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Supplements Deaths, Dollars, and Diverted Resources: Examining the Heavy Price of the Opioid Epidemic
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Douglas L. Leslie, PhD; Djibril M. Ba, MPH; Edeanya Agbese, MPH; Xueyi Xing, PhD; and Guodong Liu, PhD
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Gary Zajac, PhD; Samaan Aveh Nur, BA; Derek A. Kreager, PhD; and Glenn Sterner, PhD
Considering the Child Welfare System Burden From Opioid Misuse: Research Priorities for Estimating Public Costs
Daniel Max Crowley, PhD; Christian M. Connell, PhD; Damon Jones, PhD; and Michael W. Donovan, MA
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The Opioid Epidemic, Neonatal Abstinence Syndrome, and Estimated Costs for Special Education Services
Paul L. Morgan, PhD; and Yangyang Wang, MA
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Preventing the Next Crisis: Six Critical Questions About the Opioid Epidemic That Need Answers
Dennis P. Scanlon, PhD; and Christopher S. Hollenbeak, PhD
Beyond Rescue, Treatment, and Prevention: Understanding the Broader Impact of the Opioid Epidemic at the State Level
Laura Fassbender, BPH; Gwendolyn B. Zander, Esq; and Rachel L. Levine, MD
The Cost of the Opioid Epidemic, In Context
Sarah Kawasaki, MD; and Joshua M. Sharfstein, MD
The Opioid Epidemic: The Cost of Services Versus the Cost of Despair
Alonzo L. Plough, PhD, MPH

The Opioid Epidemic, Neonatal Abstinence Syndrome, and Estimated Costs for Special Education Services

Paul L. Morgan, PhD; and Yangyang Wang, MA
Children whose mothers used or misused opioids during their pregnancies are at an increased risk of exhibiting cognitive or behavioral impairments in the future, which may result in identifiable disabilities that require special education services in school. The costs associated with these additional educational services, however, have remained unknown. Using data from available empirical work, we calculated a preliminary set of cost estimates of special education and related services for children diagnosed with neonatal abstinence syndrome (NAS). We estimated these costs for a single cohort of children from the Commonwealth of Pennsylvania with a diagnosis of NAS. The resulting cost estimates were $16,506,916 (2017 US$) in total educational services provisions, with $8,253,458 (2017 US$) of these costs attributable to the additional provision of special education services. This estimate includes both opioid use during pregnancy that was linked to NAS in general and NAS that resulted specifically from prescription opioid use. We estimate the total annual education costs for children born in Pennsylvania with NAS associated with maternal use of prescription opioids to be $1,012,506 (2017 US$). Of these costs, we estimate that $506,253 (2017 US$) are attributable to the additional provision of special education services. We detail the calculation of these cost estimates and provide an expanded set of estimates for additional years of special education services (3-year, 5-year, and 13-year, or the K-12 educational time frame). We conclude with a discussion of limitations and suggestions for future work.
Am J Manag Care. 2019;25:-S0
Conceptual Framework

Maternal opioid use is hypothesized to result in neonatal abstinence syndrome (NAS), as well as in cognitive, physical, and behavioral impairments that contribute to academic and behavioral difficulties in school. Figure 1 displays a conceptual model that summarizes hypothesized or reported linkages between early exposure to opioids, including maternal prescribed use, and children’s subsequent risk for disability identification that results in  receiving special education services. We summarize findings from empirical studies reporting on these linkages below.

