OBJECTIVES:

To describe incidence, health care use, and cost trends for infants with neonatal abstinence syndrome (NAS) who are covered by Medicaid compared with other infants.

METHODS:

We used 2004–2014 hospital birth data from the National Inpatient Sample, a nationally representative sample of hospital discharges in the United States (N = 13 102 793). Characteristics and trends among births impacted by NAS were examined by using univariate statistics and logistic regression.

RESULTS:

Medicaid covered 73.7% of NAS-related births in 2004 (95% confidence interval [CI], 68.9%–77.9%) and 82.0% of NAS-related births in 2014 (95% CI, 80.5%–83.5%). Among infants covered by Medicaid, NAS incidence increased more than fivefold during our study period, from 2.8 per 1000 births (95% CI, 2.1–3.6) in 2004 to 14.4 per 1000 births (95% CI, 12.9–15.8) in 2014. Infants with NAS who were covered by Medicaid were significantly more likely to be transferred to another hospital and have a longer length of stay than infants without NAS who were enrolled in Medicaid or infants with NAS who were covered by private insurance. Adjusting for inflation, total hospital costs for NAS births that were covered by Medicaid increased from $65.4 million in 2004 to $462 million in 2014. The proportion of neonatal hospital costs due to NAS increased from 1.6% in 2004 to 6.7% in 2014 among births that were covered by Medicaid.

CONCLUSIONS:

The number of Medicaid-financed births that are impacted by NAS has risen substantially and totaled $462 million in hospital costs in 2014. Improving affordable health insurance coverage for low-income women before pregnancy would expand access to substance use disorder treatment and could reduce NAS-related morbidity and costs.

What’s Known on This Subject:

Neonatal abstinence syndrome (NAS) disproportionately impacts Medicaid beneficiaries. However, NAS incidence and associated costs among infants with Medicaid are poorly defined and overall national estimates of NAS in the United States are out-of-date.

What This Study Adds:

Between 2004 and 2014, NAS incidence rose over fivefold among a nationally representative sample of infants with Medicaid. By 2014, NAS impacted 14.4 infants per 1000 births and totaled $462 million in hospital costs among births financed by Medicaid.

The incidence of neonatal abstinence syndrome (NAS) rose sharply between 2000 and 2012 as the opioid epidemic expanded across the United States.1,3 NAS is a withdrawal syndrome that occurs in infants who are exposed to opioids in utero. The syndrome is characterized by tremors, irritability, poor feeding, respiratory distress, and seizures, all of which develop shortly after birth.4 Infants with NAS have longer hospital stays, higher rates of readmission, and are more likely than nonopioid-exposed newborns to require care in the NICU for management of their symptoms.5,7 

Maternal opioid use and NAS disproportionately impact low-income women and infants who receive medical care covered by Medicaid.3,5 Although Medicaid pays for the majority of NAS-related births, the incidence of NAS among births financed by Medicaid remains poorly defined.3,5 Furthermore, although reports of hospital costs for NAS-related care exist, there are no data describing aggregate NAS-related hospital costs among infants enrolled in Medicaid, nationally.8,9 Hospital costs are important to consider because Medicaid does not reimburse on the basis of charges but on a schedule often closer to costs. Information regarding NAS incidence and costs could help state and federal health officials target efforts to improve care delivery for infants with the syndrome, expand treatment for pregnant women, and prevent NAS. For these reasons, Congress called on the Government Accountability Office to report “the proportion of children born in the United States with NAS who are eligible for medical assistance under State Medicaid programs…and the costs associated with coverage under such programs.”10 However, the subsequent Government Accountability Office report was largely based on qualitative data, because little quantitative data are available to guide such an overview.11 

We sought to characterize the impact of NAS among Medicaid beneficiaries by addressing the following 3 important and unanswered questions: (1) What is the incidence of NAS among Medicaid-financed births, nationally, and how has it changed over time?; (2) What are the characteristics and health care use patterns of infants with NAS who were enrolled in Medicaid compared with infants without NAS who were enrolled in Medicaid and infants with NAS who were enrolled in private insurance?; and (3) How did mean and aggregate hospital costs change between 2004 and 2014 for infants with NAS covered by Medicaid? We also contribute to the literature on NAS by providing the most recent NAS incidence estimates based on available national data.

