The Opioid Crisis, Pregnancy, and Rising Healthcare Costs: The Case for Integrative Treatment by Kristy Taylor

The Opioid Crisis, Pregnancy, and Rising Healthcare Costs:

THE CASE FOR INTEGRATIVE REHABILITATIVE TREATMENT We help put lives and families back together.

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ABOUT US Supportive Alcohol and Drug Abuse Recovery in Tempe, AZ Recovery Oasis is an outpatient substance abuse treatment center located in the heart of Tempe, Arizona. Our team of experienced alcohol and drug abuse treatment professionals are here to assist your loved one and family. We provide a host of comprehensive, supportive substance abuse treatment services, ranging from interventions, counseling, withdrawal support, drug replacement therapy, and transitional assistance. Our commitment to helping others stems from our years of experience and dedication to serve; we believe that we can make a difference. Our caring professionals work with each client and their family to create and implement personalized care plans. Medically Managed Chemical Dependency Therapy Our team of experienced professionals have concluded that one of the best forms of outpatient services is to use a medically managed chemical dependency treatment approach. We strongly believe that under the right circumstances, it can be very beneficial for clients to remain with their loved ones while receiving treatment, and we proactively engage with them throughout the process. We provide of stabilization and withdrawal drug replacement treatment services for clients who have become physically or mentally dependent on opioids, alcohol, and other illicit drugs. We combine medically managed chemical dependency with individual, group, and family counseling services to get to the root cause of issues. Each client is assigned a Behavioral Health Technician, that works under the supervision of a licensed Behavioral Therapist, to provide ongoing support with their diagnosis and treatment needs. Our wholistic approach helps to ensure that your loved one is fully supported throughout their recovery. Caring, Committed, Compassionate Substance Abuse Treatment We offer supportive alcohol and substance abuse treatment services to individuals throughout Maricopa County. If your loved one needs a team of caring, committed, compassionate substance abuse treatment professionals, we are here to help. Our success is not measured by revenues or by the number of clients we assist; we focus on providing quality substance abuse treatment services. Your loved oneâ&#x20AC;&#x2122;s health is our number one priority; we are here to care for you and your family. Contact us today to schedule a free consultation at (480) 699-1233.

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Table of content The Opioid Crisis in America.......................................................................................................................................... 02 The Economic Costs of Substance Abuse................................................................................................................... 03 NIDA Estimated Combined Economic Impact of Substance Abuse...................................................................... 03 Substance Abuse and Pregnancy.................................................................................................................................. 04 Cost of Care Routine Care and Delivery...................................................................................................................... 05 Prenatal and Post-Pregnancy Routine Care Costs.................................................................................................. 05 Estimated Total Median Costs of Pregnancy............................................................................................................. 06 The Cost of Pregnancy, Illicit Drug Use, and Alcohol.............................................................................................. 06 Emergency Room and Inpatient Visit Aggregated Costs....................................................................................... 07 E.R. Charges and Costs Based on Payers................................................................................................................... 07 Inpatient Charges and Costs Based on Payers.......................................................................................................... 08 Estimated Costs to Medicaid and Health Insurance Companies........................................................................... 09 Estimated Hospital Costs for Substance Abuse Pregnancies............................................................................... 09 Estimated Hospital Costs Paid by Medicaid and Health Insurance........................................................................ 10 Estimated Lifetime Healthcare Costs.......................................................................................................................... 10 Indicators of Rising Costs............................................................................................................................................... 10 2015 Estimated NAS Cases and Treatment Costs Continue to Rise................................................................... 10 2015 NAS Related Pregnancy Costs Estimates: 6 per 1,000 Births................................................................. 11 2015 NAS Related Pregnancy Costs Estimates: 27 per 1,000 Births............................................................... 11 Why Invest in Rehabilitation for Pregnant Women?.................................................................................................. 12 Integrative Rehabilitative Treatment Recommendations........................................................................................ 13 Childhood Death and Substance Abuse in Arizona................................................................................................... 15 Premature Deaths (Total)............................................................................................................................................... 15 Maltreatment (Total)........................................................................................................................................................ 15 Disparities (Overall)......................................................................................................................................................... 15 Arizona Pregnancy Related Emergency Room Visits................................................................................................ 15 Arizona Pregnancy Related Inpatient Hospital Stays.............................................................................................. 17 Arizona Estimated Hospital Costs for Pregnancy, Illicit Drug Use, & Alcohol Abuse...................................... 18 Arizona Estimated Hospital Costs for Pregnancy, Illicit Drug Use, & Alcohol Abuse by Payer.................... 18 Washington Inpatient Hospital Stays (No ER Data Available)............................................................................... 19 Resources........................................................................................................................................................................... 20

The Opioid Crisis in America On October 27th, 2017, President Donald Trump declared a public health emergency for the opioid crisis in America.46 During his speech, he stated that: â&#x20AC;&#x153;We can be the generation that ends the opioid epidemic. We can do it.â&#x20AC;? 46 By declaring the crisis as a public health emergency, the federal government in conjunction with state governments can improve collaborative efforts to further confront the crisis head-on. 18,32,39,46 According to the National Institute of Drug Abuse, opioids are a type of central nervous system (CNS) depressant, that affect the opioid receptors in the brain and spinal cord; the drugs help to relieve the intensity of pain.24,30 In the process of relieving pain, opioids also affect other regions of the brain that cause feelings of euphoria that can lead to drug misuse, abuse, and addiction.24,30 In 2015, it is estimated that over 50,000 Americans died of a drug overdose, and approximately 63% (33,091) of those deaths were directly attributed to opioid usage have quadrupled in the few past years.46 Side effects of opioids consist of mental confusion, drowsiness, nausea, constipation, and respiratory depression; the euphoric feeling occurs when the drugs are administered in a manner other than intended and higher than normally prescribed dosages are taken.24,43 Examples of common types of opioids are drugs with hydrocodone, oxycodone, morphine, codeine, and fentanyl.24,43 Misuse and abuse of these drugs can lead iincreased tolerance, dependence, and health complications. There is a broad amount of research available regarding the rate of opioid abusers amongst individuals with chronic pain (3-26%), but there are also many individuals who abuse non-prescribed opioids for the euphoric feeling. 24 Combining opioids with other CNS depressants such as alcohol exacerbates the problem.24 Symptoms of an opioid overdose include pinpointed pupils, confusion, drowsiness, mood swings, nausea, vomiting, and a lack of responsiveness. 4,11,20,24 This growing trend affects individuals, families, employers, and the most vulnerable individuals of society. 20,23,36 Research has demonstrated that healthcare costs associated with opioid users is significantly higher than non-users. 11,22,23,24 One study, for example, cited that between 2000-2012, there was a five-fold increase in the number of children being born with neonatal abstinence syndrome (NAS) due to the number of pregnant women who use opioids.6,21,29,40 Additionally, the economic burden associated with the opioid crisis will have systemic, long-term effects. 1,3,43,44 This research examines the rising financial costs and economic impact of substance abuse related pregnancies utilizing estimates based on publicly available data in alignment with peer a peer reviewed research and statistics published by the National Institute of Drug Abuse and the Substance Abuse and Mental Health Services Administration (SAMHSA). Further insight is provided as to why integrative, preventative treatment programs should be a major component of a greater interventionist strategy.