Opioid Misuse and Children’s Risk for Disability Identification

Children who are prenatally exposed to opioids are about twice as likely as nonexposed children to display intellectual disabilities and mild developmental impairments at 1 year of age.1 Exposed children are at a greater risk for attention-deficit/hyperactivity disorder (ADHD) and other types of behavioral disorders2 that can occur up to 8 years after birth.3 Children born to parents addicted to opioids display risk alleles for ADHD.4 These children also experience cognitive delays not fully explained by other factors (eg, low birth weight),5 which become increasingly more severe over time. For example, at 8 years of age, both boys and girls who were prenatally exposed to opioids demonstrated levels of general cognitive functioning that averaged about 1 standard deviation lower than those of children who were not exposed.6 A linear relationship between increased prescription opioid dosage and greater risk for adverse clinical outcomes among infants is evident, including an increased risk for prematurity and longer postdelivery hospitalization despite statistical control for a range of covariates.7

Opioid misuse is likely intergenerational. Children born to mothers using opioids are more likely to misuse opioids as adults.8 Clinical practice recommendations suggest that children with ADHD, speech or language impairments, specific learning disabilities, or other types of disorders or disabilities that impair their major life activities (eg, schooling) should be provided with specialized services and interventions. Doing so may improve educational opportunities over time and reduce the risk for opioid use during adolescence or adulthood.4

NAS and Increased Risk for Academic and Behavioral Difficulties

NAS is a general multisystem disorder that predominantly involves the central and automatic nervous systems. NAS results from a sudden discontinuation of fetal exposure to substances used or misused by mothers during their pregnancies, including prescription opioids.9 Infants with NAS experience sudden withdrawal symptoms and later exhibit high levels of stress, dysregulated behavior, hyperactivity, poor sleep, rapid respiration, and other indicators of nervous system distress. About 75% to 90% of prenatal opioid–exposed infants are diagnosed with NAS.10,11 NAS is considered an expected and treatable condition in these infants.12 Opioid agonist pharmacotherapy can help manage the neurobiological effects of opioid exposure or social impacts of maternal addiction that may result in NAS. Opioid agonist pharmacotherapy can also help to improve adherence to addiction treatment as well as prenatal care.12 

Use of opioids by women during their pregnancies, including as prescribed by a physician, is associated with a greater risk for NAS. Current estimates of NAS are 5.9 per every 1000 deliveries (95% CI, 5.6 to 6.2).13 A dose-response relationship has been observed between the use of prescription opioids and a child’s risk for NAS.13 The risk for NAS increases with a cumulative dose of opioids as well as with later (eg, third trimester) versus earlier (eg, first trimester) use. Absolute risk for NAS among mothers who are long-term users of prescription opioids with no other measured risk factors (eg, history of alcohol, smoking, substance misuse, or use of other psychotropic medications) is estimated to be 4.2 per 1000 live births (95% CI, 3.3 to 5.4).13 The adjusted relative risk for long-term versus short-term users in propensity score–matched analyses is estimated to be 5.67 per 1000 live births (95% CI, 3.07 to 10.47).13 The risk for NAS, however, increases in mothers who use prescription opioids and present with other risk factors.

The incidence of NAS has been increasing rapidly throughout the United States. The Centers for Disease Control and Prevention (CDC) estimated that the overall incidence rate of NAS in 2013 increased by 300%—from 1.5 per 1000 live births to 6.0 per 1000 live births.14 In 2011, it was estimated that the Middle Atlantic region (ie, New York, Pennsylvania, and New Jersey) had a mean NAS incidence rate of 6.8 per 1000 live births.14 Between 2000 and 2013, the incidence rates of NAS in West Virginia increased sharply—from 0.5 per 1000 live births to 33.4 per 1000 live births. The rise in NAS incidence rate occurred simultaneously with a similar increase in the rate of delivering mothers diagnosed as opioid-dependent or using opioids at the time of delivery—from 1.19 per 1000 hospital births to 5.63 per 1000 hospital births nationally between 2000 and 2009.15 The incidence of both maternal opioid use and NAS has been on the rise, particularly in rural counties in the United States,16,17 suggesting that rural communities are disproportionately affected.