We conducted a serial cross-sectional analysis by using data from the 2004 through 2014 National Inpatient Sample (NIS) compiled by the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality.12 The NIS is the largest annual all-payer database of hospital discharges in the United States. It includes patient and hospital-level data from more than 1000 nonfederal hospitals in 46 states and encompasses 97% of the US population. Before 2012, the NIS sample included all discharges from 20% of US hospitals. Beginning in 2012, the NIS sampling frame changed to 20% of discharges from all US hospitals. To account for this sampling redesign, we applied trend weights provided by the Healthcare Cost and Utilization Project to allow for comparison across years.

Our sample consisted of infant discharge records of all hospital births from 2004 through 2014 in the NIS. Births were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes V30.0× to V39.0×. Infants with NAS were identified if ICD-9-CM code 779.5 was listed in any diagnosis field. We excluded cases of iatrogenic NAS that occur when an infant is exposed to opioids after birth, using previously described methods.1,3,5 

The NIS provides a primary payer for each hospital discharge. For purposes of this study, the primary payer was categorized as either private, Medicaid, or uninsured. Discharges with any public primary payer were categorized as Medicaid because Medicaid paid for >99% of birth-related discharges covered by a public payer in all our sampled years.5 

We examined characteristics of infants with NAS who were enrolled in Medicaid and compared them to (1) infants enrolled in Medicaid without NAS, and (2) infants enrolled in private insurance with NAS. We compared differences in sex, income quartile of patient’s zip code, and rural status. We also estimated incidence of preterm deliveries (ICD-9-CM codes 765.21–765.28) and presence of comorbidities known to be common among infants with NAS by using previously described methods (ie, respiratory diagnoses, low birth weight, seizures, or feeding difficulty).5 

NAS Incidence

We first calculated the annual national incidence of NAS among all infants per 1000 hospital births. We then determined the annual incidence of NAS within Medicaid and private payer subgroups. The purpose of this subgroup analysis was to ultimately determine costs among infants whose care was financed by a health insurance entity, and thus, we did not examine NAS incidence among uninsured infants.

Health Care Use and Costs

We compared the rate of hospital transfer to another facility, mean length of stay, and mean cost of birth hospitalization among infants with NAS who were enrolled in Medicaid to infants without NAS who were enrolled in Medicaid and to infants with NAS who were enrolled in private insurance.

To obtain hospital costs, we used Agency for Healthcare Research and Quality’s cost-to-charge ratio files to convert charges.8,12 We applied the cost-to-charge ratio to each charge in our analytic sample and inflation-adjusted resultant costs to 2014 dollars by using the Consumer Price Index for All Urban Consumers.13 

We aggregated hospital costs for all NAS births covered by Medicaid in each year of our study. Less than 4% of NAS discharges were missing cost information. Next, we aggregated hospital costs for all births covered by Medicaid in each year of our study. We then determined the proportion of birth-related hospital costs due to NAS in each year of our study among infants covered by Medicaid. Similar analyses were conducted for total birth-related costs due to NAS among all-payers.

Finally, we estimated excess costs among infants covered by Medicaid due to NAS over the course of our study period by multiplying the number of weighted NAS births in each time period by the average cost for a non-NAS birth who were covered by Medicaid and subtracting these values from aggregated hospital costs for infants with NAS who were covered by Medicaid.

We used weighted frequencies to describe characteristics of infants with NAS who were enrolled in Medicaid, infants without NAS who were enrolled in Medicaid, and infants with NAS who were enrolled in private insurance. Differences were compared by using Pearson’s χ2 tests. We similarly estimated health care use and mean hospital costs among these groups by using univariate frequencies and compared differences with χ2 tests and t tests. To characterize broad time trends, we determined length of stay and mean hospital costs during 3 time periods (2004–2006 vs 2007–2010 vs 2011–2014). Because transfer to another facility was only available for years 2010–2014, we did not examine changes in transfer rates over time.

We used multivariable negative binomial and logistic regression to compare length of stay and transfer rates, respectively, between infants with NAS enrolled in either Medicaid or private insurance. Our models accounted for year, sex, income quartile of patient’s zip code, urban versus rural residence, hospital type (rural versus urban nonteaching versus urban teaching), and prematurity.

To obtain annual hospital costs for infants with and without NAS covered by Medicaid we used Stata’s total commands with survey weights. We determined excess costs among infants with NAS covered by Medicaid using methods described in the previous section.

We used logistic regression and predictive margins to obtain unadjusted NAS incidence nationally and among infants who were enrolled in Medicaid or private insurance. NAS incidence is reported as NAS cases per 1000 hospital births.

