This document summarizes a conference held to discuss the issue of neonatal abstinence syndrome (NAS) among newborns in the Appalachian region. Experts from 8 Appalachian states discussed what is known about NAS epidemiology in the region, identified gaps in knowledge, and made recommendations. Common themes included the need for improved education of healthcare providers, treatment resources, and prevention strategies. The conference aimed to facilitate collaboration across states to address this growing public health problem.

1. Exploring Drug Dependent
Newborns In Appalachia: a
Conference of Experts
April 2-3, 2014
Johnson City, TN
Bruce Behringer
Deputy Commissioner
Tennessee Department of
Health
Eric Stockton
Health Program Manager
Appalachian Regional
Commission

2. ARC
Region
with
County
Economic
Status:
FY
2014

4. ARC Programs
• Research and advocacy
• Public/private partnerships
• Grantmaking for local initiatives
– Bottoms-up grantmaking
– Guided by regional strategy
– Local development districts and states =
gatekeepers

5. ARC Grantmaking
• Job creation
– Business capital, food systems, entrepreneurs
• Human capacity
– Education, workforce, health, leadership
• Physical infrastructure
– Water, sewer, industrial sites
– Clinics and hospitals
– Highway network & intermodal transport

6. ARC Priority Setting
• Strategic Plan
• State Development Plans
• Annual State Strategy Statements
• OMB Performance Targets
• Distressed Area mandate
• Advisory groups

7. Appalachian Health Policy
Advisory Council
• Health career development pathways.
• Rural primary care provider base.
• State and community-based HPDP.

8. Appalachian Health Policy
Advisory Council
• Integration of treatment and coordination of
services.
• Health disparities economic disparities

9. Major Health Research
• An Analysis of Disparities in Health Status
and Access to Health Care in the
Appalachian Region (Halverson: 2004)
• (Published at www.arc.gov)

12. Substance Abuse in Appalachia:
2006 findings
• Addiction = business (covert economy).
• Substance use is culturally accepted.
• Widespread incidence and prevalence of
addiction and additive behaviors.
• Lack of health services infrastructure  reduced
capacity for people and communities
From “A Community-Based Approach to Substance Abuse Including Methamphetamine in
Appalachia,” Johnson City, TN, 2006

13. Substance Abuse in Appalachia:
2006 findings
• Legal drugs and generational use of substances
are legitimized by:
– historical medical practice
– the media
• Appalachian life contributes a unique set of life
and community stressors:
– poverty and disenfranchisement
• From “A Community-Based Approach to Substance Abuse Including Methamphetamine in
Appalachia,” Johnson City, TN, 2006

14. Major Health Research
• An Analysis of Mental Health and
Substance Abuse Disparities & Access to
Treatment Services in the Appalachian
Region (August 2008)
• National Opinion Research Center (NORC) at the University of
Chicago, and East Tennessee State University
• (Published at www.arc.gov)

15. NORC Study Outcomes
• Meth vs. prescription opioids
• Treatment access poor but better than
expected
• Variability within region
• Place-based study of regional conditions
• National researchers (NORC) helped
legitimize findings

16. Ongoing activities
• Mini-grant competitions for coalitions
• Other grantmaking interests:
• Facilities
• Integrated care demonstrations
• (Not ongoing operations)
• Workforce development
• Business opportunity?
• Links to economic development

17. NAS in Tennessee and Appalachia
• Tennessee: greater NAS prevalence in
Appalachian counties than non-ARC
• ARC co-funded multi-state project
– Other states’ experience?
– What is known…or unknown?
– Is this an Appalachian issue?

18. www.arc.gov

19. Neonatal Abstinence Syndrome
Conference of Experts:
Exploring the Issue of Drug Dependent
Newborns in the Appalachian Region
Tennessee Department of Health
Johnson City, TN
April 2-3, 2014
Supported by a conference grant
from the Appalachian Regional Commission

20. Conference Design
• Cooperative regional venture to assess regional Neonatal
Abstinence Syndrome (NAS) epidemic
• Objectives
– Summarize what is known about the epidemiology
of NAS in Appalachia
– Generate a set of questions and potential inquiries
that would address that which is unknown
– Identify existing and ideas for proposed
collaborations and cooperative ventures

21. Conference Agenda
• The agenda
– The national picture
– Expert panels – Research, Practice, Partnerships and
State Policy
– Federal and national organizations reflections
– Closing thoughts on a public health epidemic
• The thirty-eight attendees were “experts” from eight
Appalachian states representing multiple stakeholder
interests

22. Active participation by attendees as inputs
• Pre-conference questionnaire
• Idea collection sheets by panel:
– What we know (findings);
– What we don’t know (gaps);
– Recommendations (key elements needed for change)
• Notes from facilitated audience discussion with panels
• “We Believe” statements from all participants
Approach: Active
participation will
inform conference report

23. From the History Lesson…
Southern Appalachia was the target market
and became the epicenter of prescription
opiate abuse (Oxycontin) fifteen years ago,
and now has become a part of the regional
culture sowing the seed of death and
destruction of people, families communities
and a proud culture.