Children with NAS have a lower birth weight, length, and mean head circumference at birth, and they are more likely to be born with birth defects.18 Children with NAS are also more likely to be hospitalized,19 and to exhibit significantly lower levels of language ability and general cognitive functioning over time. This includes low levels of functioning and a greater likelihood of displaying extremely low levels of functioning, which increases the risk for disability identification among these children and may result in the receipt of special education services. For example, in 2015, Beckwith and Burke reported that 14.3% and 7.1% of children with NAS exhibited extremely low levels of language and general cognitive functioning, respectively.20 The contrasting percentages from a general sample of children were 3.7% and 2.4%, respectively,20 suggesting that infants and toddlers with NAS are approximately 3 to 4 times more likely to exhibit extremely low levels of language and general cognitive functioning. Neurodevelopmental impairment is evident as early as 6 months of age21 and remains evident at 3 years of age,22 as indicated across multiple measures of cognitive functioning, intelligence, social maturity, and psychomotor abilities.

Children with NAS display declining academic achievement relative to their peers during elementary and middle school.23 This group of children average lower levels of reading, mathematics, and writing achievement compared with children without NAS who are similar in gestational age, year of birth, gender, and socioeconomic status. Children with NAS are approximately 2 to 3 times more likely to fail to attain grade-level achievement, and are also more likely to require additional specialized support and intervention throughout school compared with children without NAS. Specifically, children with NAS had odds that were 3.5 (95% CI, 2.8 to 4.4), 2.8 (95% CI, 2.4 to 3.2), and 2.4 (95% CI, 1.9 to 2.9) times higher of failing to attain grade-level achievement in third, fifth, and eighth grade, respectively, compared with controls.23 In fact, children with NAS had odds that were 2.5 (95% CI, 2.2 to 2.7) times higher of failing to attain grade-level achievement at any one of the study’s measured time periods (Figure 2).23

A 2016 longitudinal study reported that children with NAS are also more likely to exhibit a general set of behavioral deficits (eg, more frequent externalizing and internalizing problem behaviors; greater levels of impulsivity, inattention, and other behavioral indicators of ADHD) as they attend school, as reported by both teachers and caregivers.3 Children who struggle academically are at greater risk for having disabilities and requiring special education services.24

Recent longitudinal analysis also finds that children with NAS are at a greater risk of being identified as having disabilities and receiving special education services in school. In 2018, Fill and colleagues reported that children with a history of NAS were approximately 1.3 to 1.4 times more likely to meet the criteria for exhibiting a disability and receiving special education services for the specific conditions of developmental delays and speech or language impairments during early childhood compared with children without a history of NAS, who were matched for gender, age, birth region, race/ethnicity, and medical enrollment status.25 Children with a history of NAS had a significantly higher risk of being identified with educational disabilities compared with matched controls without NAS. An increased risk associated with NAS was evident after accounting for potential confounders, including maternal education status, maternal tobacco use, gestational age, and birth weight.25

Opioid Use in Pennsylvania

Although the aforementioned empirical work indicates that children of mothers using opioids are at a greater risk for later being identified as having disabilities, the expected costs of special education services have been largely unknown. Therefore, we calculated a preliminary set of cost estimates of special education and related services for children diagnosed with NAS—specifically, costs for a single cohort of children from Pennsylvania with an NAS diagnosis. The Commonwealth of Pennsylvania currently ranks high in the United States for the prescription of opioid pain relievers, long-acting/extended-release opioids, high-dose opioids, and benzodiazepines. For example, the CDC estimates that Pennsylvania ranked 21st and 14th in the United States for the prescription of opioids and high-dose opioids, respectively, in 2014.26

Gross Cost Estimates

Costs for Special Education Services in the Commonwealth of Pennsylvania

In 2015, public school expenditures per student in Pennsylvania were $14,717 (2015 US$).27 The cost to educate a student in special education is typically estimated to be, on average, about twice that of educating a student in general education.28 Thus, a reasonable cost estimate per student who receives both general and special education in Pennsylvania in 2015 would $29,434 (2015 US$) or $30,682 (2017 US$), using a Bureau of Labor Statistics Consumer Price Index (BLS CPI) correction factor for inflation. 

Increased Special Education Costs for Children in Pennsylvania With NAS

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