All analyses were conducted by using Stata 15.0 (StataCorp, College Station, TX). Estimates are weighted, unless otherwise noted, to allow for nationally representative inferences and to account for changes to the NIS sampling strategy in 2012. We considered 2-sided P < .05 to be statistically significant. Our study was exempt from human subjects review per the Minneapolis Medical Research Foundation’s policy on de-identified data sets.

Our sample consisted of 9 115 457 birth discharge records from 2004 through 2014, representative of 43.6 million weighted births. In this sample, 3 991 336 infants were covered by Medicaid, representative of 19.1 million weighted births. Medicaid was the primary payer for 43.9% of hospital births (95% confidence interval [CI], 42.8%–44.9%) in our pooled national sample. There were 35 629 infants with a diagnosis of NAS during our study period, representative of 173 384 weighted births. Medicaid was the primary payer for 73.7% (95% CI, 68.9%–77.9%) of NAS-related births in 2004 and 82.0% (95% CI, 80.5%–83.5%) of NAS-related births in 2014.

Infants with NAS who were enrolled in Medicaid were significantly more likely to be male, reside in a rural county, and have comorbidities reflective of the syndrome than infants without NAS who were enrolled in Medicaid. Similarly, infants with NAS who were enrolled in Medicaid were more likely to live in poor and rural counties but were less likely to be diagnosed with a NAS-related comorbidity compared with infants with NAS enrolled in private insurance (Table 1).

TABLE 1

Characteristics of Infants Enrolled in Medicaid With NAS, Medicaid Without NAS, and Private Insurance With NAS, United States, 2004–2014

CharacteristicMedicaid With NAS, Weighted % (95% CI)Medicaid Without NAS, Weighted % (95% CI)PaPrivate With NAS, Weighted % (95% CI)Pa
Unweighted, n 28 251 3 963 085 na 4906 na 
Weighted population estimate 137 575 18 961 469 na 23 834 na 
Female 46.0 (45.3–46.6) 49.0 (48.9–49.0) <.001 44.1 (42.7–45.6) .02 
Income quartile   .15  <.001 
 1, lowest income 39.4 (37.7–41.1) 40.0 (38.5–41.4)  21.0 (19.1–23.1)  
 2 27.6 (26.6–28.7) 28.7 (27.8–29.5)  22.4 (20.9–23.9)  
 3 21.6 (20.5–22.7) 20.8 (20.0–21.5)  27.5 (26.0–29.1)  
 4, highest income 11.4 (10.6–12.2) 10.7 (9.7–11.6)  29.0 (27.0–31.1)  
Rural residence 21.1 (19.2–23.1) 16.8 (15.9–17.8) <.001 14.5 (13.0–16.1) <.001 
Preterm delivery, <37 wk 17.7 (17.0–18.3) 8.4 (8.1–8.6) <.001 17.5 (16.3–18.7) .78 
Any comorbidityb 43.9 (42.9–44.9) 12.8 (12.6–13.1) <.001 47.2 (45.5–49.0) <.001 
CharacteristicMedicaid With NAS, Weighted % (95% CI)Medicaid Without NAS, Weighted % (95% CI)PaPrivate With NAS, Weighted % (95% CI)Pa
Unweighted, n 28 251 3 963 085 na 4906 na 
Weighted population estimate 137 575 18 961 469 na 23 834 na 
Female 46.0 (45.3–46.6) 49.0 (48.9–49.0) <.001 44.1 (42.7–45.6) .02 
Income quartile   .15  <.001 
 1, lowest income 39.4 (37.7–41.1) 40.0 (38.5–41.4)  21.0 (19.1–23.1)  
 2 27.6 (26.6–28.7) 28.7 (27.8–29.5)  22.4 (20.9–23.9)  
 3 21.6 (20.5–22.7) 20.8 (20.0–21.5)  27.5 (26.0–29.1)  
 4, highest income 11.4 (10.6–12.2) 10.7 (9.7–11.6)  29.0 (27.0–31.1)  
Rural residence 21.1 (19.2–23.1) 16.8 (15.9–17.8) <.001 14.5 (13.0–16.1) <.001 
Preterm delivery, <37 wk 17.7 (17.0–18.3) 8.4 (8.1–8.6) <.001 17.5 (16.3–18.7) .78 
Any comorbidityb 43.9 (42.9–44.9) 12.8 (12.6–13.1) <.001 47.2 (45.5–49.0) <.001 

Medicaid with NAS is the reference group. na, not applicable.

a

Medicaid With NAS is the reference group.

