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The opioid epidemic is a public health emergency. Over 11 million Americans currently misuse prescription opioids. About 130 Americans die every day from an opioid overdose. The Centers for Disease Control and Prevention (CDC) estimates the economic burden to the U.S. in one calendar year to be $80 billion from prescription opioid misuse due to additional healthcare and criminal justice costs. The state of Indiana has cumulatively sustained over $43 billion in economic damages in 15 years from opioid misuse, due to lost economic contributions and labor supply reductions from opioid-related deaths.
Although many of the epidemic’s costs are experienced by adults, others are experienced by children. This includes children born to mothers using or misusing opioids during pregnancy. These children often are born experiencing central nervous system distress due to the sudden discontinuation of fetal exposure to opioids or other substances. As a result, children born with neonatal abstinence syndrome (NAS) can display high levels of stress, hyperactivity, poor sleep, and seizures. Although NAS is a treatable condition and the use of prescribed opioids can improve adherence to addiction treatment as well as prenatal care, the risk of being born with NAS also increases with greater use of prescription opioids. For example, the likelihood of being born with NAS among mothers who are long-term users of prescription opioids but who do not present with other risk factors (e.g., a history of smoking or substance misuse) is 4.2 per 1,000 births. The CDC estimates a fivefold increase in NAS from 2004 to 2014. The incidence rate in West Virginia increased from 8 to 32 per 1,000 births from 2007 to 2013, with rural communities disproportionately affected. By 2017, West Virginia’s NAS incidence rate was 51 per 1,000 births. Some counties reported incidence rates over 100. In Pennsylvania, the NAS incidence rate increased 1,000% between 2001 and 2017.
New longitudinal work is finding that children born with NAS are more likely to experience lower levels of cognitive and academic functioning and to have increased need for additional health care and special education services throughout school. For example, children born with NAS are more likely to display cognitive and behavioral difficulties as they age. As these children attend elementary and middle schools, they are more likely to average lower levels of reading, mathematics, and writing achievement compared to children of similar gestational age, year of birth, and socioeconomic status. Children born with NAS are two or three times as likely to not display grade-level achievement and are about 1.5 times as likely to meet criteria for disability identification. This increased risk associated with being born with NAS is evident even after accounting for other factors including maternal education, age, and birth weight.
How much might federal, state, and local governments expect in increased special education costs due to the opioid epidemic and the resulting greater incidence of NAS? We calculated an example set of cost estimates for special education and related services for children with NAS. We did so by estimating the costs that might be expected to occur for a single cohort of children from Pennsylvania born with a NAS diagnosis.
In 2015, the per student public school expenditures in Pennsylvania was $14,717. The cost to educate a student in special education is estimated on average to be about twice the amount to educate a student in general education, or $29,434 in total. In 2015, 2,691 children were diagnosed with NAS in Pennsylvania, or about 2% of the 138,000 recorded births. About 20% of these children might be expected to receive special education services due to identified disabilities. Thus, estimated costs to provide these children with additional special education services for a single year would be $14,717 x 538 = $7,917,748, or $8,554,964 corrected for inflation in 2019. A conservative estimate based on a limited provision of three to five years of additional special education services to children born with NAS who are subsequently identified as having disabilities would range from $14,717 x 538 x 3 or 5 = $23,753,238 to $39,588,730, or $25,664,886 to $42,774,810 adjusted for inflation. The federal government would be expected to provide 15% of these additional special education costs. The remaining 85% would be provided through the Commonwealth’s state and local governments.
The opioid epidemic in the U.S. has been devastating. One way to understand the human cost is to examine its financial cost. Federal, state, and local governments are now working to understand and assess these costs as they seek damages from pharmaceutical companies that aggressively marketed opioid medications. An emerging cost of the epidemic is the care of children born with NAS. Such children are more likely to struggle academically and behaviorally as they attend school and to be identified as having disabilities requiring special education services. Federal, state, and local governments should anticipate these costs in their budgets and legal actions so children born with NAS receive appropriate care and services as they age.