The Economic Costs of Substance Abuse

In 2015 the cost of healthcare in the United States (U.S.) increased by 5.8% to a total of 3.2 trillion dollars annually or around $10,000 dollars per person.8 Research published in, Facing Addition in America: The Surgeon Generalâ&#x20AC;&#x2122;s Report on Alcohol, Drugs, and Health (2016), indicated that in 2015, 27 million people self-reported using illegal drugs or misusing prescription drugs.43 Additionally, another 66 million individuals self-reported binge drinking within the past 30 days during the period that the survey was being conducted.33,35,41 In total, these numbers account for approximately 29% of the overall U.S. population of 323.1 million dollars. 34,35,36,43 40% of non-maternity and ICU hospital beds are used to treat conditions related to drug and alcohol abuse. 34,35,36,43 The Surgeon Generalâ&#x20AC;&#x2122;s Office estimates that the economic impact of drug and alcohol abuse in 2015 was $442 billion.43 Additional data published by the National Institute on Drug Abuse (NIDA), examined substance abuse trends from 2007-2013 and concluded U.S. spends upwards of $820.5 billion dollars annually on substance abuse related costs such as work absenteeism, lost productivity, crime, and healthcare expenses combined.24 Substance abuse is inclusive of tobacco, alcohol, illegal drug use, and prescription drug abuse (opioids), the chart below provides overall costs as outlined by NIDA:

NIDA Estimated Combined Economic Impact of Substance Abuse Substance Type Tobacco Alcohol Illegal Drugs Rx Opioids Total

Healthcare $168 $27 $11 $26 $232 Billion

Overall $300 $249 $193 $78.5 $820.5 Billion

Source: National Institute on Drug Abuse, (April 2017 updates). Overall costs include work absenteeism & lost productivity, crime, and healthcare and statistics based on research data trends from 2007-2013.

Although, researchers estimated in 2013 that the cost associated with prescription opioid use was upwards of $78 billion dollars a year, this did not take into consideration heroin abuse and dependence.39 The latest CEA estimates on the economic impact of the opioid abuse crisis are around $504 billion dollars annually.39 This exceeds the original estimates provided in the 2016 Surgeon Generalâ&#x20AC;&#x2122;s report for the overall economic costs of drug and alcohol abuse, which was estimated to be around $442 billion dollars annually.42 It also increases the original estimated costs of $820.5 billion dollars annually cited by NIDA, who had included the $78.5 billion dollar figure as a part of its calculations.24 The November 2017 CEA report, cites that estimated lost productivity costs are around $30,000 dollars per person per year, which is also in alignment with data published by the U.S. Department of Labor regarding the average salary per person from this same time period of $30,000 dollars annually.13,39 This number has been adjusted due to inflation rates to approximately $31,399 dollars, but $30,000 dollars will be used for all calculations to coincide with the most recently published research.13 04

Substance Abuse and Pregnancy According to data from the National Center for Health Statistics, there were 3,978,497 total births in 2015; 8.1% of newborns had a low birthweight and 9.6% were born prematurely.19 Health factors associated with NAS births include low birth weight, birth defects, premature birth, SIDS, and developmental delays. 1,14,15,16,21,26,29,40 60% of substance abuse neonatal stays are attributed to withdrawal symptoms and 20% attributed to low-birthweight. 7,12,28,37,38 A 2016 study titled, Substance Use During Pregnancy, revealed that women accounted for 40% of all lifetime drug use disorders and 26% of those individuals meet the criterial for both drug and alcohol use disorders during the previous 12 months.12 Overall, however men still account for the majority of drug misuse and abuse; this may indicate a greater need to target women who suffer from systemic forms of drug abuse disorders. 12,24,36 The 2016 National Survey on Drug Use and Health indicated that 6.3% of pregnant women between the ages of 15-44 use and exposed 258,602 offspring to illicit drugs. 12,15,19,36,37 Additionally, 12.6% of pregnant women in this same age group use a combination of illicit drugs and alcohol, exposing 505,269 offspring annually. 2,15,19,36,37

Substance Type Illicit Drugs Tobacco Products

% Total Number Of Women Ages Pregnant 15-44 Substance Abusers by Category 6.30% 13%

Alcohol Use Binge Drinking Heavy Alcohol Use Combination of Illegal Drug Use, Tobacco, or Alcohol Illegal Drugs or Alcohol Tobacco or Alcohol

Not Pregnant 93.70%

21.30%

10.60%

89.40%

51.80% 27.70% 5.60%

8.30% 4.30% 0.90%

91.70% 95.30% 99.10%

60.50%

20.00%

80%

54.90% 59%

12.60% 17.6

87.60% 82.40%

Source: United States Department of Health & Human Services. Substance Abuse Mental Health Services Administration. Centers for Behavioral Health Statistic and Quality: 2016 National Survey on Drug Use and Health. * Offspring projections are estimated calculations utilizing a percentage of all U.S. births in 2015 and data from the 2016 National Survey on Drug Use and Health.

