Higher long-term unemployment rates and a greater lack of mental health clinicians were both associated with higher rates of neonatal abstinence syndrome (NAS) in U.S. counties, researchers found.
Counties with higher 10-year unemployment rates were associated with higher rates of NAS, and higher mental health clinician shortage areas were linked with increased rates of NAS, reported Stephen W. Patrick, MD, MPH, of Vanderbilt University in Nashville, and colleagues.
But there was also substantial county-level variation in the unemployment rate, as well as NAS rates, with the two often overlapping, they wrote in JAMA.
However, there was no significant link between primary care shortage areas and rates of neonatal abstinence syndrome, they noted.
The authors pointed out that opioid use disproportionately affects impoverished rural counties, and that chronic opioid use during pregnancy can result in NAS, a type of neonatal drug withdrawal syndrome.
They argued that there is scant research on the link between rates of NAS and county-health infrastructure, such as clinician supply.
“A better understanding of the association among community characteristics such as healthcare infrastructure and macroeconomic conditions and NAS is needed to inform community-level interventions aimed at improving opioid-related outcomes for these vulnerable populations,” the authors wrote.
They examined retrospective outcome data from 580 counties in eight states (Florida, Kentucky, Massachusetts, Michigan, New York, North Carolina, Tennessee, and Washington) from 2009 to 2015, as well as economic data from 2000 to 2015.
Outcome data was derived from the Healthcare Cost and Utilization Project’s State Inpatient Database and the Tennessee All-Payer Database, with additional data from the Health Resources and Services Administration Area Health Resources Field. Annual rates of infants with NAS per 1,000 hospital births per county was calculated through inpatient admissions, using ICD-CM codes.
Overall, there were over 6 million births and over 47,000 diagnoses of NAS, with a median rate of NAS at 7.1 per 1,000 hospital births. Moreover, the overall 10-year unemployment rate was 7.6%, though the authors noted it increased from 6.5% to 8.2% (P<0.001 for trend).
Rates of NAS and unemployment varied by county, ranging from 0 to >100 per 1,000 births, the authors said, while the 10-year unemployment rate in certain counties ranged from 4.1% to 15.8%.
Examining clinician supply, they found that during the course of the study, the proportion of counties designated as primary care health professional shortage areas increased from 76.6% to 85.3%, while the portion of counties that were mental health professional shortage areas jumped from 79.5% to 88.2%.
Adjusted analyses found that mental health shortage areas had higher NAS rates (adjusted incidence rate ratio 1.17, 95% CI 1.07-1.27), though this occurred primarily in metropolitan counties, they noted. Moreover, the 10-year unemployment rate was associated with higher rates of NAS (adjusted IRR 1.11, 95% CI 1.00-1.23), though the authors noted this association was significant for rural remote counties, but not metropolitan counties or rural counties adjacent to metropolitan counties.
In an accompanying editorial, Katy B. Kozhimannil, PhD, of the University of Minnesota in Minneapolis, and Lindsay K. Admon, MD, of the University of Michigan in Ann Arbor, called the fact that mental health shortage areas were associated with higher NAS rates a “key finding.”
“Frequently, care for pregnant patients with opioid use disorder is concentrated within academic medical centers located in metropolitan counties,” the editorialists wrote. “These data suggest that policy and workforce initiatives should be framed around both strengthening treatment capacity when baseline services are lacking and identifying metropolitan residents with opioid use disorder who may lack the treatment access they need.”
Kozhimannil and Admon discussed renewed efforts to “prevent, direct and treat opioid use disorders among childbearing women,” including focusing prevention efforts more broadly on reproductive-age women, regardless if they are pregnant or not; amending laws that discourage women from disclosing substance use during pregnancy; and allowing pregnant and postpartum women priority access to insurance coverage expansion programs that allow for treatment continuation.
Citing a role in these efforts for clinicians, the editorialists wrote “most clinicians who are permitted to prescribe medication-assisted therapy treat relatively few patients, and not all of these clinicians accept pregnant patients,” adding that “a more detailed assessment of the workforce may reveal the unmet treatment needs of pregnant women with opioid use disorder.”
Study limitations included the ecological design of the study and absence of patient-level data; the potential for misclassification bias in hospital discharge data used to determine NAS rates; and unmeasured time-varying county-level confounders that may have impacted the analysis.
The study was supported by the National Institute for Healthcare Management Foundation, the National Institute on Drug Abuse, and RAND Health Care.
Patrick and co-authors disclosed no relevant relationships with industry.
Kozhimannil and Admon disclosed support from the Federal Office of Rural Health Policy, Health Resources and Services Administration.