Rise in Neonatal Abstinence Syndrome Rate is Associated With Increased Buprenorphine Prescription Rate

Neonatal Abstinence Syndrome (NAS) is the condition which occurs when newborn babies experience withdrawal symptoms from medications taken by their mothers during pregnancy. Prior research suggest NAS is associated with long-term educational difficulties and alterations in neonatal brain structure. Between 2008 and 2017, NAS rates more than tripled in the United States. An epicenter of the NAS epidemic is Southern Appalachia. West Virginia, the only state with all counties located in Southern Appalachia, has an NAS rate roughly seven times the national average, and in 2017, four of the 10 states with the highest NAS rates were part of Southern Appalachia. Upon reviewing Tennessee data, it was noted that increasing NAS rates had a similar curve to buprenorphine prescribing patterns. Buprenorphine is an opioid partial-agonist prescribed in medication assisted therapy (MAT) intended to help individuals, including those pregnant, avoid withdrawal symptoms. Previous research at an East Tennessee clinic identified buprenorphine in urine drug screens of 16% of all pregnant patients; patients admit to both prescribed and illicit use, including snorting, smoking, and injecting. These findings align with a 2017 study suggesting that mothers of NAS infants in eastern Tennessee, compared to mothers across the state, were more likely to use substances prescribed to another person. Despite the drug’s increasing prescribing patterns and popularity for illicit use, its effects on the mother and fetus remain controversial. We therefore felt it appropriate to investigate possible linkages between buprenorphine prescriptions and NAS rates. For the purposes of this study, we define Southern Appalachia as 250 counties from 7 states, including Tennessee, West Virginia, Virginia, North Carolina, Kentucky, Ohio, and Maryland. Annual NAS rates, buprenorphine prescription rates, drug-induced death rates, and opioid prescribing rates from each county in the region were assessed for the years 2008-2018 using data provided by governmental agencies. It was found that buprenorphine prescriptions in the region more than quintupled between 2008 and 2018. NAS rates and drug-induced death rates did not decrease as well; unfortunately, they dramatically increased. We identified a significant linear association between the rate of NAS diagnoses and buprenorphine prescriptions (r = 0.9774, R2 = 0.9553, p-value less than 0.001) and between the rate of buprenorphine prescriptions and drug-induced deaths (r = 0.7129, R2 = 0.5082, p-value .0311). This is the first report which documents a relationship between NAS rates and increasing buprenorphine prescribing. Discussions regarding current policies for buprenorphine management during pregnancy are warranted. We encourage further research on establishing the lowest effective buprenorphine dose for each patient, and we support the CDC’s resumption of tracking the morphine milligram equivalents (MME) of buprenorphine prescribed during pregnancy so that researchers can further study the effect of congenital MME exposure on fetal outcomes