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Substance Use and Addiction Medicine

Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses in the US, 2010-2017

Educational Objective
To understand the relationship of maternal substance use and the development of neonatal abstinence syndrome.

1 Credit CME

JAMA

Published Online: January 12, 2021

Original Investigation

Article Information and Disclosures

Ashley H. Hirai, PhD¹;

Jean Y. Ko, PhD^2,3;

Pamela L. Owens, PhD⁴;

Carol Stocks, PhD, RN^5,6;

Stephen W. Patrick, MD, MPH, MS^2,7,8,9

Author Affiliations

¹Maternal and Child Health Bureau, Health Resources and Services Administration Department of Health and Human Services, Rockville, Maryland
²Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention Department of Health and Human Services, Atlanta, Georgia
³Commissioned Corps Public Health Service Department of Health and Human Services, Rockville, Maryland
⁴Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality Department of Health and Human Services, Rockville, Maryland
⁵West Virginia University, School of Public Health, Morgantown
⁶formerly with the Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality Department of Health and Human Services, Rockville, Maryland at the time of analysis
⁷Department of Pediatrics, Vanderbilt Center for Child Health Policy, Nashville, Tennessee
⁸Department of Health Policy, Vanderbilt Center for Child Health Policy, Nashville, Tennessee
⁹Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee

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Viewpoint

Long-Acting Opioids for Treating Neonatal Abstinence Syndrome

Gary Peltz, MD, PhD; Kanwaljeet J. S. Anand, MBBS, DPhil
Review

Neonatal Abstinence Syndrome: A Review

Elisha M. Wachman, MD; Davida M. Schiff, MD, MSc; Michael Silverstein, MD, MPH
Comment & Response

US Hospital Data About Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses—Reply

Ashley H. Hirai, PhD; Jean Y. Ko, PhD; Stephen W. Patrick, MD, MPH, MS
Comment & Response

US Hospital Data About Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses

Marjorie Meyer, MD; Jerilyn Metayer, RN
Correction

Error in Supplement
Research Letter

Neonatal Abstinence Syndrome Rates During the Opioid Abuse Epidemic

Joshua D. Brown, PharmD, MS; Pratik A. Doshi, MS; Nathan J. Pauly, BS; Jeffery C. Talbert, PhD
Original Investigation

Pharmacological Treatments for Neonatal Abstinence Syndrome

Timothy Disher, PhD(c); Courtney Gullickson, BSc; Balpreet Singh, MD; Chris Cameron, PhD; Leah Boulos, MLIS; Louis Beaubien, PhD; Marsha Campbell-Yeo, PhD

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Key Points

Question In the US from 2010 to 2017, what were national-level and state-level rates in neonatal abstinence syndrome (NAS) and maternal opioid-related diagnoses (MOD)?

Findings In this repeated cross-sectional analysis including 11.8 million hospitalizations from 47 states and the District of Columbia, the national estimated rate of NAS was 7.3 per 1000 birth hospitalizations and the rate of MOD was 8.2 per 1000 delivery hospitalizations in 2017. From 2010 to 2017, estimated rates significantly increased nationally and for the majority of states, with substantial state-level variation.

Meaning In the US, NAS and MOD rates increased from 2010 to 2017, with notable state-level variation.

Abstract

Importance Substantial increases in both neonatal abstinence syndrome (NAS) and maternal opioid use disorder have been observed through 2014.

Objective To examine national and state variation in NAS and maternal opioid-related diagnoses (MOD) rates in 2017 and to describe national and state changes since 2010 in the US, which included expanded MOD codes (opioid use disorder plus long-term and unspecified use) implemented in International Classification of Disease, 10th Revision, Clinical Modification.

Design, Setting, and Participants Repeated cross-sectional analysis of the 2010 to 2017 Healthcare Cost and Utilization Project’s National Inpatient Sample and State Inpatient Databases, an all-payer compendium of hospital discharge records from community nonrehabilitation hospitals in 47 states and the District of Columbia.

Exposures State and year.

Main Outcomes and Measures NAS rate per 1000 birth hospitalizations and MOD rate per 1000 delivery hospitalizations.

Results In 2017, there were 751 037 birth hospitalizations and 748 239 delivery hospitalizations in the national sample; 5375 newborns had NAS and 6065 women had MOD documented in the discharge record. Mean gestational age was 38.4 weeks and mean maternal age was 28.8 years. From 2010 to 2017, the estimated NAS rate significantly increased by 3.3 per 1000 birth hospitalizations (95% CI, 2.5-4.1), from 4.0 (95% CI, 3.3-4.7) to 7.3 (95% CI, 6.8-7.7). The estimated MOD rate significantly increased by 4.6 per 1000 delivery hospitalizations (95% CI, 3.9-5.4), from 3.5 (95% CI, 3.0-4.1) to 8.2 (95% CI, 7.7-8.7). Larger increases for MOD vs NAS rates occurred with new International Classification of Disease, 10th Revision, Clinical Modification codes in 2016. From a census of 47 state databases in 2017, NAS rates ranged from 1.3 per 1000 birth hospitalizations in Nebraska to 53.5 per 1000 birth hospitalizations in West Virginia, with Maine (31.4), Vermont (29.4), Delaware (24.2), and Kentucky (23.9) also exceeding 20 per 1000 birth hospitalizations, while MOD rates ranged from 1.7 per 1000 delivery hospitalizations in Nebraska to 47.3 per 1000 delivery hospitalizations in Vermont, with West Virginia (40.1), Maine (37.8), Delaware (24.3), and Kentucky (23.4) also exceeding 20 per 1000 delivery hospitalizations. From 2010 to 2017, NAS and MOD rates increased significantly for all states except Nebraska and Vermont, which only had MOD increases.