Cost of Care Routine Care and Delivery

The average total cost of a NAS pregnancy is between $159,000 and $238,000 dollars annually.7,25 There was a 71% increase in overall costs associated with substance abuse pregnancies between 2006-2012 and hospital costs increased by 135%.5 Neonatal substance abuse costs 4 to 5 times more than a non-substance abuse pregnancy, and newborns affected by substance abuse spend 4 to 5 times longer in the hospital (19 days compared to 3.7 days). 5,41,42 1 /4th of maternal inpatient hospital stays related to substance abuse include mental health disorders as concurring conditions. 34,43 Information published by the Department of Health and Human Services in 2014 states, that the average cost of delivery and maternal care for a normal pregnancy is around $13,524; a comparable rate of delivery and maternal care for substance abuse users is around $54,168 (based on 4x cost principles). 18,29,40,41,42 Direct care costs for healthy newborns is approximately $3,660 for routine care, compared to $14,640 infants with NAS in addition to specialty care costs. 18,29,40,41,42 Total costs for normal delivery and newborn care is approximately $30,000-$50,000, which aligns with the median $200,000 cost of a NAS Pregnancy (based on 4x cost principles).18,29,40,41,42

Prenatal and Post-Pregnancy Routine Care Costs Service Prenatal Visits Diagnostic X-Rays & Laboratory Costs

Normal Pregnancy

Substance Abuse Pregnancy

$1,620

$6,480

$40

$160 $40

Toxicology Tests Ultrasounds Post Pregnancy (Mother, 6, week post-partum) Post Pregnancy (Up to 12 months) Total

* *

$975 $975

$159

$636

$108

$432

$1728

$2,359

$10,736

$160

* Similarly, one study estimated the maternal care costs for pregnant drug users at around $10,869.00. Source: 9,14,29,39,40

When assessing substance abuse during pregnancy, maternal drug testing utilizing urine specimens are common, but these tests are not always conclusive.27 Different types of toxicology tests my be utilized such as urine, hair samples, or mass spectrometry to get the correct results.27 Toxicology tests can range between $50-80 dollars for urine and $100-650 for blood and hair tests.9,27 A 2013 study recommends using more robust methods than urine testing for pregnant substance abuse users, such as blood or hair samples to include testing newborns.27 The recommendation provided in the above chart is based on a minimum of one toxicology screening during each trimester and one post pregnancy test, utilizing a midpoint costs range of $325.00 per test: the additional cost of screening newborns is not included with the maternal care costs projections.9,27 06

Estimated Total Median Cost of Pregnancy Estimated Total Costs

Normal Pregnancy

Substance Abuse

Total

$40,000 $2,300 $42,300

$200,000 $10,736 $210,736 Normal Pregnancy

Substance Abuse $210,736

$42,300 Total

$2,300 $42,300

Cost Difference = $168,436 $10,736 $210,736

Per research published by, Goler et al., early screening and access to integrative treatment programs should be priority to decrease overall costs of care to the mother and child and improve pregnancy outcomes by reducing prenatal exposure.14,27

The Cost of Pregnancy, Illicit Drug Use, and Alcohol Abuse The national average costs for an ER visit is $1,233; pregnant substance abuse users can expect to spend up to $4,932 per emergency room visit. 9,29,39,40 The cost of care for substance abuse patients utilizing the ER and inpatient services is significantly higher than those of nonsubstance abuse users.17,46 In most cases, many substance abuse users are uninsured or rely on Medicaid to cover healthcare costs.17,46 The information below was retrieved from the Agency for Healthcare Research and Qualityâ&#x20AC;&#x2122;s, Healthcare Cost and Utilization Project Database (HCUPNet), and is based on specific ICD10 code reporting. A query was conducted on all available codes for pregnancy utilizing the Clinical Classification Software (CCS system). The available information is broken down by national and state data. There was not any national data available based on racial stratification for ER or inpatient visits; there was also no data available for ER visits for the state of Washington. A sampling of the total number of newborns born in 2015 was used for this analysis based on the estimated exposure of 258,602 (6.3%) offspring to illicit drug use during pregnancy; the higher estimate of 505,269 (12.6%) offspring exposed to illicit drugs and alcohol was also used. 12,19 A similar model was used in the study conducted by Forray (2016) titled, Substance use During Pregnancy.12 Utilizing the total estimated exposure rates provides further insights into the problem associated with this growing epidemic. A secondary analysis based on 2015 data indicates that estimates may be even higher than current research demonstrates.37

Emergency Room and Inpatient Visit Aggregated Costs Query Codes Used: Diagnoses--Clinical Classification Software (CCS), Principal Diagnosis: #180 Ectopic pregnancy, #181 Other complications of pregnancy, #182 Hemorrhage during pregnancy, abruptio placenta, placenta previa, #183 Hypertension complicating pregnancy, childbirth and the puerperium, #185 Prolonged pregnancy, #186 Diabetes or abnormal glucose tolerance complicating pregnancy, childbirth, or the puerperium, #196 Normal pregnancy and/or delivery

E.R. Charges and Costs Based on Payer All visits Sex Payer

Female Medicare Medicaid Private insurance Uninsured Other Missing

Discharged ED visits with admissionto from the ED the same hospital Aggregate charges Aggregate Total number Total number of visits: N charges, $ (the of visits: N “national bill”)

All ED visits Number Total number of visits: N 2978959.385

2753514.923

225444.4618

5159412312

2978936.262 43929.00376 1712911.305

2753491.8 40348.46332 1571481.958

225444.4618 3580.540445 141429.3469

5159412312 105650089.9 349,263,517

798321.4883

731495.4328

66826.05545

1589639261

320460.6335 94730.32167 8606.632479

311123.4442 90884.36071 8181.26372

9337.189271 3845.960957 425.3687591

216224485.6 92728363.07 5906594.786

Aggregated Charges for All Pregnancies:

$5,159,412,312

Pregnancy & Illicit Drug Use:

$320,042,976

Pregnancy, Illicit Drug Use, and Alcohol

$650,085,951

Aggregated Costs for All Pregnancies: Pregnancy & Illicit Drug Use: Pregnancy, Illicit Drug Use, and Alcohol:

