Neonatal Abstinence Syndrome is Booming, Most Common in Medicaid Patients

Tyler Winkelman, MD, MSc

Annual neonatal abstinence syndrome (NAS) rates among infants in the US worsened by 433% from 2004 to 2014, according to a new study.

Now at the height of the opioid epidemic, every 15 minutes an infant is born in the US with withdrawal symptoms due to pre-birth exposure to opioids. The study — from researchers at Vanderbilt University, Hennepin Healthcare in Minneapolis, MN, and other institutions — found this rate equates to 8.0 diagnoses per 1000 hospital births (95% CI; 7.2 — 8.7). It is a fivefold-plus increase from the 2004 rate of 1.5 per 10000 births (95% CI; 1.2 – 1.9).

The rate has worsened even more for infants born under Medicaid health care coverage. In sampling 43.6 million weighted births from the observed period, researchers found 19.1 million (43.9% [95% CI; 42.8 — 44.9]) were under Medicaid primary care. Of the 173,384 observed births to include an NAS diagnosis, Medicaid was the primary payer for 73.7% (95% CI; 68.9 – 77.9) of the births in 2004 and 82% (95% CI; 80.5 – 83.5) of the births in 2014.

First author Tyler Winkelman, MD, MSc, a clinician-investigator for the Division of General Internal Medicine at Hennepin, told MD Magazine the disparity between Medicaid-based and private insurer-based NAS rates is “particularly striking.

“Almost 1.5% of every birth covered by Medicaid involved NAS, according to our study,” Winkelman said. “It is 7 times more prominent in those infants than those covered by private insurance.”

NAS has been widely linked to mothers’ use of both illicit opioids such as heroin, and prescription therapies. Many infants exposed to opioids during pregnancy xperience withdrawal symptoms shortly after birth that include feeding and breathing problems, and are also more likely to be born at a lower bodyweight.

The researchers’ findings sit with broader literature that has previously observed the relation between lower-income individuals and susceptibility to substance abuse disorder, Winkelman said. In cases of NAS, lower-income individuals on Medicaid are also more susceptible to worse outcomes. Winkelman noted that infants covered by Medicaid reported a longer mean hospital stay for NAS than privately-insured by nearly 2 days, and were also more likely to be transferred to another facility for supplemental care between 2010-2014.

“There are substance abuse disorder in every wage bracket, but they occur at a higher rate for lower income individuals,” Winkelman said. “There are many reasons why that is the case, but it is the case.”

Despite patients’ shortcomings, the Centers for Medicare and Medicaid Services remain the nation’s leader payer for NAS-related care, paying for approximately $2.5 billion in mother and infant therapies over the observed decade, researchers wrote. They encouraged the agency and its related state programs to embrace more standard clinical protocol, noting clinical benefits for nonpharmacologic treatment of infants with NAS including rooming-in, breast-feeding, swaddling, feeding schedules, and minimized sleep disruption.

Winkelman emphasized treatment access for both expecting mothers and women at child-bearing ages, stating it’s a proven fact the mothers and children involved in NAS diagnoses report better outcomes under standardized treatment.

“It comes back to this point of treatment,” Winkelman said. “The first line of treatment for opioid addiction is methodone and suboxone. Women who are of child-bearing age should have access to medication-assisted treatment — it improves outcomes.”

The study, "Incidence and Costs of Neonatal Abstinence Syndrome Among Infants With Medicaid: 2004—2014," was published online in Pediatrics this week.