Conclusions and Relevance In the US from 2010 to 2017, estimated rates of NAS and MOD significantly increased nationally and for the majority of states, with notable state-level variation.

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Article Information

Corresponding Author: Ashley H. Hirai, PhD, Office of Epidemiology and Research, Maternal and Child Health Bureau, Health Resources and Services Administration, 5600 Fishers Ln, Rockville, MD 20857 (ahirai@hrsa.gov).

Accepted for Publication: December 2, 2020.

Correction: This article was corrected on June 8, 2021, to correct an error in the Supplement that inadvertently included 2 “in remission” International Classification of Disease, 10th Revision, Clinical Modification codes. An updated Supplement has been provided.

Author Contributions: Drs Owens and Hirai had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Hirai, Ko, Owens, Patrick.

Drafting of the manuscript: Hirai, Ko.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hirai, Ko, Owens, Patrick.

Administrative, technical, or material support: Hirai, Owens, Stocks.

Supervision: Patrick.

Conflict of Interest Disclosures: Dr Patrick reported receiving grants from the National Institute on Drug Abuse, the Centers for Medicare and Medicaid Innovation, the Robert Wood Johnson Foundation, The Boedecker Foundation, and the National Institute on Child Health and Human Development outside the submitted work. No other disclosures were reported.

Funding/Support: No extramural funding was provided for this work. This research was conducted as part of a collaboration between the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the Health Resources and Services Administration. Data collection and manipulation for this research was supported, in part, by the Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project contract No. HHSA-290-2018-00001-C (awarded to IBM Watson Health).

Role of the Sponsor: The Agency for Healthcare Research and Quality sponsors had a role in the design and conduct of the Healthcare Cost and Utilization Project and in the collection and management of the data. The manuscript underwent clearance within the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the Health Resources and Services Administration prior to submission. However, no agency had a role in the preparation of the manuscript or in the decision to submit the manuscript for publication.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Department of Health and Human Services, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, or the US Public Health Service.

Additional Contributions: The authors gratefully acknowledge Marguerite Barrett, MS (M.L. Barrett, Inc, subcontractor to IBM Watson Health), and Minya Sheng, MS (IBM Watson Health), for assistance in programming and data management, who received compensation through a contract (HHSA-290-2018-00001-C) awarded to IBM Watson Health, and the 48 HCUP Partner organizations that contributed to the HCUP National Inpatient Sample and State Inpatient Databases used in this analysis: Alaska State Hospital and Nursing Home Association, Arizona Department of Health Services, Arkansas Department of Health, California Office of Statewide Health Planning and Development, Colorado Hospital Association, Connecticut Hospital Association, Delaware Delware Department of Health and Social Services, District of Columbia Hospital Association, Florida Agency for Health Care Administration, Georgia Hospital Association, Hawaii Laulima Data Alliance, a subsidiary of the Healthcare Association of Hawaii (and Hawaii Health Information Corporation), Illinois Department of Public Health, Indiana Hospital Association, Iowa Hospital Association, Kansas Hospital Association, Kentucky Cabinet for Health and Family Services, Louisiana Department of Health, Maine Health Data Organization, Maryland Health Services Cost Review Commission, Massachusetts Center for Health Information and Analysis, Michigan Health & Hospital Association, Minnesota Hospital Association, Mississippi State Department of Health, Missouri Hospital Industry Data Institute, Montana Hospital Association, Nebraska Hospital Association, Nevada Department of Health and Human Services, New Jersey Department of Health, New Mexico Department of Health, New York State Department of Health, North Carolina Department of Health and Human Services, North Dakota (data provided by the Minnesota Hospital Association), Ohio Hospital Association, Oklahoma State Department of Health, Oregon Association of Hospitals and Health Systems, Pennsylvania Health Care Cost Containment Council, Rhode Island Department of Health, South Carolina Revenue and Fiscal Affairs Office, South Dakota Association of Healthcare Organizations, Tennessee Hospital Association, Texas Department of State Health Services, Utah Department of Health, Vermont Association of Hospitals and Health Systems, Virginia Health Information, Washington State Department of Health, West Virginia Health Care Authority, Wisconsin Department of Health Services, and Wyoming Hospital Association.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.