epidemic spreading across the nation erica wilson m.p.h. community services director tennessee...

Epidemic Epidemic Spreading Across Spreading Across

the Nationthe Nation Erica Wilson M.P.H.

Community Services DirectorTennessee Department of Health

East Region(No Financial Disclosures)

Neonatal Neonatal Abstinence Abstinence SyndromeSyndrome

What is it?What is it?

Neonatal abstinence syndrome (NAS) is a term for a group of problems a baby experiences when withdrawing from exposure to narcotics.

What Causes It?What Causes It?Almost every drug passes from the mother's blood stream through the placenta to the fetus. Illicit substances that cause drug dependence and addiction in the mother also cause the fetus to become addicted.

What Happens to the What Happens to the Baby??

At birth, the baby’s dependence on the substance continues. However, since the drug is no longer available, the baby’s central nervous system becomes overstimulated causing the symptoms of withdrawal. http://youtu.be/2eP5EnFSG0c

What’s the What’s the Incidence of Incidence of

Neonatal Neonatal Abstinence Abstinence Syndrome?Syndrome?

• 626 cases in Tennessee as of 8/30/14 compared to 564 at same point in 2013

• Increase of 11%

Maternal County of Residence by Region October 25, 2014

# Cases % Cases

Davidson 40 5.1

East 217 27.7

Hamilton 12 1.5

Jackson/Madison 2 0.3

Knox 80 10.2

Mid-Cumberland 69 8.8

North East 113 14.4

Shelby 32 4.1

South Central 26 3.3

South East 19 2.4

Sullivan 63 8.1

Upper Cumberland 88 11.2

West 22 2.8

Total 783 100.0%

• Exposure source trends in East TN vary from those seen in all cases state-wide

Highest rates based on provisional county birth estimates

Why is Why is Neonatal Neonatal

Abstinence Abstinence Syndrome a Syndrome a

Concern?Concern?

The BabyThe Baby

• Tragedy and suffering of the babies and their caregivers.

• With increased likelihood of foster care, families are torn apart. 

The CostThe Cost• According to current

statistics in Tennessee, the TennCare costs for a healthy newborn were $4,237 compared to an average cost of $66,973 for an infant born dependent on drugs, diagnosed with NAS.

The FutureThe Future• There may be other

economic, psychological and physiological costs associated with their medical condition at birth since it is not yet known what challenges and needs these infants will have as they grow older.

What can we do in Public Health ?

• NAS became a reportable condition in TN on January 1, 2013

• NAS Taskforce was formed July 11, 2013 – Collaborative effort with East Region and Knox

• NAS/PPI Sub-committee was formed on September 5, 2013

Primary PreventionPrimary PreventionInitiativeInitiative

LARC Pilot ProjectLARC Pilot Project

East RegionEast Region

The ProcessThe Process• CollaborationCollaboration

– Sheriff/Jail Administrator/Jail NurseSheriff/Jail Administrator/Jail Nurse

• EducationEducation– Partners (Pamphlet)Partners (Pamphlet)– Participants (PowerPoint and Pamphlet)Participants (PowerPoint and Pamphlet)

• Referrals Referrals (Referral/Follow-Up Form)(Referral/Follow-Up Form)

• Clinical ServicesClinical Services• Data Collection Data Collection (Referral/Follow-Up Form)(Referral/Follow-Up Form)

• 1/14/14 – first education session at Cocke County

• As of 10/29/14, 10 sessions have been held for a total of 197 persons educated– Cocke County Jail: 3 sessions, 49 participants– Jefferson County Jail: 1 session, 40 participants– Sevier County Jail: 6 sessions, 108 participants

• Anticipated referrals of the 197 = 99 (50.0%)

Jail Settings

•Of the 197 educated, 63 (32%) completed referral to Cocke, Sevier, or Jefferson County HD

•Difference from number of anticipated referrals (99) likely due to lag time between session and first exam

Referral Outcomes

•Females ranging in age 20 – 45 (avg. age: 27)

•Predominately non-Hispanic white•Mostly residents of Sevier and Cocke

County, but a few from other areas:County No. PercentCocke 14 32.6%Davidson 1 2.3%Jefferson 1 2.3%Knox 1 2.3%Sevier 24 55.8%Out-of-State 2 4.7%Total 43 100.0%

Patient History

Method of Birth Control

• 54/63 patients (85.7%) received some form of contraceptive

• Of the 9 that did not, 7 had been released or transferred before placement could occur

• One patient was provided a 3 mos. supply of COCs

• One patient refused all methods offered

Contraceptive Placement

(N = 54)

• Education levels

• FP barriers – 28% of referrals

were previous FP patients

• Specific drug use history including during pregnancy

• History of unplanned pregnancy

FOR HEALTH DEPARTMENT STAFF USE ONLY

CL

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1. Was the client referred as a condition of probation/parole? Yes No 2. Is the client currently incarcerated for drug-related issues? Yes No 3. For inmates, please verify the address listed above to determine if it is the facility address.

If it is, please also ask the client for their address prior to incarceration: City:____________________ County:___________________ State:_________ Zip:____________

4. Highest level of education completed:

Some Middle School HS Diploma/GED Associates Professional Degree Some HS Some College Bachelors

5. Is the client an established Health Department FP patient? Yes No

If Yes, list date of last visit: _______________ If last visit was >1 year ago, what was the reason? Problem getting appt Appt with another provider Other (specify):__________________ Problem with BC method Not important

6. Has the client ever had child(ren) previously or currently in State custody?

Yes No Refused to answer 7. Has the client ever had child(ren) born drug-dependent?

