This story, originally published by the Bristol Herald Courier, appeared Sept. 3, 2017. Copyright 2017 Bristol Herald Courier.
Shawna Ramos clings tightly to newborn Ashton, sitting in the intensive care unit of a local hospital while her baby screams, squirms and struggles to shake off the drugs disquieting his tiny body.
Sometimes, Ashton is inconsolable. Sometimes, his 26-year-old mother is, too.
Ashton came into this world like so many Mountain Empire babies, forced to overcome his mother’s addictions. Whether the drug of choice is abused prescription pain medications, synthetic replacements or illicit street drugs, all such babies receive a common diagnosis: neonatal abstinence syndrome.
Doctors and politicians label this region the “epicenter of the nation’s opioid crisis.” Babies with NAS are collateral damage.
A seven-month investigation by the Bristol Herald Courier revealed:
Since 2009, doctors at Niswonger Children’s Hospital in Johnson City treated 1,829 Tri-Cities-area babies for neonatal abstinence syndrome.
Sullivan County reported 77 NAS cases in 2016 or 50.5 per 1,000 births – the highest rate among Tennessee counties for the fifth straight year.
Nationwide in 2013, an average of 5.8 babies per 1,000 births were diagnosed with NAS. In Sullivan County in 2013, the rate was 54 per 1,000 and Northeast Tennessee registered 41 per 1,000.
Southwest Virginia reported 316 NAS births from 2011-2015, that state’s highest rate.
Nearly two of every three out-of-state NAS babies treated in Tennessee are from Virginia.
Treating NAS babies is expensive due to lengthy stays in neonatal intensive care units. An average NAS baby costs around $65,000 to treat and the care of about 78 percent of NAS babies is charged to state Medicaid programs.
In the U.S., a third of reproductive-aged women filled a prescription for an opioid medication, and between 14 percent and 22 percent of women filled an opioid medication prescription during pregnancy.
We are hooked, and so are our children.
In a 2011 study, Tennessee ranked second in the U.S. for the total number of prescriptions written — enough to provide every person in the state an average of 17 prescriptions, or about 40 percent above the national average.
The Volunteer State also ranks second nationally for the sheer volume of painkiller prescriptions. In 2010, doctors in Tennessee wrote prescriptions for 275 million hydrocodone pills, including Lortab, Lorcet and Vicodin; 113 million oxycodone pills, which includes OxyContin, and 116 million Xanax, which is used to treat anxiety.
Virginia ranks substantially lower in the number of those prescriptions — between 72 and 82 prescriptions per 100 people — according to an audit by the Centers for Disease Control.
The drugs are powerful. Some would argue too powerful.
A recent Harvard study shows that going to an emergency room and getting started on a 30-day prescription of such opioids significantly increases someone’s risk of becoming addicted.
“I think we as physicians have dramatically underestimated the addiction potential,” said Dr. David Wood, chief medical officer of Niswonger Children’s Hospital in Johnson City. “I sympathize with my ER colleagues because when the patient comes in and says they’re in pain, they have to treat the pain. We have to figure out different ways to treat pain, but it’s very easy to overwrite a prescription. We probably prescribe too many pills for any episode of pain, and we underestimate how addicting that really is.”
Wood said the problem often involves patient “self-medication” to ease both physical and emotional pain. That need is more than met by the region’s proliferation of under-regulated pain clinics.
A 2002 Tennessee law opened the door for doctors to prescribe powerful painkillers for people with intractable pain, but it created a generation of addicts, said Sullivan County District Attorney General Barry Staubus. While the law no longer exists, its results have multiplied.
“The legislature finally repealed that law, but you can’t undo the aftermath of more than 10 years of all the consequences of the legislation,” Staubus said. “That opens a vacuum for treatment, and a very prevailing treatment is Suboxone. ‘We will wean you from opioids with this synthetic product.’
“They’re still going to be addicts, but we’ll give them a drug that will stop the craving but doesn’t get them high. … Now, we have all these pain clinics, and what we see in law enforcement is people use this as a stop-gap measure when they’re feeling bad, feeling the effects. There are people who have recovered, but there are many who take it and take it and are not stepping down into complete sobriety.”
In Tennessee over the past decade, the incidence of addicted mothers giving birth to babies with NAS increased 15-fold. Between 2000 and 2002, there were 15 reported cases of NAS in Washington County, Tennessee, eight in Sullivan County and 42 across all eight counties of Northeast Tennessee. Between 2009 and 2011, those numbers climbed to 84 in Sullivan County, 75 in Washington County and 337 across the eight-county region, according to the Tennessee Department of Health.
Tennessee had 1,034 cases in 2014, 1,049 in 2015 and 1,068 in 2016.
