Cover: Association Among County-Level Economic Factors, Clinician Supply, Metropolitan or Rural Location, and Neonatal Abstinence Syndrome

Association Among County-Level Economic Factors, Clinician Supply, Metropolitan or Rural Location, and Neonatal Abstinence Syndrome

Published in: Journal of the American Medical Association, Volume 321, Number 4, pages 385-393 (2019). doi: 10.1001/jama.2018.20851

Posted on Feb 1, 2019

by Stephen W. Patrick, Laura J. Faherty, Andrew W. Dick, Theresa A. Scott, Judith Dudley, Bradley D. Stein

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The Issue

Many babies born after being exposed to opioids have neonatal abstinence syndrome (NAS), a drug withdrawal syndrome that occurs shortly after birth. Infants with NAS can have symptoms severe enough to require treatment with a medication like morphine, often involving the NICU. Rates of NAS increased nearly sevenfold from 2000 to 2014. An infant is now born with NAS about every 15 minutes.

Study Focus

Researchers from Vanderbilt and RAND analyzed information from about 6.3 million births from 2009 through 2015 in 580 counties across eight states—Florida, Kentucky, Massachusetts, Michigan, North Carolina, New York, Tennessee and Washington.


Neonatal abstinence syndrome (NAS) has increased over the last 2 decades, but limited data exist on its association with economic conditions or clinician supply.


To determine the association among long-term unemployment, clinician supply (as assessed by primary care and mental health clinician shortage areas), and rates of NAS and evaluate how associations differ based on rurality.

Design, Setting, and Participants

Ecological time-series analysis of a retrospective, repeated cross-sectional study using outcome data from all 580 counties in Florida, Kentucky, Massachusetts, Michigan, New York, North Carolina, Tennessee, and Washington from 2009 to 2015 and economic data from 2000 to 2015. Negative binomial models were used with year and county-level fixed effects. Interactions were tested and stratified analyses were conducted by metropolitan counties, rural counties adjacent to metropolitan counties, and rural remote counties.


County-level 10-year unemployment rate and mental health and primary care clinician supply obtained from the Health Resources and Services Administration Area Health Resources Files.

Main Outcomes and Measure

Rates of NAS, excluding iatrogenic withdrawal, obtained from state inpatient databases.


The sample included observations from 580 counties over 7 years (1803 county-years from metropolitan counties, 1268 county-years from rural counties adjacent to metropolitan counties, and 927 county-years from rural remote counties). During the study period, there were 6,302,497 births and 47,224 diagnoses of NAS. The median rate of NAS was 7.1 per 1000 hospital births (interquartile range [IQR], 2.2-15.8), the 10-year unemployment rate was 7.6% (IQR, 6.4%-9.0%), and 83.9% of county-years were partial or complete mental health shortage areas. In the adjusted analyses, mental health shortage areas had higher NAS rates (unadjusted rate in shortage areas of 14.0 per 1000 births vs unadjusted rate in nonshortage areas of 10.6 per 1000 births; adjusted incidence rate ratio [IRR], 1.17 [95% CI, 1.07-1.27]), occurring primarily in metropolitan counties (adjusted IRR, 1.28 [95% CI, 1.16-1.40]; P = .02 for test of equivalence between metropolitan counties and rural counties adjacent to metropolitan counties). There was no significant association between primary care shortage areas and rates of NAS. The 10-year unemployment rate was associated with higher rates of NAS (unadjusted rate in highest unemployment quartile of 20.1 per 1000 births vs 7.8 per 1000 births in lowest unemployment quartile; adjusted IRR, 1.11 [95% CI, 1.00-1.23]) occurring primarily in rural remote counties (adjusted IRR, 1.34 [95% CI, 1.05-1.70]; P = .04 for test of equivalence between metropolitan counties and rural remote counties).

Conclusions and Relevance

In this ecological analysis of counties in 8 US states, there was a significant association among higher long-term unemployment, higher mental health clinician shortage areas, and higher county-level rates of neonatal abstinence syndrome.

Key Findings

  • The rate of babies born with NAS varied across the 580 counties examined, but rates were often highest in the most rural counties.
  • Counties with the highest unemployment rates, especially rural counties, had NAS rates over 2.5 times greater than counties with the lowest unemployment rates.
  • Counties with shortages of mental health workers also had significantly more NAS cases.


Implications for Policy

  • The opioid crisis is not just a health problem: it is affected by a community’s economic conditions. Approaches will vary by community, but a revitalized economy and social safety net may have important benefits for a community’s health.
  • We face an uphill battle addressing the opioid crisis until we are providing better access to effective mental health care. Clinician training programs targeting communities in shortage areas, telehealth, loan forgiveness programs, and integrated collaborative care models that enhance both access and quality all have the potential to increase access to effective mental health care.

Support for Decisionmaking

  • An interactive tool based on study findings can help decisionmakers explore how changing a county’s economic conditions or the supply of mental health providers could affect the county’s NAS rate.

Research conducted by

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