A Growing and Costly Public Health Problem: In 2009, One Baby per Hour was Born Drug-Affected in the United States

Study by RWJF scholar finds big increases in women on opiate drugs while pregnant, and newborns suffering withdrawal.

Between 2000 and 2009, the number of babies born experiencing drug withdrawal increased nearly three-fold, and the number of pregnant women using opiate drugs at the time of delivery increased nearly five-fold, according to a study led by Stephen W. Patrick, MD, MPH, MS, a Robert Wood Johnson Foundation (RWJF) Clinical Scholar (2010-2012) at the University of Michigan.

During the same period, the cost of health care for these babies nearly quadrupled, the study concludes. It is believed to be the first study to examine the increasing trend of drug withdrawal in newborns—known as Neonatal Abstinence Syndrome, or NAS—and its impact on the U.S. health care system.

“In 2009, there were more than 13,000 infants born with NAS, about the equivalent of one baby per hour born with the syndrome,” says Patrick, a physician in the Division of Neonatal-Perinatal Medicine and the Department of Pediatrics and Communicable Diseases at the University of Michigan Health System in Ann Arbor. “That’s a pretty astonishing statistic, and one that warrants much more attention to this issue” by policy-makers and health care professionals, he says.

Although the research data did not specify which opiate drugs affected what proportion of mothers and babies, the study spans a decade in which medical practitioners significantly increased their rate of prescribing opioid analgesics, the class of prescription pain relievers that includes brand names such as Vicodin and OxyContin. The Centers for Disease Control and Prevention now identifies prescription drug abuse as the fastest growing drug problem in the United States and reports that since 2003, more overdose deaths have involved opioid analgesics than have involved cocaine and heroin combined.

“In the study data, we were not able to see exactly what opiates the moms were using, so we can’t say with certainty that the rise of opioid pain relievers caused the increases” described in the study, Patrick says. “But given the increased use of these drugs across the United States today, it is quite possible that the increase in maternal opiate use we see is due to opiate pain relievers.”

Patrick presented findings of the study, “Neonatal Abstinence Syndrome and Associated Health Care Expenditures—United States, 2000-2009,” on April 30th at the Pediatric Academic Societies annual meeting in Boston. The same day, the study was published online in JAMA, the Journal of the American Medical Association.

For the study, Patrick and his co-authors used data compiled by the Agency for Healthcare Research and Quality, a branch of the U.S. Department of Health and Human Services. The agency collects detailed hospital billing data from states, removes all personal identifying information from it, and makes the resulting databases available to researchers. To find cases of NAS, Patrick and his co-authors used the agency’s Kids’ Inpatient Database (KID), considered an authoritative source on pediatric hospitalizations because of its size and scope. In 2009, the latest year for which KID is available, the database held information on 7.4 million discharges from more than 4,100 hospitals in 44 states. The study authors analyzed a cross-section of pediatric discharges in 2000, 2003, 2006 and 2009 to find newborns diagnosed with the drug withdrawal syndrome, and from that created national estimates.

To find cases in which mothers’ deliveries were associated with substance abuse, the authors looked at the agency’s Nationwide Inpatient Sample (NIS), a similarly large and nationally-representative database that tracks discharges from U.S. hospitals. They then created estimates by analyzing, for the same four years, a cross-section of discharges of mothers identified as using or dependent upon opiates. That would have included methadone or other opioid analgesics used under medical supervision as well as drugs used illicitly.

The study concluded that in 2009, the incidence of NAS was 3.39 per 1,000 hospital births per year, nearly a three-fold increase over the rate of 1.2 per 1,000 hospital births per year in 2000. It also reported that newborns with NAS were significantly more likely than other newborns to be diagnosed with respiratory problems, and to have low birthweight, seizures and difficulty feeding. “And those are just the complications right after birth,” Patrick says. “We really need further study to follow these babies longitudinally, to examine their neurodevelopmental outcomes, health care utilization patterns and other issues.”

On average, hospital charges for caring for newborns with NAS were about five times more than charges for babies in other hospital births, the study reports. From 2000 to 2009, the cost of health care for newborns diagnosed with NAS nearly quadrupled, soaring from $190 million to $720 million, the study finds. During that time, although medical advances shortened hospital stays for some other conditions, the length of stay for NAS babies stayed about the same, at a mean of 16 days. “This finding raises the possibility that care for opiate-using expectant mothers and their newborns might be able to be delivered in a more efficient and effective manner, which could more effectively relieve symptoms of withdrawal, shorten length of stay and reduce expenditures,” Patrick says.

In the case of 78 percent of NAS newborns and 60 percent of opiate-using mothers, the health care costs were billed to state Medicaid programs, the study found. Patrick believes that this information should “give states increased incentive” to address the problem.

Not every baby born to an opiate-using mother experiences withdrawal, Patrick says. However, studies have found withdrawal syndrome in 60 to 80 percent of babies born to women who were using heroin or methadone, and a somewhat smaller share of women who were using opiate pain relievers. That means that the nearly five-fold increase in the rate of delivering mothers using opiates—from 1.19 per 1,000 hospital births per year in 2000 to 5.63 per 1,000 hospital births per year in 2009—represents a growing public health challenge.

Patrick hopes the study will “draw attention to a syndrome and an issue that people just aren’t talking about. From a policy perspective, we need to think about the ways we use opiate pain relievers in the United States and how their use might be decreased. Researchers must continue to investigate ways to maximize approaches to alleviating these babies’ symptoms in the most effective way. Most of all, the study calls for a coordinated public health approach to decrease and prevent opiate exposure before it begins.”

The report, “Neonatal Abstinence Syndrome and Associated Health Care Expenditures—United States, 2000-2009” was published online in JAMA on April 30th. Co-authors with Patrick on the study were Robert E. Schumacher, MD; Brian D. Benneyworth, MD, MS; Elizabeth E. Krans, MD, MS; Jennifer M. McAllister, MD; and Matthew M. Davis, MD, MAPP, who is co-directorâ?¨of the Michigan RWJF Clinical Scholars program.