While the number of cases appears to be leveling off, the epidemic shows no sign of abating. Sullivan County had 77 cases of NAS in 2016 or 50.5 per 1,000 births, while Davidson County — which includes the city of Nashville and has four times the population of Sullivan — reported 58 cases and a rate of 5.6 per 1,000.
Through the first 27 weeks of 2017, Sullivan County reported 38 cases of NAS, the same number as Davidson County while the state reported 476. Those totals are slightly less than the same point in 2016, when Sullivan reported 41 cases and the state had 500.
Statewide in Virginia, the number of NAS babies has risen steadily from 385 in 2012 to an estimated 741 in 2016. Like Northeast Tennessee, Southwest Virginia leads its state in NAS births. The number of cases in the 10 counties and two cities has more than doubled, from 38 in 2011 and 39 in 2012 to 90 in 2015.
And the problem of drug-exposed babies is actually far worse, according to Alan Levine, president and CEO of Mountain States Health Alliance.
“The NAS cases we report are the most severe cases, but we deliver hundreds of babies with some form of drug exposure every year,” Levine said. “In just January and February of this year, Mountain States hospitals in Tennessee and Virginia have delivered 102 newborns who were affected by exposure to harmful substances before birth. This includes alcohol and tobacco exposure, as well as cocaine and prescription opioids.”
On any given day, nearly half of the babies in the NICU of Niswonger Children’s Hospital in Johnson City and Holston Valley Medical Center in Kingsport are being treated for NAS, as hospital nurseries across the region regularly funnel their worst cases there. The Johnson City hospital recently completed a 19-bed expansion solely to care for babies with NAS.
“The problem is such a big deal to us that we’ve invested millions of dollars in capital to expand our neonatal intensive care unit because the requirements of neonatal abstinence syndrome babies are very different from regular NICU babies,” Levine said.
A Hell for Children
For the NAS babies, it is a hellish beginning to life because they experience the same symptoms an adult drug abuser would feel.
“Your autonomic nervous system goes haywire, so they’re salivating, get very jittery and have a hard time calming down,” explained Wood. “They have a hard time eating and digesting food, so they have a hard time with growth in a normal trajectory … after birth, which is typically very rapid. If they have a very bad withdrawal, it can provoke a seizure. They’re all hyped up. What we do is replace the opioid and taper it down slowly to calm down their nervous system and their brains. Then you withdraw it, but it’s not such an abrupt withdrawal.”
Babies with NAS remain hospitalized for weeks and sometimes months.
Nationally, NAS babies are hospitalized an average of 17 days, but the Tri-Cities region’s average is about 21 days, according to Wood.
“These babies are costing $65,000 to $90,000.Just monitoring them for five days doubles the cost of a normal newborn. If they’re in the NICU, the cost skyrockets,” Wood said.
According to the Tennessee Department of Health, the average cost of delivering a healthy newborn can range up to $8,500.
NAS babies are slightly more likely to be premature, but their mortality rate is typically low, and many are otherwise healthy, Wood said.
More than 90 percent of the Tennessee mothers with NAS babies are on TennCare, the state-supported Medicaid program. In 2012, TennCare paid more than $45.8 million to treat 736 infants with NAS, where an average hospital stay was 26 days, according to the Tennessee Department of Health.
Of those 736 babies, nearly a fourth were subsequently taken into the care of the Department of Children’s Services.
Where do we go from here?
Lawmakers in Tennessee and Virginia are working to address the problem through legislation
The Tennessee General Assembly’s House Task Force on Opioid Abuse recently visited Johnson City and is gathering input and searching for solutions to the state’s opioid addiction problems.
“My goal is [that] this task force will look into the possibility of pilot programs, measure results of these programs and determine best practices,” House Speaker Beth Harwell, R-Nashville, said recently.
A series of bills from Virginia Del. Todd Pillion, R-Abingdon, were signed into law earlier this year and will limit the prescriptions physicians can write.
On the medical front, Levine said the region has “underinvested” in treatment and prevention.
“We have a whole cadre of children and teens who, if we invest properly, we can both stop this cycle by treating the people who have the problem and then focus on prevention. You have to do both. If we just treat people who are already addicted, you haven’t dealt with the other problem of people entering addiction. It’s just a continuous cycle,” Levine told the task force during its visit to the region.
A treatment center, Levine said, is vital to that response.
“There is no robust addiction treatment facility in this region. Through our merger with Wellmont, one of the commitments we’ve made is to invest millions of dollars in constructing and operating a residential addiction treatment facility,” Levine said. “You can’t just keep people in the environment that has led to the addiction and think you’re actually going to solve this problem — if you don’t get them out of that environment.”
David McGee, Bristol Herald Courier