b

Any respiratory diagnosis, low birth wt, seizure, and feeding difficulty.5 

Between 2004 and 2014, the incidence of NAS in the United States increased from 1.5 per 1000 hospital births (95% CI, 1.2–1.9) to 8.0 per 1000 hospital births (95% CI, 7.2–8.7), a more than fivefold increase (Fig 1). The rising incidence of NAS was driven in large part by a substantial increase in NAS among Medicaid covered births. In 2004, the incidence of NAS among Medicaid-financed births was 2.8 per 1000 hospital births (95% CI, 2.1–3.6). By 2014, 14.4 per 1000 hospital births (95% CI, 12.9–15.8), or 1.4% of all Medicaid-financed births, were affected by NAS. The incidence of NAS births financed by private insurance also increased between 2004 and 2014, but to a lesser degree (2004: 0.5 per 1000 births [95% CI, 0.4–0.6] vs 2014: 2.0 per 1000 births [95% CI, 1.8–2.2]).

FIGURE 1

Incidence of NAS by primary payer.

FIGURE 1

Incidence of NAS by primary payer.

Close modal

In unadjusted analyses, infants with NAS who were covered by Medicaid were significantly more likely to be transferred to another hospital for care than were infants without NAS who were covered by Medicaid or infants with NAS who were covered by private insurance between 2010 and 2014 (Table 2). In each time period we examined, infants with NAS who were covered by Medicaid had hospital stays that were significantly longer than infants without NAS who were covered by Medicaid or infants with NAS who were covered by private insurance (Table 2).

TABLE 2

Unadjusted Health Care Use and Cost Among Infants Enrolled in Medicaid With NAS, Medicaid Without NAS, and Private Insurance With NAS, United States, 2004–2014

CharacteristicMedicaid With NAS, Weighted Estimate (95% CI)Medicaid Without NAS, Weighted Estimate (95% CI)PaPrivate With NAS, Weighted Estimate (95% CI)Pa
Transfer to another hospital, % 8.6 (7.8–9.4) 1.8 (1.7–1.9) <.001 7.0 (6.0–8.1) .01 
Mean length of stay, d      
 2004–2006 14.7 (13.5–15.8) 3.3 (3.2–3.4) <.001 13.2 (12.0–14.3) .02 
 2007–2010 16.9 (16.0–17.8) 3.5 (3.4–3.6) <.001 15.2 (13.7–16.7) .04 
 2011–2014 16.6 (16.1–17.1) 3.5 (3.5–3.6) <.001 14.9 (14.1–15.8) <.001 
Mean costb of birth hospitalization per infant, $      
 2004–2006 15 350 (13 660–17 050) 3060 (2830–3290) <.001 16 610 (14 190–19 020) .28 
 2007–2010 18 510 (16 860–20 160) 3360 (3110–3600) <.001 19 670 (17 400–21 930) .30 
 2011–2014 19 340 (18 290–20 390) 3700 (3670–3840) <.001 21 050 (19 340–22 760) .04 
CharacteristicMedicaid With NAS, Weighted Estimate (95% CI)Medicaid Without NAS, Weighted Estimate (95% CI)PaPrivate With NAS, Weighted Estimate (95% CI)Pa
Transfer to another hospital, % 8.6 (7.8–9.4) 1.8 (1.7–1.9) <.001 7.0 (6.0–8.1) .01 
Mean length of stay, d      
 2004–2006 14.7 (13.5–15.8) 3.3 (3.2–3.4) <.001 13.2 (12.0–14.3) .02 
 2007–2010 16.9 (16.0–17.8) 3.5 (3.4–3.6) <.001 15.2 (13.7–16.7) .04 
 2011–2014 16.6 (16.1–17.1) 3.5 (3.5–3.6) <.001 14.9 (14.1–15.8) <.001 
Mean costb of birth hospitalization per infant, $      
 2004–2006 15 350 (13 660–17 050) 3060 (2830–3290) <.001 16 610 (14 190–19 020) .28 
 2007–2010 18 510 (16 860–20 160) 3360 (3110–3600) <.001 19 670 (17 400–21 930) .30 
 2011–2014 19 340 (18 290–20 390) 3700 (3670–3840) <.001 21 050 (19 340–22 760) .04 
a

Medicaid With NAS is the reference group.

b

Costs are inflation-adjusted to 2014 US dollars and do not include costs after hospital transfer.

