Kristina Box, M.D., FACOG
State Health Commissioner
Indiana State Department of Health
The opioid epidemic is a timely topic when discussing current health obstacles in our state. You are part of a statewide neonatal abstinence task force. What interventions has the task force prioritized?
Indiana State Department of Health (ISDH) has been working with the Indiana Perinatal Quality Improvement Collaborative’s (IPQIC) Perinatal Substance Use (PSU) Task Force on several efforts. In 2016, we launched a pilot program with delivering hospitals to better collect information about the incidence of Neonatal Abstinence Syndrome (NAS) and to standardize the definition and treatment of NAS in our state. As a part of this pilot program, we have been collecting umbilical cords and testing the cords of babies considered to be at risk of substance exposure. The primary goal is to determine the incidence of babies born exposed to substances in our state and to specify what those substances are. By sending this data to the United States Drug Testing Laboratories (USDTL) in Chicago, we have been able to compare our results with results from around the Midwest. Currently, 30 delivering hospitals are participating in the program.
Working with our pilot sites across the state has allowed the PSU task force to put together best practices for addressing substance use disorder in pregnancy and the resultant neonatal effects. The need for wrap-around mental health services and health professionals experienced in treating substance use disorder (SUD) in pregnancy was identified immediately as a gap in care in many facilities. Also, the need for a patient care coordinator to facilitate the connection to needed resources to address socio-economic barriers to women getting into care and maintaining it throughout their pregnancy, and beyond, was identified. Follow-up for both the mother and the child post-delivery is critical and was outlined carefully throughout this process. The need to address the strong association of SUD with infectious diseases like HIV and hepatitis C was also addressed, and best practices for testing and follow up were delineated.
IPQIC created a Perinatal Substance Use and NAS bundle, or tool kit, in 2018 to ensure providers have the tools necessary to support families impacted by substance use disorder during pregnancy. The IPQIC perinatal substance use task force is working in 2019 to roll the bundle out to the 56 remaining Indiana delivering hospitals so every Hoosier mom and baby will have the support needed.
How successful have the above interventions been in decreasing the number of mothers and infants impacted by substance use disorder in Indiana?
Indiana’s overall drug death rate and opioid death rates increased from 2016 to 2017. Preliminary data for 2018, however, is very encouraging. Since 46 percent of our female drug overdose deaths are in the 20- to 40-year old age group, pregnancy is an opportune time to identify women with SUD and intervene through education and referral to treatment.
Many of our pilot sites have been very successful at engaging pregnant women with SUD in treatment and care. Our most successful sites are seeing 70 to 75 percent of women who screen positive for substances in early pregnancy screen negative at delivery for all substances except buprenorphine, the medication assisted therapy (MAT) of choice for treating opiate use disorder in pregnancy. In Indiana, the rate of NAS diagnosis per 1,000 live births in 2018 was 11.1. Nationally, this number ranges between 6 and 20 newborns per 1,000 live births. Our costs for treating NAS have decreased, with fewer babies needing NICU stays or prolonged treatment. Most babies are managed without sublingual morphine.
The pilot sites have been testing umbilical cords of babies considered to be at-risk of substance exposure in the womb, such as babies whose mother has a positive verbal or biologic screen, women who have a history of substance use or those who come in and deliver having not received any prenatal care. The USDTL lab in Chicago tests for 10 different substances and alcohol. In this at-risk population we have found 17 percent of the cords are positive for cannabinoids, 11.5 percent positive for opiates, and 2.6 percent are positive for barbiturates. Unfortunately, Indiana’s rate of cords testing positive for buprenorphine, the MAT of choice for SUD in pregnancy, is about one-third of the national rate. This indicates that we still are not screening for and identifying enough women with SUD in pregnancy.
Indiana does not currently require mandatory drug screening for women during pregnancy, so the number of mothers and babies impacted by substance use is unknown. However, as part of Governor Eric Holcomb’s agenda, legislation was introduced this year that would require providers to verbally screen pregnant women for substance use disorder as early in pregnancy as possible and throughout the pregnancy as indicated. Then they will need to treat or refer these women to care. We know that women are more likely to seek care when they are pregnant, so we believe this initiative will help ensure that every pregnant woman and newborn has the opportunity to receive the help needed to address this challenge.