Yes No Refused to answer If yes, how many?___________________

CL

INIC

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1. Has the client ever used prescription/non-prescription drugs? Yes No Refused to answer If yes, which drugs? (check all that apply) Marijuana Meth/Methamphetamines Other (specify) ____________ Cocaine/Crack/Coke Ecstasy/E/Ex Heroin Oxy/Oxycontin

2. Has the client ever used drugs during a pregnancy? Yes No Refused to answer Never pregnant If yes, which drugs? (check all that apply) Marijuana Meth/Methamphetamines Other (specify) ____________ Cocaine/Crack/Coke Ecstasy/E/Ex Heroin Oxy/Oxycontin

3. Has the client ever had an unplanned pregnancy? Yes No Refused to answer Never pregnant

4. Is the client currently taking medications for chronic pain? Yes No

5. Is the client currently taking medications for anxiety? Yes No 6. What type of birth control is the client currently using?

Condoms IUD Other (specify)_______________________________ Pills Nexplanon None

Tennessee House Bill Tennessee House Bill 12951295

As enacted, provides that a woman may be prosecuted for assault for the illegal use of a narcotic drug while pregnant, if her child is born addicted to or harmed by the narcotic drug.

Long Acting Reversible Long Acting Reversible ContraceptivesContraceptives

TheThe

““YOU CAN’T FORGET YOU CAN’T FORGET ME”ME”

MethodsMethods

IUDIUDEffectivenessOver 99 per cent effective. Less than two women in 100 will get pregnant over five years. Older IUDs have less copper and are less effective.

IUDIUDHow it worksA small plastic and copper device is put into the uterus. It stops sperm reaching an egg, and may also stop a fertilized egg implanting in the uterus.How long it lastsCan stay in 5–10 years depending on type but can be taken out sooner.

IUDIUDHow it affects periodsYour periods may be heavier or longer or more painful.How it affects fertilityWhen the IUD is removed your fertility will return to normal.

IUDIUDHow it is inserted/removedA doctor or nurse practitioner will insert the IUD. This takes 15–20 minutes. It can be uncomfortable or painful and you may want to use a local anesthetic. A doctor or nurse can remove the IUD in a simple office visit.

IUDIUD

EffectivenessOver 99 per cent effective. Less than one woman in 100 will get pregnant over five years. 

Mirena IUDMirena IUDHow it worksA small, T-shaped plastic device, which releases the hormone progestin, is put into the uterus. This thins the lining of the uterus to prevent a fertilized egg implanting, thickens cervical mucus to prevent sperm reaching an egg, and may stop ovulation. How long it lastsWorks for five years but can be taken out sooner.

Mirena IUDMirena IUD

How it affects periodsYour periods usually become lighter, shorter and sometimes less painful. They may stop altogether.How it affects fertilityWhen the IUD is removed your fertility will return to normal.

Mirena IUDMirena IUDHow it is inserted/removedA doctor or nurse practitioner will insert the IUD. This takes 15–20 minutes. It can be uncomfortable or painful and you may want to use a local anesthetic. A doctor or nurse can remove the IUD in a simple office visit. 

ImplantsImplants

EffectivenessOver 99 per cent effective. Less than one woman in 1,000 will get pregnant over three years.  

ImplantsImplantsHow it works

A small flexible rod is put under the skin of the upper arm. It releases the hormone progestin. It stops ovulation, thickens cervical mucus to stop sperm reaching an egg, and thins the lining of the uterus (womb) to prevent a fertilized egg implanting.

How long it lasts

Works for three years but can be taken out sooner. 

ImplantsImplants

How it affects periodsYour periods may stop, be irregular or longer.How it affects fertilityWhen the implant is removed your fertility will return to normal. 

ImplantsImplantsHow it is inserted/removedA doctor or nurse practitioner numbs your skin in the inner area of your upper arm with a local anesthetic and inserts the implant. It takes a few minutes and feels similar to having an injection. To remove it, the doctor or nurse uses a local anesthetic, makes a tiny cut and gently pulls the implant out.•  

What if the LARC What if the LARC can’t be placed can’t be placed

before my release?before my release?

InjectionInjection

EffectivenessOver 99 per cent effective. Less than four women in 1,000 will get pregnant over two years.

InjectionInjectionHow it worksIt releases the hormone progestin which stops ovulation, thickens cervical mucus to prevent sperm reaching an egg and thins the lining of the uterus to prevent a fertilized egg implanting.How long it lastsLasts for 12 weeks.  

InjectionInjection

How it affects periodsYour periods may stop, be irregular or longer.How it affects fertilityYour periods and fertility may take time to return after you stop using the injection.  

InjectionInjectionHow it is inserted/removedThe hormone is injected into a muscle, usually in your buttocks. It can also be injected into the arm. The injection cannot be removed from the body so any side effects may continue for as long as it works and for some time afterwards.

Cost SavingsCost Savings• Preventing the birth of one drug dependent Preventing the birth of one drug dependent

infant saves an average cost of $66,973.infant saves an average cost of $66,973.• Preventing the birth of one drug dependent Preventing the birth of one drug dependent

infant in each of the counties in the East infant in each of the counties in the East Region would be a cost savings of Region would be a cost savings of $1,004,595.$1,004,595.

• Preventing the birth of one drug dependent Preventing the birth of one drug dependent infant in each of the counties in Tennessee infant in each of the counties in Tennessee would be a cost savings of $6,362,435.would be a cost savings of $6,362,435.

QuestionsQuestions

• Erica Wilson M.P.H.• Community Services Director• East TN Regional Health Office• Erica.Wilson@TN.gov• (865) 909-9404 Ext. 103 • Cell – (865) 337-4125