Differences in transfer rates and length of stay between infants with NAS who were covered by Medicaid and private insurance persisted after controlling for patient and hospital-level factors. In adjusted analyses, infants with NAS who were covered by Medicaid were more likely to be transferred to another hospital for care (8.6% vs 7.1%; P = .02) and to have longer lengths of stay (16.5 days vs 14.6 days; P < .001) compared with infants with NAS who were covered by private insurance.

The mean cost for an infant with NAS was significantly higher than for an infant without NAS. Between 2011 and 2014, mean hospital costs for an infant with NAS covered by Medicaid were over fivefold higher than for an infant without NAS ($19 340 per birth vs $3700 per birth; P < .001). Mean inflation-adjusted hospital costs for infants with NAS covered by Medicaid increased 26% between 2004 and 2006 and 2011 and 2014 ($15 350 vs $19 340; P < .001; Table 2).

Annual hospital costs (adjusted for inflation to 2014 US dollars) for infants with NAS who were covered by Medicaid increased significantly during our study period. Costs totaled $65.4 million (95% CI, 46.4–84.4) for all infants with NAS who were covered by Medicaid in 2004 and increased to $462 million (95% CI, 383–541) in 2014 (Fig 2). Between 2004 and 2014, hospital costs totaled $2.5 billion (95% CI, 2.3–2.7) for infants with NAS who were covered by Medicaid. If none of these infants had developed NAS, hospital costs would have totaled roughly $487 million. Therefore, NAS resulted in ∼$2 billion in excess costs among Medicaid-financed deliveries during our study period. Total costs by other payers (ie, Medicaid, private, and all-payers) can be found in the Supplemental Information. Hospital costs among infants with NAS covered by Medicaid accounted for 79.4% of all NAS-related hospital costs during our study period.

FIGURE 2

Total hospital costs for NAS among infants who were enrolled in Medicaid.

FIGURE 2

Total hospital costs for NAS among infants who were enrolled in Medicaid.

Close modal

As hospital costs for infants with NAS who were covered by Medicaid increased from 2004 through 2014, the proportion of birth-related costs due to NAS also increased (Fig 3). In 2004, 1.6% of hospital costs for births covered by Medicaid were for the births of infants with NAS. By 2014, NAS accounted for 6.7% of all birth-related hospital costs among infants who were covered by Medicaid. The proportion of birth-related costs among all payers due to NAS can be found in the Supplemental Information.

FIGURE 3

Proportion of birth-related hospital costs due to NAS among infants who were enrolled in Medicaid.

FIGURE 3

Proportion of birth-related hospital costs due to NAS among infants who were enrolled in Medicaid.

Close modal

From 2004 to 2014, the incidence of NAS increased fivefold among infants who were covered by Medicaid, reaching 14.4 per 1000 births in 2014. As the number of infants enrolled in Medicaid with the syndrome grew, so did hospital costs. The proportion of birth-related costs due to NAS grew from 1.6% in 2004 to 6.7% in 2014 among infants enrolled in Medicaid, with annual costs of ∼$462 million in the final year of available data. The opioid epidemic is increasingly and disproportionately affecting families and infants covered by Medicaid, along with state and federal budgets.

The overall incidence of NAS in the United States, regardless of insurance coverage, increased substantially between 2004 and 2014. However, the incidence of NAS was over 7 times higher among infants who were covered by Medicaid compared with infants who were covered by private insurance in 2014. Although other studies have reported a large proportion of infants with NAS are insured by Medicaid, ours is the first to quantify incidence differences between infants who are covered by Medicaid and private insurance over time.3,5,7 With the disproportionate impact of NAS on the Medicaid population, we suggest that NAS incidence rates are unlikely to improve without interventions targeted at low-income mothers and infants.

Infants with NAS who were covered by Medicaid also had higher rates of hospital transfer (between 2010 and 2014) and longer lengths of stay compared with infants with NAS who were privately insured, even after adjustment. However, we were unable to account for some differences between infants who were covered by Medicaid and private insurance that may delay discharge and prolong hospitalization (eg, social factors like housing or transportation). Authors of future work should evaluate factors that contribute to differences in transfer rates and length of stay among infants with NAS to identify opportunities for care improvement and cost savings.

