Addressing neonatal abstinence syndrome before birth

In 2012, doctors and nurses at an OB-GYN clinic in rural Athens County, Ohio, started observing an uptick in pregnant patients addicted to opioids. The clinic's practice manager, Pam Born, who had lived in the county since 1985, had witnessed plenty of medical problems in her 32 years as a registered nurse, but this was different.

The proportion of babies across rural America born dependent on opioids has soared in the past decade or so. This condition, neonatal abstinence syndrome, causes tremors, vomiting and other withdrawal symptoms, and heightens the risk of health complications. It is also expensive: hospital costs for a baby born with the condition average $66,700, compared with $3,500 for babies without it.

Many providers were trying to treat neonatal abstinence syndrome in babies, Born noticed, but fewer sought to prevent it by managing addiction during pregnancy. So she set out to do just that, enlisting help from several others at the clinic, OhioHealth O'Bleness Hospital Athens Medical Associates Obstetrics and Gynecology.

They started small. Born found a local provider that could offer medication-assisted treatment for opioid addiction, and she reached out to a team of nurse navigators at Ohio University.

At first, these nurse navigators worked to simply connect patients with addiction services because the priorities were to provide prenatal care and medication-assisted treatment to wean patients off opioids.

The program soon expanded, however, as providers realized that other forms of help—counseling, transportation housing, food, job training—would improve their patients' chances of overcoming addiction. Often those services were already offered by state agencies; patients just needed to know how to access them.

Nurse navigators played a key role in this process. They scheduled appointments for patients, coordinated transportation services, and followed up to ensure patients attended appointments.

Also vital was a shared electronic health record system so that everyone involved in a patient's care was on the same page. Once patients sign a release, nurse navigators, addiction specialists and providers at the OB-GYN clinic have access to a patient's record and could reinforce each other's care plans.

The clinic did that by giving navigators and behavioral health providers access to its cloud-based EHR system, which was developed by Boston-based Athenahealth. “They basically just gave them logins and passwords and they were good to go,” said Dr. Todd Rothenhaus, chief medical officer at Athenahealth.

As for the cost of the approach, it wasn't much. Many of the patients are enrolled in Medicaid or have insurance that covers the services. Transportation and newborn supplies like diapers constituted the biggest costs.

In 2013, Ohio launched the Maternal Opiate Medical Support Project, a three-year, $4.2 million grant to four communities across Ohio aimed at reducing the incidence of neonatal abstinence syndrome. The state program builds on the approaches pioneered by Born's team, though she hesitated to take credit for its genesis. The Athens clinic is participating in the MOMS pilot as part of a project based at a Health Recovery Services facility that's expected to reach between 90 and 150 pregnant women.

Early data from the Athens experiment offer promising results. From 2014 to 2016 in the state of Ohio, 85.5% of babies born to Medicaid-eligible women with addiction were full-term. In Athens, 93.8% were.

If rural providers elsewhere want to do the same, they should “look at (their) patients, decide the needs, and look at the organizations that are in place already,” Born said. To bring them all together, she said, “there just needs to be a catalyst.”