Vermont has the second highest rate of admissions to state-funded substance abuse treatment programs in the U.S. This unprecedented access to care in Vermont reflects a culture of treating addiction as a chronic disease. In recent years, access to medication assisted therapy (MAT) to treat opioid dependence has increased dramatically. In 2003 buprenorphine was legalized to treat opioid dependence, in 2004 the first methadone clinic opened in Vermont, and in 2012 the State of Vermont initiated the Care Alliance for Opioid Addiction, a statewide partnership of clinicians and treatment centers to provide MAT to Vermonters. Pregnant women are a critical population of adults dependent on opioids. The American College of Obstetricians and Gynecologists recommends that all pregnant women with opioid dependence be in active treatment, including the use of MAT. Since 2002, Vermont hospitals have gone through rigorous quality improvement in treating opioid dependent pregnant women and their infants, such as the Improving Care for Opioid-exposed Newborns (ICON) project at the University of Vermont and the University of Vermont Medical Center. In Vermont, the vast majority of opioid exposed infants are delivered to women who are in treatment. Once a pregnant woman is identified as opioid dependent, her infant is diagnosed as “exposed to opioids.” Opioid-exposed infants may be monitored for four days in the hospital. Many of these infants never show signs or symptoms of NAS. Of those who do, only a small proportion need to be treated with methadone or morphine.
The rate of newborns diagnosed as exposed to opioids in Vermont has increased significantly from 2008 to 2015, based on the presence of ICD-9-CM diagnosis code 779.5 or ICD-10-CM diagnosis code P96.1 (codes pertaining to neonatal withdrawal symptoms). This increase may be partially explained by increases in provider awareness and access to treatment.
In contrast, in 2016, the rate of diagnosis of these newborns decreased from 34.0 to 28.3 per 1,000 live births. This decrease may reflect significant changes and variability in provider and hospital coding practices. To date, there is no standard system for identifying and assigning diagnosis codes to newborns exposed to opioids. Additional codes (ICD-9-CM diagnosis code 760.72 and ICD-10-CM diagnosis code P04.49) are defined as neonatal exposure to maternal drugs of addiction, including narcotics. The chart below provides comparative information on rates of newborns exposed to drugs of addiction based on 1) any mention of diagnosis code 779.5/P96.1, or 2) any mention of diagnosis codes 779.5/P96.1 and/or 760.72/P04.49. The chart indicates that as the rate based on just one diagnosis code has leveled off and then decreased, the rate based on either of two diagnosis codes has increased, with a substantial change from 2015 to 2016. Reasons for this change are currently being explored and results will be available at a later date.
While the Vermont rates of opioid misuse and overdose are similar to the U.S. average, the rate of infants born exposed to opioids is much higher. However, for 2012, the average length of stay for NAS infants was 36% of the U.S. average and the average cost of care per infant was 23% of the U.S average. Given these findings, it is possible that the difference between the Vermont rate and the U.S. rate of infants born exposed to opioids is due to differences in awareness, treatment models and hospital coding. Changes in the Vermont rate over time can be partially explained by an increase in provider awareness and increased access to treatment in Vermont over that same time period.
A Vermont Joint Fiscal Issue Brief provides further information. https://ljfo.vermont.gov/assets/Subjects/Other-Health-Care-Issues-Information/d120cbb719/Issue_Brief_Babies_Born_in_VT_with_Exposure_to_Opioids.pdf