Rising NAS incidence led to higher NAS-associated hospital costs over the study period, both in aggregate and as an overall proportion of birth-related costs for state Medicaid programs. Hospital costs associated with care of infants with NAS who were enrolled in Medicaid accounted for ∼$2.5 billion over the course of our 10-year study period. As the nation’s leading payer of NAS-related care, the Centers for Medicare and Medicaid Services and state Medicaid programs have an opportunity to set national standards to advance the “triple aim” of reduced costs, improved outcomes, and enhanced experience for infants with NAS and their families.14 Although such a goal is ambitious, the Centers for Medicare and Medicaid Services and state Medicaid programs have shown through their work to reduce early elective deliveries that it is possible to improve maternal and infant outcomes while reducing costs.15 

Medicaid programs could promote standardization of clinical protocols to reduce hospital costs and improve outcomes for infants with NAS.5 Mounting evidence supports nonpharmacologic treatment of infants diagnosed with NAS. Systematic implementation of policies that support rooming-in, breastfeeding, swaddling, on-demand feeding schedules, and minimization of sleep disruption may reduce symptoms of NAS and reduce the duration of, or even eliminate the need for, pharmacologic treatment of NAS.16,22 Opportunities for improved newborn care and reduced costs exist even among infants who require pharmacologic treatment of the management of NAS. Pharmacologic treatment with buprenorphine, for example, has been shown to reduce hospital length of stay by 35%.23 

Policies that improve access to opioid use disorder treatment for women before, during, and after pregnancy may also reduce NAS-related morbidity and costs.24 Medication-assisted treatment (MAT) during pregnancy improves outcomes and reduces costs associated with NAS compared with attempted abstinence.22,25,28 Although MAT does not necessarily reduce the incidence of NAS, it may prevent prolonged hospital stays due to preterm birth, reduce NICU admissions, decrease the severity of NAS symptoms, and improve birth outcomes for some infants. States could rapidly expand access to MAT for reproductive-aged women by using funding made available by recent federal legislation.10,29 

Ultimately, a public health approach that targets patient-, family-, and community-level factors will be necessary to prevent women from developing opioid use disorders.30 Individual level predictors of opioid use disorders include mental health disorders and preexisting substance use disorders.31 Screening, referral, and treatment for these conditions may reduce the incidence of opioid use disorders among reproductive-age women. At the family level, adolescents with strained parental relationships are at increased risk of opioid use disorders and may benefit from family-based therapy.32 At the community-level, low socioeconomic status and unemployment are strong predictors of opioid use.33 Collaboration among a diverse set of stakeholders will be required at each level to reduce factors that contribute to opioid use among reproductive-aged women.

This study has several important limitations. NIS data are aggregated from hospital discharge information and reflect coding practices in which misclassification bias is possible. Current evidence suggests NAS is underreported in hospital billing data.34 Therefore, the incidence and costs associated with NAS we report here are likely conservative. Alternatively, rising NAS incidence may be because of an improved awareness and recognition of the clinical syndrome over time or iatrogenic cases of NAS not accounted for in our exclusion criteria. However, the associated increase in maternal opioid use described elsewhere3,5 and opioid use trends among the general population35 do not suggest a progressive diagnostic bias in NAS. Finally, because of data limitations, we were not able to calculate state-level cost variation.

Federal and state Medicaid program administrators have the opportunity to implement policies that promote prevention and treatment of NAS. Reducing NAS incidence will require the adoption of a public health approach to opioid use disorders among reproductive-aged women.

     
  • CI

    confidence interval

  •  
  • ICD-9-CM

    International Classification of Diseases, Ninth Revision, Clinical Modification

  •  
  • MAT

    medication-assisted treatment

  •  
  • NAS

    neonatal abstinence syndrome

  •  
  • NIS

    National Inpatient Sample

Dr Winkelman conceived and designed the study, acquired data, conducted data analysis and interpretation, and drafted the manuscript; Dr Villapiano conceived and designed the study, interpreted data, and provided critical revisions to the manuscript; Drs Kozhimannil and Davis interpreted data and provided critical revisions to the manuscript; Dr Patrick conceived and designed the study, interpreted data, provided critical revisions to the manuscript, and supervised the study; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Dr Patrick was supported by the National Institute on Drug Abuse of the National Institutes of Health under award K23DA038720. The views expressed in this publication do not necessarily represent the official views of this funding organization. Funded by the National Institutes of Health (NIH).

We thank Latasha Jennings, MPH for her assistance with editing and formatting the manuscript. We also thank 3 anonymous reviewers who helped strengthen the manuscript with their insightful comments and suggestions.

