Rural and Urban Differences in Neonatal Abstinence Syndrome and Maternal Opioid Use, 2004 to 2013

Abstract

Incidence rates for neonatal abstinence syndrome (NAS) and maternal opioid use increased nearly 5-fold in the United States between 2000 and 2012. 1 Previous studies suggest the incidence of NAS may be increasing rapidly in some rural states, 2 in parallel with rising rural rates of other opioid use-related conditions including hepatitis C and overdose deaths. 3,4 To our knowledge, no study has examined national trends in NAS and maternal opioid use among rural patients compared with their urban counterparts. Methods | We used 2004 to 2013 data from the National Inpatient Sample, a nationally representative, all-payer sample of hospital discharges in the United States compiled by the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality.The study population consisted of all neonatal births and obstetric deliveries between 2004 and 2013. 5 Infants with NAS were identified using the International Classifica-tion of Diseases, Ninth Revision, Clinical Modification code of 779.5 in any diagnosis field. Cases of potentially iatrogenic NAS were excluded using previously described methods. 6 Maternal opioid use was defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes 304.0x, 304.7x, or 305.5x. The University of Michigan institutional review board determined the study was exempt because the National Inpatient Sample Data contain deidentified data. Patient consent was therefore neither required or obtainable.Location of residence was defined as rural or urban using the National Center for Health Statistics Classification Scheme for Counties. We tabulated demographic characteristics for infants with NAS and mothers with opioid use by rural/urban status and calculated the proportion of NAS cases accounted for by rural infants in each 2-year period. Incidence rates of NAS and maternal opioid use by rural/urban status were calculated using predictive margins with 2 separate logistic regression models that interacted variables for each 2-year period with rural/urban status.To allow for comparisons over time, we used trend weights provided by the Healthcare Cost and Utilization Project that account for National Inpatient Sample sampling changes in Table. Characteristics of Infants and Mothers With Opioid-Related Diagnoses in the United States, 2004-2013 Characteristic No. (weighted %)

Disparities in Chronic Conditions Among Women Hospitalized for Delivery in the United States, 2005–2014

“…These findings are consistent with recent reports of rising neonatal abstinence syndrome incidence, 7 including disproportionate increases among neonates residing in the rural United States. 16 While substance use screening is recommended for all women during prenatal care, 17 effective provision of this service has been complicated by a recent surge in legislation penalizing pregnant women for disclosing substance use. Punitive legislation has disproportionately impacted women in rural states, 18 where additional barriers to treatment may already exist, including a scarcity of addiction providers willing to treat pregnant women.…”

Maternal Opioid Use Disorder and Neonatal Abstinence Syndrome Among Rural US Residents, 2007–2014

“…Maternal OUD and NAS disproportionately affect rural communities, where poverty levels are higher and where health care access is more limited . From 2004‐2013, the incidence of both NAS and maternal OUD increased more rapidly in rural counties, where rates rose from 1.2 to 7.5 per 1,000 compared to urban counties, where rates rose from 1.4 to 4.5 per 1,000 .…”

“…Maternal OUD and NAS disproportionately affect rural communities, where poverty levels are higher and where health care access is more limited . From 2004‐2013, the incidence of both NAS and maternal OUD increased more rapidly in rural counties, where rates rose from 1.2 to 7.5 per 1,000 compared to urban counties, where rates rose from 1.4 to 4.5 per 1,000 . Further, compared with their urban peers, rural women and infants with opioid‐related diagnoses are more likely to be from lower‐income families, and rural infants are more likely to be transferred to another hospital following delivery .…”

“…From 2004‐2013, the incidence of both NAS and maternal OUD increased more rapidly in rural counties, where rates rose from 1.2 to 7.5 per 1,000 compared to urban counties, where rates rose from 1.4 to 4.5 per 1,000 . Further, compared with their urban peers, rural women and infants with opioid‐related diagnoses are more likely to be from lower‐income families, and rural infants are more likely to be transferred to another hospital following delivery . Rural infants in the United States are over‐represented among those diagnosed with NAS, with the proportion of infants diagnosed with NAS from rural counties increasing from 12.9% in 2003‐2004 to 21.2% in 2012‐2013 .…”

Neonatal abstinence syndrome: an update

“…The recent rise of opioid use in pregnancy and NAS has disproportionately occurred in rural areas (9, 10)** Using administrative data from 2004 to 2013, Villapiano et al(11)* found the incidence of NAS per 1000 hospital births increased from 1.2 to 7.5 among rural infants and from 1.4 to 4.8 among urban infants. The demographic differences between rural and urban areas is also apparent in state surveillance data.…”