overall average usage by women aged 15 to 44 years is about 4.4% (Bersani, 2013) to 5.4% (NSDUH, 2014). The NAS epidemic has been described as driven primarily by a nationwide increase in prescription drug use (Patrick, Dudley, Martin, Harrell, Warren, & Hartmann, 2015).
Of 26,314 deliveries studied by Kellogg, et. al., 167 (6.34 per 1,000) women chronically used prescription narcotics during pregnancy. The prevalence of chronic, opium-using pregnant women increased between 1998 and 2009 (Kellogg, Rose, Harms, & Watson, 2011).
Opiate use is increasing across the United States. It is not limited to illicit drugs. The misuse of opioid medications has been called the most rapidly increasing drug problem in the US (Peltz & Drover, 2012). In Florida, opiate pain reliever-related deaths account for 4 times the number of deaths as all illicit drugs (Centers for Disease Control and Prevention, 2011a). The Centers for Disease Control and Prevention found both sales and deaths related to opiate pain relievers quadrupled between 1999 and 2008 in the United States (2011b).
VI. Other Drug Causation
Alcohol use in pregnancy has well-established adverse fetal health effects. Heavy alcohol use in pregnancy is associated with a range of negative birth outcomes such as miscarriage, stillbirth, infant mortality, congenital anomalies, low birthweight, reduced gestational age, preterm delivery, small-for-gestational age, cognitive challenges, adverse neurodevelopmental outcomes, behavioral challenges, psychosocial consequences in adulthood, speech difficulties, and adverse language outcomes (Forray, 2016).
Smoking tobacco during pregnancy causes many negative birth outcomes, such as umbilical cord damage, miscarriage, ectopic pregnancy, low birthweight, placental abruption, preterm birth, increased infant mortality. Moreover, post-birth, second-hand smoke creates higher rates of respiratory and ear infections in newborns, sudden infant death syndrome, behavioral dysfunction and cognitive impairment (Forray, 2016).
Marijuana during pregnancy has been linked to preterm labor, low birthweight, small-for-gestational age, admission to the neonatal intensive care unit, adverse consequences for the growth of fetal brains, adverse adolescent brain growth, reduced attention, reduced executive functioning skills, poorer academic achievement and behavioral problems (Forray, 2016).
In several large, recent studies, cocaine use in pregnancy is associated with negative outcomes such as premature rupture of membranes, placental abruption, preterm birth, low birthweight, and small-for-gestational-age infants (Forray, 2016).
Methamphetamine use is linked with shorter gestational ages, lower birthweight, fetal loss, developmental defects, behavioral problems, preeclampsia, gestational hypertension, and intrauterine fetal death (Forray, 2016).
Other drugs such as benzodiazepines, opioids, mood-stabilizing drugs, and selective serotonin reuptake inhibitors may induce NAS. Such drugs are metabolized by the placenta, and their metabolites cross the placental barrier. These drugs produce prenatal injuries such as NAS and symptoms such as intrauterine growth restriction, preterm birth, low birth weight, gastroschisis, heart defects, cleft lip, sudden infant death syndrome, increased respiratory infections, ear infections, sinus infections, neurological disorders and behavioral disorders (Bersani, 2013).
VII. Treatment
Newborns suffering with NAS may be treated with pharmacotherapies such as morphine, methadone, or phenobarbitol (Burns & Mattick, 2007) (Petz & Anand, 2015). From 2004 to 2013, the proportion of infants with NAS who received pharmacotherapy increased from 74% to 87% (Tolia, et. al., 2015). Morphine is the most common medication used to treat infants suffering from NAS, up to 72% in 2013, from 49% in 2004 (Tolia, et. al., 2015). Other medications used to treat NAS include benzodiazepines (clonazepam, diazepam, lorazepam, or midazolam), opioids, mood-stabilizing drugs, selective serotonin reuptake inhibitors, buprenorphine, clonidine, dilute tincture of opium, and nicotine (Bersani, 2013) (Tolia, et. al., 2015).
