JAMA Editorial Focuses on Prescription Opiate Abuse Epidemic in Newborns

As the national epidemic of opiate abuse and addiction continues to swell, the social and financial burden of treating infants born to drug-addicted mothers grows, too. 

In poor, rural states like Maine, where opiate abuse rates are among the highest in the nation, clinicians and researchers have developed an expertise born of necessity in managing opiate addiction in pregnant women and Neonatal Abstinence Syndrome (NAS) in the infants they bear. But rural states also are the most likely feel the pinch in their cash-strapped Medicaid budgets of the increased demand for treatment.

The current issue of the “Journal of the American Medical Association” features an editorial co-written by University of Maine psychology professor Marie Hayes and Dr. Mark Brown, chief of pediatrics and director of nurseries at Eastern Maine Medical Center in Bangor. The article, “The Epidemic of Prescription Opiate Abuse and Neonatal Abstinence,” details the challenges of caring for this vulnerable population, cautions against defunding maternal treatment programs, and calls for stepped-up research into effective medications and other protocols.

“The burden of addiction on state Medicaid budgets threatens retrenchment of recently established programs despite increased need. This poses a crisis of care for affected fetuses and newborns,” Brown and Hayes write. “However, without accessible treatment of both maternal opiate addiction and new methods of treating NAS, state and federal systems may pay in the future because many of these infants require special services for developmental and behavioral disorders.”

Maine’s high rate of opiate abuse – 386 admissions per 100,000 population in 2009 compared to the 45/100,000 national average – has challenged clinicians at the state’s two largest hospitals, Eastern Maine Medical Center in Bangor and Maine Medical Center in Portland, according to the editorial.

The JAMA issue also features a report on the rapidly increasing cost of treating NAS in the United States, entitled “Neonatal Abstinence Syndrome and Associated Health Care Expenditures, United States, 2000-2009.” Lead author Dr. Stephen W. Patrick of the University of Michigan Health System in Ann Arbor calls on the medical community to develop treatment innovations and efficiencies in order to improve outcomes and drive down costs for state Medicaid programs, even as demand for treatment grows.

Hayes, who is a member of UMaine’s Graduate School of Biomedical Sciences, and Brown are conducting an ongoing longitudinal study of NAS babies, tracking their physiological and cognitive development into their toddler years.

Symptoms of NAS include tremors, neurologic irritability, seizures, respiratory distress, feeding difficulties, gastric distress and sleep disturbance. Approximately 60 to 80 percent of infants exposed to opiate drugs in utero develop some or all of these symptoms shortly after birth. In some cases, medical providers are aware of the mother’s drug use and are on the lookout for NAS in their infants, which improves outcomes. In many other cases, clinicians have not anticipated the possibility of NAS and treatment is delayed.

Infants who develop NAS require 24-hour hospital inpatient monitoring and pharmacological management of their withdrawal. The average length of hospitalization is 16 days. Patrick estimates the average cost of NAS hospitalization in 2009 was about $53,000 per case, increasing in recent years by more than five times the rate of other hospital costs. Between 2000 and 2009, the incidence of hospital-treated NAS rose from 1.2 cases per 1,000 births to 3.39/1,000.

The rate of maternal opiate use increased over the study period by a factor of five. The standard of care for managing opiate-dependent women during pregnancy is replacement drug therapy, using either methadone or buprenorphine, along with psychotherapy. Women who comply with replacement therapy protocols are less likely to deliver prematurely and their babies are generally healthier than those born to women who continue to use street drugs.

Treatment protocols vary widely and Patrick’s study does not specifically address this cost. But the cost of both prenatal maintenance therapy and NAS treatment is borne most often by state Medicaid programs.

“The increasing incidence of NAS and its related health care expenditures call for increased public health measures to reduce antenatal exposure to opiates across the United States,” Patrick concludes. “In addition, further innovation and standardization of treatment of NAS may mitigate NAS symptoms and reduce hospital [length of stay.] States are poised to seek innovative solutions to decreasing the burden of NAS, because the majority of hospital expenditures for this condition are shouldered by state Medicaid programs.”

Contact: Margaret Nagle, (207) 581-3745