$1,444,635,447 $91,012,033 $182,224,066

* Costs are calculated based on 6.3% estimated total pregnancies affected by illicit drug use and the 12.6% of pregnancies affected by illicit drug use and alcohol abuse. All estimates for aggregated charges and costs are based are based on a median of 28% of aggregated charges if no data was provided in the original query. The estimate of aggregated charges and costs paid utilizing are based on researched data published by published by SAMHSA, which cited 52.5 % actual costs for substance abuse pregnancies are covered by Medicaid and 4.6% private insurance. Sources: 36,37,43

Inpatient Charges and Costs Based on Payer National Costs (racial stratification for national costs for this were not available)

Number

All discharges Sex Female Missing Payer Medicare Medicaid Private insurance Uninsured Other Missing

Aggregate charges Aggregate charges, $ (the “national bill”)

Aggregate costs

Total number of discharges: N

Percent of discharges

1488690.063

100.0000043

25,350,086,908

6,793,320,102

1488625.063 65 13249.99398 695980.1107

99.995638 0.004366255 0.890043863 46.75117793

25349148438 938470 298906702.3 11950045531

6,792,984,870 335231.665 80110235.56 3155956853

692179.9962

46.49591226

11,666,120,249

3,184,252,882

42639.99543 41644.95911 2995.007953

2.864262904 2.797423178 0.201184125

736983812.2 656039915.5 41990698.37

180561472.8 180735029.2 11703628.47

Aggregate costs, $

Estimated Total Aggregated Charges for Pregnancy & Illicit Drug Use $1,597,055,475 Total Aggregated Charges $25,350,086,908 Pregnancy & Illicit Drug Use $1,597,055,475 Pregnancy, Illicit Drug Use, and Alcohol $3,194,110,950 Aggregated Charges Pregnancy & Illicit Drug Use by Payer Medicaid $838,454,124 Private Insurance $73,464,552 Estimated Total Aggregated Charges for Pregnancy, Illicit Drug Use, & Alcohol $3,194,110,950 Aggregated Charges Pregnancy, Illicit Drug, & Alcohol Use by Payer Medicaid $1,676,908,249 Private Insurance $146,929,104 Total Estimated Aggregated Costs Total Aggregated Costs $6,793,320,102

Pregnancy & Illicit Drug Use $427,979,166 Pregnancy, Illicit Drug Use, and Alcohol $855,958,333 Estimated Total Aggregated Costs for Pregnancy, Illicit Drug Use, & Alcohol Absuse $427,979,166 Aggregated Costs Pregnancy & Illicit Drug Use by Payer Medicaid $224,689,062 Private Insurance $20,312,027.10

Estimated Total Aggregated Costs for Pregnancy, Illicit Drug, and Alcohol Alcohol Absuse $855,958,333 Aggregated Costs Pregnancy, Illicit Drug, and Alcohol Use by Payer Medicaid $449,378,125 Private Insurance $39,374,083 * Costs are calculated based on 6.3% estimated total pregnancies affected by illicit drug use and the 12.6% of pregnancies affected by illicit drug use and alcohol abuse. All estimates for aggregated charges and costs are based are based on a median of 28% of aggregated charges if no data was provided in the original query. The estimate of aggregated charges and costs paid utilizing are based on researched data published by published by SAMHSA, which cited 52.5 % actual costs for substance abuse pregnancies are covered by Medicaid and 4.6% private insurance. Sources: 36,37,43

Estimated Costs to Medicaid and Health Insurance Companies Data published by the Center for Behavioral Health Statistics and Quality in the CBHSC Report states that approximately 52.5% of substance abuse pregnancies for women between ages 15-44 were covered by Medicaid.36 Additionally, 32.7% substance abuse pregnancies did not have health insurance coverage and 4.6% used private health insurance. Per the National Institute on Drug Abuse, in many cases up to 81% of hospital costs associated with NAS pregnancies were paid by state Medicaid programs.21,36 When data from the CBHSC Report is combined for those covered by Medicaid (52.5%) and the uninsured (32.7%), similar findings occur.36 This data also coincides with results from the 2016 National Survey on Drug Use and Health, which indicated around 4% of pregnant respondents who utilized illicit drugs relied on private insurance to help pay for their healthcare expenses to include maternity care and delivery.36,43 The National Institute on Drug Abuse cites that substance abuse related pregnancies costs hospitals up to $1.5 billion dollars annually.21

Estimated Hospital Costs for Substance Abuse Pregnancies Emergency Room Costs Pregnancy, Illicit Drug Use, and Alcohol

$182,224,066

Inpatient Stay Costs Pregnancy, Illicit Drug Use, and Alcohol

$855,958,333

Estimated Total Costs (in alignment with research)

$1,038,182,399

Estimated Hospital Costs Paid by Medicaid and Health Insurance Medicaid 52.5% Private Insurance 4.6%

$545,045,759 $ 47,756,390

* All data is calculated utilizing 12.6% in alignment with the annual estimated $1.5 billion dollars in hospital costs and prior calculations.

Estimated Lifetime Healthcare Costs As estimated in this research, based on the HCUP analysis, upfront hospital costs for private insurers equate to $47,756,390 dollars annually, but the lifetime healthcare costs for individuals affected by illicit drug and alcohol abuse will result in billions of dollars being spent. Of the approximately 505,269 children exposed to illicit drugs and alcohol abuse, it is estimated that 4.6% have immediate access to private insurance or about 23,242 patients each year.36,43 Lifetime medical treatment for patients affected by prenatal drug and alcohol exposure can cost upwards of $1.6 million per person.21 This means that of the 23,000+ children exposed to illicit drugs and alcohol, covered by private insurance total lifetime costs equate to $37,187,200,000. If this trend continues over a period of 5 years, lifetime costs are projected to be $185,986,000,000, if maintained at a steady rate.