As always, breastfeeding is recommended. Although the amount of methadone in breast milk is low, breast-fed newborns are characterized by less severe NAS and lower need for pharmacologic treatment. It is not clear if these effects are secondary to the drug itself or the calming effect of breastfeeding. (Bersani, 2013). However, methadone in breast milk is insufficient to prevent NAS (Henshaw, Cox, & Barton, 2009). In any case, ongoing irritability associated with the syndrome (excessive crying, feeding difficulties and sleep disturbances that may recur over the first 6 months) can hinder the attachment process between the newborn and mother (Burns & Mattick, 2007).
Babies suffering with NAS are frequently cared for in neonatal intensive care units (NICUs). NICUs offer minimization of external stimulation that can exacerbate withdrawal symptoms, but NICUs are costly. Studies suggest that caring for NAS-suffering babies in hospital settings outside NICUs (Saiki, Lee, Hannam, & Greenough, (2009) and outpatient management reduce both length of stay and cost (Backes et. al., 2011). NICU days attributed to NAS increased 7-fold from 0.6% in 2004 to 4% in 2013. Up to 20% of all NICU days in some centers are used by babies suffering from NAS (Petz & Anand, 2015).
However, it has been shown babies fare better rooming with their mothers than being in the NICU or the nursery. This is not typical practice in United States, even for normal babies. But breast-feeding, skin -to-skin contact, and bonding greatly reduce the amount of medication needed (Knopf, 2016). Studies have found rooming-in reduces costs. (Holmes, 2016a) (Holmes, 2016b). On the other hand, substance-using pregnant women can develop an early dysfunctional mother-infant relationship that can exacerbate negative effects of prenatal drug exposure. (Forray, 2016).
Some researchers argue that scientific evidence does not support linking substance use with judicial determinations of maternal unfitness. The argument is that further criminalizing substance use by pregnant women causes pregnant women to refrain from seeking obstetric care and substance use treatment, which can negatively affect the health of both mother and child (Lund, et. al., 2015).
Tolia, et. al. studied 674,845 infants at 299 clinical centers from 2004 through 2013. 10,327 infants, almost 2% met the criteria for NAS. From 2004 to 2013, NICU admissions for NAS increased from 7 cases per 1000 admissions to 27 cases per 1000 admissions (2015). Furthermore, throughout the period of study, the rate of increase accelerated (Tolia, et. al., 2015). Total NICU days attributed to infants with NAS increased from 0.6% in 2004 to 4.0% in 2013 (Tolia, et. al., 2015).
23 of 213 centers reported that more than 10% of their NICU days were attributable to infants suffering from NAS in 2013, as compared with 1 of 157 centers in 2004 (Tolia, et. al., 2015). Moreover, in 2013, more than 20% of NICU days at 8 centers were devoted to NAS babies, and more than 40% of NICU days at 2 centers were devoted to NAS babies. (Figure 2B) (Tolia, et. al., 2015). In 2013, 4% of all NICU hospital days nationwide were used by infants suffering with NAS. This is a 6 to 7 times increase over 2004 (Tolia, et. al., 2015).
The median length of hospital stay for NAS-suffering babies was 13 days in 2004 (Tolia, et. al., 2015). In the intervening years it climbed. Burns and Mattick reported 16 days (2007). Agthe, et al reported 16 days (2009). Patrick et al. reported 15-17 days (2012). By 2015, Tolia et. al. reported the average had been 19 days in 2013. Patient admissions, length of stay, and resource utilization for infants suffering from NAS, and admitted to NICUs, are increasing. Effective strategies are required for prenatal prevention and postnatal treatment of NAS (Tolia, et. al., 2015).
VIII. Conclusion
NAS incidence and hospital charges have steadily and substantially grown. A typical NAS-suffering newborn's cost has been measured at $159,000 to $238,000 more than other newborns (Petz & Anand, 2015). We must act to reduce human suffering and to reduce the growing societal costs of in-utero and newly-born opium addicts.
These numbers, however alarming, may understate the costs of this epidemic. Unless a mother is arrested or reports opiate use, and this is committed to the medical record, the opiate use is not be included in the newborn baby's file. Thus maternal opiate use is likely underestimated. We must seek to limit the costs created by both illicit drugs and the effects of opioid pain reliever misuse (Patrick, Davis et. al., 2015). North Carolina should seek innovative solutions to decrease the burdens of NAS, because the majority of hospital expenditures for this condition are shouldered by state Medicaid programs.
IV. References
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