Neonatal Abstinence Syndrome Rising Sharply in Rural Areas

Nicola M. Parry, DVM

December 14, 2016

The number of infants with neonatal abstinence syndrome (NAS) has increased substantially more in rural areas than in cities in the United States during the last decade, according to a research letter published online December 12 in JAMA Pediatrics.

"Compared with their urban peers, rural infants and mothers with opioid-related diagnoses were more likely to be from lower-income families, have public insurance, and be transferred to another hospital following delivery," write Nicole L. G. Villapiano, MD, from the Robert Wood Johnson Foundation Clinical Scholars Program at the University of Michigan, Ann Arbor, and colleagues.

NAS comprises the complications and withdrawal symptoms that result when infants are no longer exposed to opioids that were taken by the mother during pregnancy.

From 2000 to 2012, the incidence of NAS in the United States increased nearly fivefold, with studies suggesting it may be increasing dramatically in some rural areas, along with mounting rates of other opioid use–related conditions in these regions. However, data comparing national trends in NAS and maternal opioid use among patients in rural and urban areas are lacking.

With this in mind, Dr Villapiano and colleagues used data from the National Inpatient Sample for neonatal births and obstetric deliveries to study national trends in NAS and maternal opioid use among rural patients compared with their urban peers between 2004 and 2013.

They found that the percentage of infants with NAS who were from rural counties increased significantly during this period, going from 12.9% to 21.2% (P < .001).

According to the authors, between 2004 and 2013, the incidence of NAS rose disproportionately in rural regions compared with urban ones. The incidence of NAS increased from 1.2 (95% confidence interval [CI], 0.9 - 1.6) to 7.5 (95% CI, 6.6 - 8.3) cases per 1000 hospital births among infants in rural areas, and from 1.4 (95% CI, 1.2 - 1.7) to 4.8 (95% CI, 4.5 to 5.0) cases per 1000 hospital births among those in urban areas.

They also found an increased frequency of hospital deliveries that were complicated by maternal opioid use during this period, rising from 1.3 (95% CI, 1.0 - 1.6) to 8.1 (95% CI, 7.3 - 8.9) complicated deliveries per 1000 hospital deliveries among mothers in rural areas and from 1.6 (95% CI, 1.3 - 1.9) to 4.8 (95% CI, 4.5 - 5.1) complicated deliveries per 1000 hospital deliveries among those in urban areas.

The results of this study highlight the geographic disparity in the incidence of NAS and underscore the need for funding for clinicians and programs to help improve access to opioid prevention and treatment services for women and children in rural areas.

Although the authors acknowledge that their evaluation may reflect changes in coding practices and heightened awareness of opioid-related problems, they indicate that these changes probably would not account for the substantial differences in findings between the rural and urban areas.

"Further dedicated research is warranted to identify factors that contribute to geographic disparities in NAS and maternal opioid use and to inform effective opioid use prevention and treatment strategies for vulnerable rural Americans," the authors conclude.

This publication was supported by the Robert Wood Johnson Foundation Clinical Scholars Program. The authors have disclosed no relevant financial relationships.

JAMA Pediatrics. Published online December 12, 2016. Full text

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