Indicators of Rising Costs

The CEAâ&#x20AC;&#x2122;s most recent report also cites that the overall financial impact of the opioid crisis has been vastly underestimated in the past because it did not take into consideration the expanded usage of heroin.36 The numbers below presented for 2015 indicate that previous estimates regarding the impact on the crisis on healthcare costs may also be under estimated. Cost continue to remain at a rate of 4 to 5 times that of non-substance abuse pregnancies, but the rate of incidence has dramatically increased.3,22,24,39,32,33

2015 Estimated NAS Cases and Treatment Costs Continue to Rise A study entitled, Neonatal Abstinence Syndrome and Associated Health Care Expenditures, published in 2009 by Dr. Stephen Patrick et al revealed that from 2000-2009, approximately 6 per 1000 births were affected by NAS, and this is the current data also published by the Department of Health and Human Services. 29,32,33,45 It is also used as the basis of a 2016 SAMHSA publication titled, A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders, and cited in this analysis. More recently, however, Dr. Veeral Tolia, Dr. Stephen Patrick, and their team from Vanderbilt University published updated findings in the New England Journal of Medicine that analyzed data trends from 2004-2013 based on maternity and infant healthcare utilization.40 The study utilized the Pediatrix Clinical Data Warehouse to perform a cross-sectional analysis on NICU admission data from 33 states and Puerto Rico.39 The updated analysis revealed that the numbers had increased from 6 births per 1,000 to around 27 per 1,000 births.7,40,45 Two estimated cost models are provided based on both studies and 2015 data:

2015 NAS Related Pregnancy Costs Estimates: 6 per 1,000 Births Total Number of Births in 2015 Estimated Total of Children Born to NAS in 2015 Estimated Cost of Care Total Cost for Hospital Treatment Medicaid Costs Private Health Insurers Lifetime Costs Per Child Lifetime Healthcare Costs Estimates based on projected 2015 NAS Cases Private Health Insurer Lifetime Estimates (estimates based off the 4.6% who initially had access to insurance) Estimated 5 Year Stable Trend

3,978,497 23,871 $200,000 $ 4,774,200,00 $2,506,455,000 $22,961,320 $1,600,000

Estimated Lost Productivity Costs

$33,419,400,000

$1,756,905,600 $8,784,523,000 $43,922,615,000

2015 NAS Related Pregnancy Costs Estimates: 27 per 1,000 Births Total Number of Births in 2015 Estimated Total of Children Born to NAS in 2015 Estimated Cost of Care Total Cost for Hospital Treatment Medicaid Costs Private Health Insurers Lifetime Costs Per Child Lifetime Healthcare Costs Estimates based on projected 2015 NAS Cases Private Health Insurer Lifetime Estimates (estimates based off the 4.6% who initially had access to insurance) Estimated 5 Year Stable Trend

3,978,497 107,406 $ 200,000 (Median Range) $21,481,200,000 $11,277,630,000 $51,877,098 $1,600,000

Estimated Lost Productivity Costs

$150,368,400,000

$171,849,600,000 $7,905,081,600

$859,248,000,000

These estimates indicate that the overall of hospital costs for NAS related cases may be even higher than then $1.6 billion dollars originally projected by the Department of Health and Human Services and information available in the HCUP database. 40 An additional crosssectional study is recommended utilizing data from 2014-2017 to determine these costs factors. 12

Why Invest in Rehabilitation for Pregnant Women? Research cites that early identification and intervention during the first trimester of pregnancy can reduce these long-term medical costs. 12,14,15,31,32,47 The average cost of one full year of outpatient maintenance treatment is around $4,700 per the National Institute on Drug Abuse.23,24 For insurance companies willing to invest in the upfront cost of treatment, investing $4,700 can result in $340 saved for every dollar spent. 23,24 Additionally, the research also suggests utilizing a targeted integrative treatment model for pregnant women during the first trimester or 90-days. 12,14,15,31,32,47 On average, these residential programs range from $12-60,000 dollars; if insurance companies, for example, invest $12,000 into residential treatment programs for pregnant women:  There is a decreased reduction a child being born with NAS, which means an upfront ROI of approximately $17 for every dollar invested, based on an average treatment costs of $200,000 per baby.10,11  There is a lifetime reduction in healthcare costs and an estimated ROI of $133.33 per dollar. Previous studies similarly indicated a monthly savings of $133 per month savings per patient when insurance companies invest in rehabilitative services. 10,11,23,24  The National Institute of Drug Abuse cites that while minimal outpatient treatment program is $4,700, it costs $24,000 for one year of prison, and there are subsequent studies that support the impact on rehab in helping to reduce the economic impact of crime. 23,24 For every $12,000 invested in an integrative rehabilitation program, there is a $2.00 per dollar return on investment.  There is a 10-15% reduction in pre- and post-natal maternal care because much of the costs associated with toxicology testing and other healthcare outcomes are included as a component of the comprehensive treatment program.27  Average lifetime labor productivity costs are around $1.4 million dollars person; the medical care costs for NAS patients exceeds this by $200,000.00.13 By investing in rehabilitative services, insurance companies not only reduce disparities associated with the onset of NAS but also play a direct role in economic sustainment.10,11,42,43,46

Integrative Rehabilitative Treatment Recommendations The research demonstrates that the upfront costs invested in rehabilitative programs can lead to a reduction in long-term systemic healthcare utilization costs and reduce the economic impact of drug abuse. 10,11,31,32,42,43,46 In August 2016, SAMHSA issued two reports that promoted improving healthcare access for pregnant and parenting women with opioid abuse disorders. In the publication, A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders, researchers recommend using a comprehensive interventionist model to provide care for pregnant women.32 The focus on providing care should utilize a model that:  Prioritizes prevention  Ensures access to affordable, comprehensive treatment services  Safeguards against discrimination and stigmatization  Provides ongoing assessment of opioid usage in pregnancy women (toxicology reports, psychological assessment, and medical examinations)  Balances the risks and benefits of non-pharmaceutical versus pharmaceutical approaches to care with consideration for the mother and child  Provides support for withdrawal management  Provides maintenance support The model utilizes a 5-point interventionist plan, which includes pre-pregnancy awareness campaigns, pro-active prenatal care and treatment referrals, testing of newborns at birth, neonatal medical support, and continued support throughout early childhood and adolescence. 31,32 The framework of the 5-point model requires collaborative effort between government agencies, third-party payers (insurance companies), and support from the local communities. 31,32 SAMHSA cites that using a shared goal, joint-strategy interventionist approach will help to reduce long-term disparities and increase access to quality healthcare.31,32 The research is further supported by the secondary publication, Advancing the Care of Pregnant and Parenting Women with Opioid Use Disorder and Their Infants: A Foundation for Clinical Guidance (2016). 31,32 In conclusion, early intervention through a network of partnerships, geared towards providing support, education, and treatment is key; rehabilitation programs that specifically target pregnant women within the first trimester can have a sustainable long-term impact. 10,11,31,32,42,43,46