1
Patrick
SW
,
Davis
MM
,
Lehman
CU
,
Cooper
WO
.
Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012.
J Perinatol
.
2015
;
35
(
8
):
667
[PubMed]
2
Ko
JY
,
Patrick
SW
,
Tong
VT
,
Patel
R
,
Lind
JN
,
Barfield
WD
.
Incidence of neonatal abstinence syndrome - 28 states, 1999-2013.
MMWR Morb Mortal Wkly Rep
.
2016
;
65
(
31
):
799
802
[PubMed]
3
Villapiano
NLG
,
Winkelman
TNA
,
Kozhimannil
KB
,
Davis
MM
,
Patrick
SW
.
Rural and urban differences in neonatal abstinence syndrome and maternal opioid use, 2004 to 2013.
JAMA Pediatr
.
2017
;
171
(
2
):
194
196
[PubMed]
4
McQueen
K
,
Murphy-Oikonen
J
.
Neonatal abstinence syndrome.
N Engl J Med
.
2016
;
375
(
25
):
2468
2479
[PubMed]
5
Patrick
SW
,
Schumacher
RE
,
Benneyworth
BD
,
Krans
EE
,
McAllister
JM
,
Davis
MM
.
Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009.
JAMA
.
2012
;
307
(
18
):
1934
1940
[PubMed]
6
Patrick
SW
,
Burke
JF
,
Biel
TJ
,
Auger
KA
,
Goyal
NK
,
Cooper
WO
.
Risk of hospital readmission among infants with neonatal abstinence syndrome.
Hosp Pediatr
.
2015
;
5
(
10
):
513
519
[PubMed]
7
Tolia
VN
,
Patrick
SW
,
Bennett
MM
, et al
.
Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs.
N Engl J Med
.
2015
;
372
(
22
):
2118
2126
[PubMed]
8
Corr
TE
,
Hollenbeak
CS
.
The economic burden of neonatal abstinence syndrome in the United States.
Addiction
.
2017
;
112
(
9
):
1590
1599
9
Okoroh
EM
,
Gee
RE
,
Jiang
B
,
McNeil
MB
,
Hardy-Decuir
BA
,
Zapata
AL
.
Neonatal abstinence syndrome: trend and expenditure in Louisiana Medicaid, 2003-2013.
Matern Child Health J
.
2017
;
21
(
7
):
1479
1487
[PubMed]
10
114th United States Congress
. Comprehensive addiction and recovery act of 2016. 2016. Available at: https://www.congress.gov/bill/114th-congress/senate-bill/524/text. Accessed June 6, 2017
11
United States Government Accountability Office
. Newborn health: federal action needed to address neonatal abstinence syndrome. 2017. Available at: https://www.gao.gov/assets/690/687580.pdf. Accessed October 20, 2017
12
Agency for Healthcare Research and Quality
. Healthcare cost and utilization project (HCUP) databases. 2017. Available at: www.hcup-us.ahrq.gov/databases.jsp. Accessed April 25, 2017
13
Bureau of Labor Statistics
. Table 24. Historical consumer price index for all urban consumers (CPI-U): U.S. city average, all items. 2017. Available at: https://www.bls.gov/cpi/tables/historical-cpi-u-201710.pdf. Accessed December 10, 2017
14
Patrick
SW
.
The triple aim for neonatal abstinence syndrome.
J Pediatr
.
2015
;
167
(
6
):
1189
1191
[PubMed]
15
Center for Medicare and Medicaid Services
.
Reducing Early Elective Deliveries in Medicaid and CHIP
.
Baltimore, MD
:
Center for Medicare and Medicaid Services
;
2012
. Available at: https://www.medicaid.gov/medicaid/quality-of-care/downloads/eed-brief.pdf. Accessed December 11, 2017
16
Holmes
AV
,
Atwood
EC
,
Whalen
B
, et al
.
Rooming-in to treat neonatal abstinence syndrome: improved family-centered care at lower cost.
Pediatrics
.
2016
;
137
(
6
):
e20152929
[PubMed]
17
Hall
ES
,
Wexelblatt
SL
,
Crowley
M
, et al;
OCHNAS Consortium
.
A multicenter cohort study of treatments and hospital outcomes in neonatal abstinence syndrome.
Pediatrics
.
2014
;
134
(
2
). Available at: www.pediatrics.org/cgi/content/full/134/2/e527
[PubMed]
18
Abrahams
RR
,
Kelly
SA
,
Payne
S
,
Thiessen
PN
,
Mackintosh
J
,
Janssen
PA
.
Rooming-in compared with standard care for newborns of mothers using methadone or heroin.
