Maternal Opioid Use and Neonatal Abstinence Syndrome Still on the Rise

Neonatal abstinence syndrome and opioid disorders among mothers continued to rise during the last decade, according to a cross-sectional study.

From 2010 to 2017, the estimated national neonatal abstinence syndrome rate increased by 3.3 per 1,000 birth hospitalizations (from 4.0 to 7.3), with a relative increase of 82%, reported Ashley Hirai, PhD, of the Health Resources and Services Administration in Rockville, Maryland, and colleagues.

Maternal opioid-related diagnoses also trended upward, with the relative risk rising by 131%, the researchers reported in JAMA.

Rates of both metrics varied widely by state, Hirai and colleagues found, suggesting that evaluating the efficacy of state opioid initiatives aimed to curb dependence and misuse may be an important next step for research.

“This issue is continuing to affect mothers and babies,” Hirai told MedPage Today. She added that the continued rises in maternal opioid disorders and neonatal abstinence syndrome occurred for nearly all states and demographic groups.

“I think that the substantial state variation underscores the importance of state-based public health programs to help prevent unnecessary opioid use and to identify and treat substance use disorders before, during, and after pregnancy,” Hirai said. She noted that quality improvement initiatives, such as the Alliance for Innovation in Maternal Health, may be effective in standardizing care for pregnant and postpartum patients with an opioid use disorder.

Courtney Townsel, MD, a maternal-fetal medicine specialist at the University of Michigan in Ann Arbor, said that it is concerning to see these relative increases given the time and effort that public health experts have put into reducing opioid prescribing habits.

“Certainly, it’s not the steep decline that we would hope our efforts have contributed to at this point,” Townsel, who was not involved in the study, told MedPage Today. She added that the state variances in these rates should inform where and how resources are allocated to care for this population.

Hirai’s group aimed to update national and state-level estimates of neonatal abstinence and maternal opioid disorders, using the most recent data from 2017. They also explored changes in associated length of hospital stay and costs.

The authors conducted a repeated cross-sectional analysis between 2010 and 2017. They used data from the Healthcare Cost and Utilization Project National Patient Sample, an all-payer database sourced from community, nonrehabilitation hospitals. State-level data was available for 47 states and the District of Columbia.

The researchers identified rates of neonatal abstinence syndrome from birth hospitalizations only, to avoid duplicates who were diagnosed at other hospital visits. They calculated maternal opioid-related diagnoses by identifying opioid dependence or abuse diagnosed at delivery.

In 2017, there were approximately 751,000 birth hospitalizations and 748,000 delivery hospitalizations that were recorded in the study. Around 5,300 infants were diagnosed with neonatal abstinence syndrome, and more than 6,000 mothers had an opioid-related disorder. The mean gestational age was around 38 weeks, and average maternal age was 29.

Babies diagnosed with neonatal abstinence syndrome were more likely to be non-Hispanic white, billed by Medicaid, live in areas with the lowest level of income, and live in rural areas. Mothers with opioid-related diagnoses were likely to have similar characteristics.

From 2010 to 2017, the absolute risk increase of neonatal abstinence syndrome was 3.3 per 1,000 birth hospitalizations. Maternal opioid-related diagnoses increased by 4.6 per 1,000 delivery hospitalizations.

Rates of neonatal abstinence syndrome ranged from 1.3 per 1,000 birth hospitalizations in Nebraska to 53.5 in West Virginia. Maine, Vermont, Delaware, and Kentucky also exceeded 20 cases of neonatal abstinence syndrome per 1,000 birth hospitalizations.

There was also a wide range of maternal opioid-related diagnoses, from 1.7 per 1,000 delivery hospitalizations in Nebraska to 47.3 in Vermont. States including Maine, Delaware, West Virginia, and Kentucky also saw rates above 20 per 1,000 delivery hospitalizations.

During the study time period, rates of neonatal abstinence syndrome and maternal opioid-related diagnoses increased in all states except Vermont and Nebraska, which only saw rises in maternal rates.

In an analysis of hospital stay and costs, researchers found that babies with neonatal abstinence syndrome had a median length of hospital stay that was 9 days longer than those who did not have a diagnosis, and cost an average of $14,600 more. Compared with other delivery hospitalizations, mothers with an opioid-related diagnosis stayed in the hospital for a median of less than a half a day longer, and cost $900 more on average.

Hirai and colleagues noted that they may have underestimated rates of neonatal abstinence syndrome by restricting analyses to birth hospitalizations, and that hospital discharge data used to estimate maternal diagnoses has limited sensitivity. They added that cost estimates are likely conservative, and maternal opioid-related diagnoses may be complicated by changes in the ICD coding system.

Townsel said the study is a reminder to clinicians that opioid misuse in pregnancy is still an issue, and recommended adhering to prescribing protocols and working with patients to determine the right medications for their needs.

“Ob-gyns need to know that this is a continuing and persistent problem,” Townsel said. “We need to continue to educate our patients about it, and continue to educate ourselves about it.”