STATE DATA

Childhood Death and Substance Abuse in Arizona Per data published by the Arizona Child Review Program (CFR), prenatal substance abuse deaths are classified as â&#x20AC;&#x153;maltreatment death due to natural manner.â&#x20AC;? In 2015, 16% of childhood deaths were attributed to maltreatment due to natural manner; the deaths were a result of premature birth or failure to receive medical care for the child. Arizonaâ&#x20AC;&#x2122;s early childhood death rates are consistent with national averages of the 12.6% of pregnant women who use some form of illicit drugs and/or alcohol. 2,24,33

Premature Deaths (Total) 20% of all premature deaths are from parents who are first generation immigrants from Mexico, and there are a disproportionately high number of premature childhood deaths among the Hispanic and African American population. 84% of premature deaths were due to pregnancy complications and 26% were attributed to the mother not receiving any prenatal care. 2,33

Maltreatment (Total) In 2015, Arizona had a total of 768 deaths for all children 17 and below; maltreatment accounted for 11% of all deaths. Substance abuse was associated with 61% of all maltreatment deaths. 2,33

Disparities (Overall) There is a high level of racial health disparities amongst Hispanics and Blacks compared to Whites. Hispanic child deaths are over represented in the natural causes and premature category; African American child deaths were over represented in natural causes, premature, and maltreatment categories. Based on the data above, it can be assumed that premature childhood deaths due to substance abuse in AZ occur primarily in African American & Hispanic communities. 2,33

Arizona Pregnancy Related Emergency Room Visits

All ED visits

ED visits with admission to the same hospital

Number

Aggregate charges

Total number of visits: N

Percent of visits

Total number of visits: N

Percent of visits

Aggregate charges, $

All visits

52608

100

3145

100

68293683

Sex

Female

52607

99.99809915

99.99798

3145

100

68293683

White

22621

42.99916363

43.20401

1251

39.77742448

28611905

5155

9.798889903

9.863939

276

8.775834658

6839084

Race/ ethnicity

Percent of visits

Black

Hispanic

21172

40.24482968

40.02588

1374

43.68839428

26793669

Asian/ Pacific Islander

1286

2.444495134

2.452338

2.321144674

1651507

Native American

1897

3.60591545

3.52789

152

4.833068363

3972060

Missing

438

0.832572993

0.847098

0.604133545

425458

Aggregated Charges $68,293,683 Pregnancy & Illicit Drug Use $4,302,502 Pregnancy, Illicit Drug Use, and Alcohol $8,605,004 Aggregated Costs $19,122,231 Pregnancy & Illicit Drug Use $1,204,701 Pregnancy, Illicit Drug Use, and Alcohol $2,409,401

Arizona Pregnancy Related Inpatient Hospital Stays Number

Aggregate charges

Aggregate costs

Aggregate charges

Total number of discharges: N

Percent of discharges

33241

100

567932105.4

138273971.8

Female

33241

100

567932105.4

138273971.8

Medicare

229

0.688908276

5929225.78

1199195.482

3145

100

68293683

Medicaid

17814

53.59044553

301407388.6

74003117.34

3145

100

68293683

Private insurance

12576

37.83279685

216654354.9

51735064.2

1251

39.77742448

28611905

Uninsured

1276

3.838633013

22883609

5692500.379

276

8.775834658

6839084

Other

1344

4.043199663

21017664

5635093.593

1374

43.68839428

26793669

Missing

2.321144674

1651507

White

15133

45.52510454

257140204.2

61696484.38

152

4.833068363

3972060

Black

2138

6.431816131

41349679

9821111.658

0.604133545

425458

Hispanic

12943

38.93685509

218308356.2

53161998.27

Asian/ Pacific Islander

1011

3.041424747

17215449

3921613.588

Native American

1700

5.114166241

28470434

8345727.512

Other

0.051141662

260929

71071.38294

Missing

299

0.899491592

5187054

1255965.058

Aggregate charges, $

ED visits with admission Aggregate costs, $ to the same hospital

Total number of Percent of visits visits: N

Aggregated Inpatient Costs $138,273,979 Pregnancy and Illicit Drug Use $8,711,261 Medicaid Costs $4,573,412 Private Insurance Costs $400,718

Aggregate charges, $

Aggregated Inpatient Charges $567,932,105 Pregnancy & Illicit Drug Use $35,779,723 Pregnancy, Illicit Drug Use, and Alcohol $71,559,445 Aggregated Inpatient Costs $138,273,979 Pregnancy, Illicit Drug Use, & Alcohol Use $17,422,522 Medicaid Costs $9,146,824 Private Insurance Costs $801,436

Arizona Estimated Hospital Costs for Pregnancy, Illicit Drug Use, & Alcohol Abuse Emergency Room $2,409,401 Inpatient Treatment $17,422,522 Total Costs 19,831,923

Arizona Estimated Hospital Costs for Pregnancy, Illicit Drug Use, & Alcohol Abuse by Payer Medicaid Costs $10,411,759 Private Insurance Costs $912,268

Washington Inpatient Hospital Stays (No ER Data Available) Number

All discharges

Aggregate charges

Aggregate costs

Total number of discharges: N

Percent of discharges

Aggregate charges, $

Aggregate costs, $

30144

100

501179139

160715666.7

Sex

Female

30144

100

501179139

160715666.7

Payer

Medicare

227

0.753052017

5130545

1602800.472

Medicaid

11742

38.95302548

199134211

64137545.27

Private insurance

16876

55.98460722

274647984

88233809.7

Uninsured

435

1.443073248

7883851

2490654.586

Other

864

2.866242038

14382548

4250856.666

White

18484

61.31900212

304166307

96680549.84

Black

1526

5.062367304

29740680

8888784.759

Hispanic

4528

15.02123142

69095047

24691859.05

Asian/ Pacific Islander

2502

8.300159236

45869209

14003597.8

Native American

501

1.662022293

8131448

2859007.545

Other

147

0.487659236

2694206

738028.5998

Missing

2456

8.147558386

41482242

12853839.1

Race/ ethnicity

Aggregated Inpatient Costs $160,715,667 Pregnancy, Illicit Drug Use, & Alcohol $ 20,250,174 Medicaid Costs $10,631,341 Private Insurance Costs $931,508 * Costs are calculated based on 6.3% estimated total pregnancies affected by illicit drug use and the 12.6% of pregnancies affected by illicit drug use and alcohol abuse. All estimates for aggregated charges and costs are based are based on a median of 28% of aggregated charges if no data was provided in the original query. The estimate of aggregated charges and costs paid utilizing are based on researched data published by published by SAMHSA, which cited 52.5 % actual costs for substance abuse pregnancies are covered by Medicaid and 4.6% private insurance. Sources: 36,37,43