Can Fam Physician
.
2007
;
53
(
10
):
1722
1730
[PubMed]
19
Hünseler
C
,
Brückle
M
,
Roth
B
,
Kribs
A
.
Neonatal opiate withdrawal and rooming-in: a retrospective analysis of a single center experience.
Klin Padiatr
.
2013
;
225
(
5
):
247
251
[PubMed]
20
Saiki
T
,
Lee
S
,
Hannam
S
,
Greenough
A
.
Neonatal abstinence syndrome—postnatal ward versus neonatal unit management.
Eur J Pediatr
.
2010
;
169
(
1
):
95
98
[PubMed]
21
Abdel-Latif
ME
,
Pinner
J
,
Clews
S
,
Cooke
F
,
Lui
K
,
Oei
J
.
Effects of breast milk on the severity and outcome of neonatal abstinence syndrome among infants of drug-dependent mothers.
Pediatrics
.
2006
;
117
(
6
). Available at: www.pediatrics.org/cgi/content/full/117/6/e1163
[PubMed]
22
Welle-Strand
GK
,
Skurtveit
S
,
Jones
HE
, et al
.
Neonatal outcomes following in utero exposure to methadone or buprenorphine: a National Cohort Study of opioid-agonist treatment of pregnant women in Norway from 1996 to 2009.
Drug Alcohol Depend
.
2013
;
127
(
1–3
):
200
206
[PubMed]
23
Kraft
WK
,
Adeniyi-Jones
SC
,
Chervoneva
I
, et al
.
Buprenorphine for the treatment of the neonatal abstinence syndrome.
N Engl J Med
.
2017
;
376
(
24
):
2341
2348
[PubMed]
24
Krans
EE
,
Cochran
G
,
Bogen
DL
.
Caring for opioid-dependent pregnant women: prenatal and postpartum care considerations.
Clin Obstet Gynecol
.
2015
;
58
(
2
):
370
379
[PubMed]
25
Burns
L
,
Mattick
RP
,
Lim
K
,
Wallace
C
.
Methadone in pregnancy: treatment retention and neonatal outcomes.
Addiction
.
2007
;
102
(
2
):
264
270
[PubMed]
26
Ordean
A
,
Kahan
M
,
Graves
L
,
Abrahams
R
,
Kim
T
.
Obstetrical and neonatal outcomes of methadone-maintained pregnant women: a Canadian multisite cohort study.
J Obstet Gynaecol Can
.
2015
;
37
(
3
):
252
257
[PubMed]
27
Fullerton
CA
,
Kim
M
,
Thomas
CP
, et al
.
Medication-assisted treatment with methadone: assessing the evidence.
Psychiatr Serv
.
2014
;
65
(
2
):
146
157
[PubMed]
28
Thomas
CP
,
Fullerton
CA
,
Kim
M
, et al
.
Medication-assisted treatment with buprenorphine: assessing the evidence.
Psychiatr Serv
.
2014
;
65
(
2
):
158
170
[PubMed]
29
114th United States Congress
. 21st century cures act. 2016. Available at: https://www.congress.gov/bill/114th-congress/house-bill/34/text. Accessed June 6, 2016
30
Ko
JY
,
Wolicki
S
,
Barfield
WD
, et al
.
CDC grand rounds: public health strategies to prevent neonatal abstinence syndrome.
MMWR Morb Mortal Wkly Rep
.
2017
;
66
(
9
):
242
245
[PubMed]
31
Boscarino
JA
,
Rukstalis
M
,
Hoffman
SN
, et al
.
Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system.
Addiction
.
2010
;
105
(
10
):
1776
1782
[PubMed]
32
Sung
H-E
,
Richter
L
,
Vaughan
R
,
Johnson
PB
,
Thom
B
.
Nonmedical use of prescription opioids among teenagers in the United States: trends and correlates.
J Adolesc Health
.
2005
;
37
(
1
):
44
51
[PubMed]
33
Spiller
H
,
Lorenz
DJ
,
Bailey
EJ
,
Dart
RC
.
Epidemiological trends in abuse and misuse of prescription opioids.
J Addict Dis
.
2009
;
28
(
2
):
130
136
[PubMed]
34
Burns
L
,
Mattick
RP
.
Using population data to examine the prevalence and correlates of neonatal abstinence syndrome.
Drug Alcohol Rev
.
2007
;
26
(
5
):
487
492
[PubMed]
35
Dart
RC
,
Surratt
HL
,
Cicero
TJ
, et al
.
Trends in opioid analgesic abuse and mortality in the United States.
N Engl J Med
.
2015
;
372
(
3
):
241
248
[PubMed]

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data