Babies Born In Opioid Withdrawal Increasing Along With Rural Addiction

Neonatal Abstinence Syndrome Growing Fastest Where Health Resources Are Most Scarce
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As much as the opioid epidemic across the United States is often characterized as a rural and suburban problem, it has been devastating in urban areas as well. Of course, this doesn't mean patterns of addiction play out the same way in all settings. A University of Michigan-based study released in Dec. 2016 found that in rural areas, opioids are a source of disproportionate harm to pregnant mothers and their babies.

Led by public health researcher and physician Nicole Villapiano, the study found that rural counties in the U.S. have seen faster growth of neonatal abstinence syndrome. Essentially, it means babies are born in withdrawal after becoming dependent on opioids their mothers took while pregnant, which can lead to a series of infant health problems. NAS cases vary widely in severity, with symptoms ranging from irritability to seizures and difficulty breathing. The initial symptoms can last several weeks after birth, and the long-term impacts on childhood developments have yet to be studied.

In a Jan. 5, 2017 interview on Wisconsin Public Radio's Central Time, Villapiano said she studied the issue to learn how NAS rates compared with other opioid-related problems taking a toll in rural areas, including overdose deaths and the spread of hepatitis C via shared needles. The study was the first of its kind, and uncovered a stark trend.

In the U.S. as a whole, both maternal opioid use and NAS have increased more rapidly in rural counties than urban ones.

"Back in 2004, for every 1,000 babies that were born, one baby would be born [with] neonatal abstinence syndrome, and this was the same across the board whether the mom was from a rural area or an urban area," Villapiano said. "Over the following 10 years, rates of NAS increased both in rural and urban areas, but in rural areas, there was a nearly sevenfold increase, whereas in urban areas there was only a fourfold increase."

Villapiano said it's too early to explain why NAS has hit rural babies and mothers harder, but like the opioid epidemic itself, this pattern has distinct characteristics. The study found that mothers giving birth to NAS-stricken infants in rural areas were more likely to be from low-income households, and depend on public health insurance like Medicaid more than their urban counterparts. The scarcity of health resources in rural areas across the country — from primary-care doctors to mental-health care — likely plays a role as well. That disparity is certainly relevant in Wisconsin, where much of the state is designated a mental health professional shortage area, as defined by federal health officials.

It is inherently difficult to calculate the rate of any public health problem in a rural county due to the number of instances occurring in a small population. This issue of small sample size becomes even more difficult when the population involved is newborn babies, because rural birth rates are declining. A Wisconsin Department of Health Services analysis of NAS diagnoses between 2009 and 2014 omits rates for 13 counties, with most of them considered rural. DHS noted that in a county with fewer than five diagnoses, the count may produce an unstable rate.

Page 1 of Neonatal Abstinence Syndrome Rate by Wisconsin County of Residence 2009 14 DHS November 2015


Released in Nov. 2015, the DHS map placed 16 counties in its most severe category — a NAS rate of between 8.4 and 27.1 percent. Many are decidedly rural. Milwaukee County and Waukesha County, though, both fall in the second-highest category, 5.8 to 8.3 percent. The pattern is a reminder of how the opioid epidemic has spread to rural and suburban settings while still growing severe in urban areas.

Opioid abuse is the fastest-growing category of substance abuse among pregnant women in Wisconsin, according to a DHS factsheet released in Oct. 2015. DHS reported that about half of the women in Wisconsin who used opioids while pregnant gave birth to babies with NAS.

Providing rural hospitals more resources and staff to deal with NAS, Villapiano said on Central Time, would mean fewer affected babies would need to transfer to larger hospitals in urban areas, and that would make it easier for mothers and babies to stay together in the days immediately following a birth. Another important way to start addressing rural NAS she suggested is to make sure people in rural areas have greater access to resources for substance abuse and mental health.

"We know that opioid use often stems from untreated mental health or chronic pain issues, so having more resources and treatment options in rural areas for moms who are having those types of problems, so that we can hopefully prevent opioid use in the first place, is I think the best approach moving forward," Villapiano said.

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