Resources 1. American University. (2015). Costs Associated with Alcohol Addicted/Exposed Infants. Retrieved from: https://jpo.wrlc.org/bitstream/handle/11204/3796/FAQ_Costs%20 Associated%20with%20the%20Birth%20of%20Drug%20and%20or%20Alcohol%20 Addicted%20Exposed%20Infants.pdf?sequence=3. 2. Arizona Department of Health Services. (2016). Arizona Child Fatality Review Program, 23rd Annual Report. Retrieved from: http://www.azdhs.gov/documents/prevention/ womens-childrens-health/reports-fact-sheets/child-fatality-review-annual-reports/ cfr-annual-report-2016.pdf. 3. Agency for Healthcare Research and Quality (AHRQ). (2014). Costs for Hospital Stays in the Unvited States, 2012. Statistical Brief #181. Healthcare Cost and Utilization Project. Retrieved from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb181-Hospital-CostsUnited-States-2012.pdf. 4. Agency for Healthcare Research and Quality (AHRQ). (2007). Hospitalizations Related to Drug Abuse, 2005. Statistical Brief #39. Healthcare Cost and Utilization Project. Retrieved from: https://hcup-us.ahrq.gov/reports/statbriefs/sb193-Neonatal-MaternalHospitalizations-Substance-Use.pdf. 5. Agency for Healthcare Research and Quality (AHRQ). (2015). Neonatal and Maternal Hospital Stays Related to Substance Use, 2006-12. Statistical Brief #193. Healthcare Cost and Utilization Project. Retrieved from: https://hcup-us.ahrq.gov/reports/statbriefs/ sb193-Neonatal-Maternal-Hospitalizations-Substance-Use.pdf. 6.Agency for Healthcare Research and Quality (AHRQ). (2014). Overview of Hospital Stays in the United States, 2012. Statistical Brief #180. Healthcare Cost and Utilization Project. Retrieved from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb180Hospitalizations-United-States-2012.pdf. 7. Areas-Holmblad, L. (2016). New Study Mirrors National Data Showing Sharp Increase in Babies Born with Withdrawal Symptoms. Drug Addiction Now. Retrieved from: https:// www.drugaddictionnow.com/2016/12/06/new-study-mirrors-national-data-showingsharp-increase-in-babies-born-with-withdrawal-symptoms/2/. 8. Centers for Medicare and Medicaid. (2016). National Health Expenditures 2015 Highlights. Retrieved from: https://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/ highlights.pdf. 9. CostHelperHealth. (2017). Drug or Alcohol Testing Cost. Retrieved from: http://health. costhelper.com/drug-alcohol-test.html. 10 .Florida Alcohol & Drug abuse Association. (n.d). Cost-Benefit Analysis: Substance Abuse Treatment is a Sound Investment. http://www.fadaa.org/documents/Legislative%20 Booklets/CostBenefit.pdf. 11. Florida Alcohol & Drug Abuse Association. (2011). The Impact of Substance Use Disorders on Health Care. Retrieved from: www.fadaa.org/documents/Legislative%20Booklets/ HealthCare.pdf. 12. Forray, A. (2016). Substance use During Pregnancy. F1000Research. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4870985/. 13. FRED Economic Data. (2017). Real Median Personal Income in the United States. Retrieved from: https://fred.stlouisfed.org/series/MEPAINUSA672N. 14. Goler et al. (2012). Early Start: A Cost-Beneficial Perinatal Substance Abuse Program. 21

Obstetrics & Gynecology. Retrieved from: http://journals.lww.com/greenjournal/ Abstract/2012/01000/Early_Start__A_Cost_Beneficial_Perinatal_Substance.15.aspx. 15. Guttmacher Institute. (2017). Substance Use During Pregnancy. State Laws and Policies. Retrieved from: https://www.guttmacher.org/state-policy/explore/substanceuse-during-pregnancy. 16. Hamdan, A. (2016). Neonatal Abstinence Syndrome Treatment & Management. Cardiac Disease and Critical Care Medic. Retrieved from: https://emedicine.medscape.com/ article/978763-treatment. 17. Health & Medicine Week. (2005). ER Patients with Substance Abuse Treatment Need Incur Higher Healthcare Costs. Academic OneFile. Retrieved from: db19.linccweb.org/ login?url=http://go.galegroup.com/ps/i.o?p=AONE&sw=w&u=lincclinid=GALE%7CA21271 9933&it=r&asid=d404a9d3c853a19bf1c6764b257e59c1. 18. Kornhauser, M. & Schneiderman R. (2010). How Plans Can Improve Outcomes and Cut Costs for Preterm Births. Managed Care Magazine. Retrieved from: https://www. managedcaremag.com/archives/2010/1/how-plans-can-improve-outcomes-and-cutcosts-preterm-infant-care. 19. National Center for Health Statistics. (2016). National Vital Statistics System: Birth Data. Retrieved from: https://www.cdc.gov/nchs/nvss/births.htm. 20. National Council on Alcoholism and Drug Dependence. (2017). Facts About Alcohol. Retrieved from: https://www.ncadd.org/about-addiction/alcohol/facts-about-alcohol. 21. National Institute on Drug Abuse. (2015). Dramatic Increases in Maternal Opioid Use and Neonatal Abstinence Syndrome. Retrieved from: https://www.drugabuse.gov/ related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioiduse-neonatal-abstinence-syndrome. 22. National Institute on Drug Abuse. (2011). Drug-Related Hospital Emergency Room Visits. Drug Facts. Retrieved from: https://www.drugabuse.gov/publications/drugfacts/drugrelated-hospital-emergency-room-visits. 23. National Institute on Drug Abuse. (2012). Principles of Drug Addiction Treatment: A Research-Based Guide, 3rd Edition. Retrieved from: https://www.drugabuse.gov/ publications/principles-drug-addiction-treatment-research-based-guide-third-edition/ frequently-asked-questions/drug-addiction-treatment-worth-its-cost. 24. National Institute on Drug Abuse. (2017). Trends and Statistics: Cost of Substance Abuse. Retrieved from: https://www.drugabuse.gov/related-topics/trends-statistics. 25.NC Drug Court. (n.d.). Medical Costs of Addicted Newborns: Neonatal Abstinence Syndrome. Retrieved from: http://ncdrugtreatmentcourts.com/NAS.html. 26. Norton, A. (2017). Medical Costs Soar for U.S. Babies Born Addicted to Opioids. WebMD. Retrieved from: https://www.webmd.com/mental-health/addiction/news/20170615/ medical-costs-soar-for-us-babies-born-addicted-to-opioids#1. 27. Newman, L. (2016). As Substance Abuse Rises, Hospitals Drug Test Mothers, Newborns. Clinical Laboratory News. Retrieved from: https://www.aacc.org/publications/cln/ articles/2016/march/as-substance-abuse-rises-hospitals-drug-test-mothersnewborns. 28.Oâ&#x20AC;&#x2122;Leary et al. (2012). Maternal Alcohol Use and Sudden Infant Death Syndrome and Infant Mortality Excluding SIDS. Retrieved from: http://pediatrics.aappublications.org/ content/pediatrics/early/2013/02/20/peds.2012-1907.full.pdf. 29. Patrick et al. (2012). Neonatal Abstinence Syndrome and Associated Health Care 22