24. To the Current Challenge
We believe that Appalachia is the epicenter of the latest
manifestation of the substance abuse epidemic because
vehicle transmission (NAS) is a lagging indicator.
Appalachia, the canary in our coalmines of the current
substance abuse epidemic, spoke loudly when our people
stated dying, but not loud enough to warn the country and
stop the epidemic. This time we can work together, be a
louder voice to turn back and stop NAS, emphasizing
prevention and destigmatization recognizing the tri-level
approach of prevention, treatment and control. “Place
matters” and in Appalachia we can make it matter for the
nation.

25. Map
of
distribuBon
of
NAS
cases
Data sources: Tennessee Department of Health; Office of Health Statistics; Hospital Discharge Data System (HDDS) and Birth Statistical System.
Numerator is number of inpatient hospitalizations with age less than one and any diagnosis of drug withdrawal syndrome of newborn (ICD-9-CM 779.5).
HDDS records may contain up to 18 diagnoses. Infants were included if any of these diagnosis fields were coded 779.5. Note that these are discharge-
level data and not unique patient data. Data suppressed for counties with fewer than 100 births.

26. Conference outcomes
• Learn more about NAS problem in Appalachia region
including gaps in knowledge
• Verify multistate place-based problem
• Recognize and validate multiple perspectives about
multiple dimensions requiring systems approaches
• Share implementation ideas and personal networking
• Collect ideas and recommendations to future ARC
consideration
• Develop common themes across states

27. Common themes
• Social and economic determinants are important.
• Professional education with prescribers is
necessary.
• Compassion, not arrest, will lead to improved
outcomes.
• NAS is just becoming recognized as a real
financial issue.
• Too little consensus on protocols: case definition,
prenatal treatment of mothers, hospital level of
care for infants.

28. Common themes
• Too little is understood about long-term
impacts on child.
• Intermediate impacts being discovered
(DCS placements).
• Treatment resources are lacking, and
prevention strategies are undeveloped.
• Policy pressures mounting to punish
mothers as “the moral thing”.

29. “We Believe” Statements
• NAS is a growing epidemic in the Appalachian
region.
• NAS is a symptom of larger issues.
• NAS is preventable! Primary prevention is a
must!
• NAS is an expected and treatable condition.
• NAS is the “wakeup call” and opportunity to
change perceptions and stigma surrounding
substance abuse and lack of education among
providers and citizens.

30. “We Believe” Statements
• Poverty and social injustice are the primary
determinants of the NAS epidemic in
Appalachia.
• NAS is: multi-dimensional, affects multiple systems; not
only a constellation of symptoms, but a family and
society unit issue

31. Is Neonatal Abstinence
Syndrome a national problem?
Provide one statement to
document or describe the
situation in your
state or region

32. Recommendations: Research Panel
• Identify effective assessment tools for identifying
NAS
• Promote universal protocols around drug
screening for OB-GYNs and hospitals
• Identify elements of successful treatment
• Fund long term studies to follow children through
childhood
• Identify structural factors that drive long lengths of
stay: Study new hospital treatment options
Neonatal Abstinence Syndrome Conference of Experts: Exploring the Issue of Drug Dependent Newborns in the
Appalachian Region, April 2014

33. Recommendations: Research Panel
• Advocate for health care provider education about
addiction and recovery
• Study effectiveness of primary prevention
strategies (injury prevention, related tobacco use,
changing prescribing polices for women of
childbearing age)
• Describe locally successful community programs
Neonatal Abstinence Syndrome Conference of Experts: Exploring the Issue of Drug Dependent Newborns in the
Appalachian Region, April 2014

34. Recommendations: Clinical Practice Panel
• Advocate that all health related students learn
about drug addiction as prerequisite and
eliminate provider bias and decrease stigma
• Improve standardized protocols for discharge
and post hospital care
• Institute universal biochemical drug testing early
in pregnancy
• Promote early prenatal engagement and
education about what to expect: Patients to be
informed about risk of NAS who receive
Medication Assisted Therapy

35. Recommendations: Clinical Practice Panel
• Expand treatment sources and resources
• Use multi-disciplinary and multipronged
approaches
• Co-locate primary health care and behavioral
health
• Advocate for non-judgmental, non punitive
approaches

36. Recommendations: Partnerships Panel
• Identify community and family factors relevant to
recovery
• Advocate for physician engagement in public NAS
education
• Gain support for buprenorphine and suboxone
oversight
• Focus on underlying social determinants of heath
(e.g., promote job training and placement).
• Improve family planning and substance abuse
education in prisons and general population.

37. Recommendations: Partnerships Panel
• Create economics case for primary prevention of
NAS
• Develop a provider and parent navigation guide
for working with Children’s Services.
• Conduct evaluation that promotes resources for
sustained effective partnership programs and
coalitions
• Be about health, not health care.