In addition to substance use disorder, what are Indiana’s most pressing health issues?
Chronic diseases are the leading causes of death and disability in Indiana, with heart disease, cancer and stroke representing the top three killers for Hoosiers. Two of Indiana’s health metrics contribute significantly to these diseases. Indiana has the 8th highest smoking rate in the nation, with 21.8 percent of our adults smoking on a daily basis. Smoking is the single most preventable cause of death and disease in our state and is a leading cause of heart disease. Smoking also causes many cancers besides lung cancer, as well as significant long-term lung disease.
Indiana is also the 12th most obese state in the nation, with two-thirds of our adults being overweight or having obesity and one-third of our children falling into those categories. Greater than 600,000 adults in Indiana have diabetes, and another 1.8 million have prediabetes. Many are not aware of their status. Diabetes is a significant contributor to heart disease and stroke in our state. Obesity also increases the risk for high blood pressure, thus completing the trifecta for heart disease risk with hypertension, diabetes and smoking.
Many chronic diseases can be prevented or managed through early detection, improved nutrition, increased physical activity, and avoiding tobacco use. Reducing smoking among pregnant women and ensuring women are at a healthy weight when they become pregnant can reduce the risks for preterm birth and infant mortality.
What programs/interventions are most promising in addressing the above issues?
The Indiana State Department of Health has been raising awareness about the risks for infant mortality for several years by engaging partners across the state about ways to address these risk factors. Our Indiana Tobacco Quitline provides free counseling and assistance for Hoosiers seeking to quit tobacco, with extra support offered to pregnant women. The ISDH Division of Nutrition and Physical Activity (DNPA) has conducted more than 46 Active Living Workshops since 2013 to educate communities about creating opportunities to live more active lives. These Active Living Workshops share best practices in creating active living communities through strategic plans, policies, programs and projects.
We also work with schools and child care environments to promote best practices for physical activity and nutrition, both by training staff and incorporating healthy food and increased physical activity for children in their care.
ISDH also works with the National Diabetes Prevention Program (DPP), led by the Centers for Disease Control and Prevention (CDC), to implement programs that can prevent and/or delay type 2 diabetes. This program has helped people cut their risk for diabetes in half!
ISDH also encourages hospitals to follow the 10 Steps to Successful Breastfeeding as a way to encourage moms to start breastfeeding and breastfeed longer.
In addition to your position as the State Health Commissioner, you still work 24 hour shifts in the labor and delivery unit at Community Hospital North and have undoubtedly made significant contributions to improving the health of Hoosiers. Beyond attending to our own physical and mental health needs, what can we do as individuals to impact the health of communities?
There are so many opportunities to become involved and help address these public health issues that affect our state. Volunteering at a National Diabetes Prevention Program, partnering to educate caregivers about safe sleep and give away free cribs and working with your local community to address the vaping epidemic in your schools are just a few examples. I truly believe we would all be better off if we spent less time behind a screen and more time walking our neighborhoods, getting to know our neighbors and engaging in outdoor activities. This would help our weight, emotional connections and overall mental health. Some ways to engage include:
- Get involved in healthy community coalitions at the local level
- Get involved in neighborhood associations
- Get involved in school boards or school wellness committees
- Speak up to your legislators on issues that are important to you
- Model healthy behaviors at home and out in the community
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Dr. Box earned her undergraduate degree at Indiana University in Bloomington and her medical doctorate at Indiana University School of Medicine in Indianapolis. She is a member of several professional organizations, including the Indiana State Medical Association and the American College of Obstetrics and Gynecology. Additionally, Dr. Box has been involved in surgical medical missions to Haiti and Bolivia for more than a decade.
Dr. Box started her career at Community Hospitals of Indianapolis in 1987 as a private practitioner in obstetrics and gynecology with Clearvista Women’s Care. Beginning in 2015, she served as the Physician Lead for Community Health Network’s Women’s Service Line. In this role, she built the first multi-disciplinary Women’s Center in Community Health Network, developed critical partnerships with area children’s hospitals to improve care and decrease health care costs, and led efforts to ensure low-income women receive the important free health screenings they need.
Dr. Box was appointed Indiana State Health Commissioner by Governor Eric Holcomb in 2017.
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