Expenditures, United States, 2000-2009. Retrieved from: https://jamanetwork.com/ journals/jama/fullarticle/1151530. 30. Peltz, G. & Anand, K. (2015). Long-Acting Opioids for Treating Neonatal Abstinence Syndrome. JAMA, 314(19), 2023. doi:10.1001/jama.2015.13537. 31. SAMHSA. (2016). Advancing the Care of Pregnant and Parenting Women with Opioid Use Disorders. Retrieved from: http://files.www.cmhnetwork.org/news/Advancing_the_ Care_of_Pregnant_and_Parenting_Women_with_Opioid_Use_Disorder_and_their_ Infants_-_A_Foundation_for_Clinical_Guidance_-.pdf. 32. SAMHSA. (2016). A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. Retrieved from: https://ncsacw.samhsa.gov/files/Collaborative_ Approach_508.pdf. 33. SAMHSA. (2016). Behavioral Health Barometers: Arizona. Retrieved from: https:// store.samhsa.gov/shin/content//SMA16-BARO-2015/SMA16-BARO-2015-AZ.pdf 34. SAMHSA. (2016). Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health. Retrieved from: https:// www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/ NSDUH-FFR1-2015.pdf. 35. SAMHSA. (2013). Results from the 2012, National Survey Drug Use and Health: Summary of National Findings. Retrieved from: https://www.samhsa.gov/data/sites/default/files/ NSDUHresults2012/NSDUHresults2012.pdf. 36. SAMHSA. (2017). Results from the 2016 National Survey on Drug Use and Health: Detailed Tables. Retrieved from: https://www.samhsa.gov/data/sites/default/files/ NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf. 37.SAMSHA. (2017). Women of Childbearing Age and Opioids. The CBHSQ Report. Retrieved from: https://www.samhsa.gov/data/sites/default/files/report_2724/ ShortReport-2724.html. 38. The Physicians Committee. (n.d.). Birth Defect Statistics. Retrieved from: http://www. pcrm.org/research/resch/reschethics/birth-defect-statistics. 39. The Council of Economic Advisors. (2017). The Underestimated Cost of the Opioid Crisis. Retrieved from: https://www.whitehouse.gov/sites/whitehouse.gov/files/images/ The%20Underestimated%20Cost%20of%20the%20Opioid%20Crisis.pdf. 40.Toliaetal.(2015).IncreasingIncidenceoftheNeonatalAbstinenceSyndromeinU.S.Neonatal ICUs. The New England Journal of Medicine. DOI: 10.1056/NEJMsa1500439. Retrieved from: http://www.nejm.org/doi/full/10.1056/NEJMsa1500439#t=articleDiscussion. 41. Truven Health Analytics. (2013). The Cost of Having a Baby in the United States. Retrieved from: http://transform.childbirthconnection.org/wp-content/uploads/2013/01/Cost-ofHaving-a-Baby1.pdfm. 42. U.S. Department of Health and Human Services. (2014). Proposed Payment Rules. Retrieved from: http://media.mcguirewoods.com/mwc/proposed-payment-rules.pdf. 43. U.S. Department of Health & Human Services. (2016). Facing Addiction in America. SAMHSA. Retrieved from: https://addiction.surgeongeneral.gov/surgeon-generalsreport.pdf 44. U.S. Department of Justice National Drug Intelligence Center. (2011). The Economic Impact Illicit Drug on America Society. Retrieved from: https://www.justice.gov/archive/ ndic/pubs44/44731/44731p.pdf. 45. Vanderbilt University Medical Center. (2017). Neonatal Abstinence Syndrome and 23

Opioid Policy. Retrieved from: https://www.vumc.org/nas/. 46. Walsh, M. (2017). “Trump Declares Public Health Emergency’ Over Opioid Crisis: “We can be the generation that ends the epidemic.” Yahoo News. Retrieved from: https:// www.yahoo.com/news/trump-declares-public-health-emergency-opioid-crisis-cangeneration-ends-epidemic-200509548.html. 47. Walz, R. & Bleuer, J. (2015). Treating Pregnant Women with Substance Abuse Issues in a OBGYN Clinic: Barriers to Treatment. Article 15, Vistas Online. Retrieved from: https:// www.counseling.org/docs/default-source/vistas/treating-pregnant-women-withsubstance-abuse-issues-in-an-obgyn-clinic-barriers-to-treatment.pdf?sfvrsn=6. 48. White et al. (2005). Direct Costs of Opioid Abuse in an Insured Population in the United States. Journal of Managed Care Pharmacy. Retrieved from: https://www.ncbi.nlm.nih. gov/pubmed/15998164