Receipt of Addiction Treatment After Opioid Overdose Among Medicaid-Enrolled Adolescents and Young Adults.
ABSTRACT: Importance:Nonfatal opioid overdose may be a critical touch point when youths who have never received a diagnosis of opioid use disorder can be engaged in treatment. However, the extent to which youths (adolescents and young adults) receive timely evidence-based treatment following opioid overdose is unknown. Objective:To identify characteristics of youths who experience nonfatal overdose with heroin or other opioids and to assess the percentage of youths receiving timely evidence-based treatment. Design, Setting, and Participants:This retrospective cohort study used the 2009-2015 Truven-IBM Watson Health MarketScan Medicaid claims database from 16 deidentified states representing all US census regions. Data from 4?039?216 Medicaid-enrolled youths aged 13 to 22 years were included and were analyzed from April 20, 2018, to March 21, 2019. Exposures:Nonfatal incident and recurrent opioid overdoses involving heroin or other opioids. Main Outcomes and Measures:Receipt of timely addiction treatment (defined as a claim for behavioral health services, for buprenorphine, methadone, or naltrexone prescription or administration, or for both behavioral health services and pharmacotherapy within 30 days of incident overdose). Sociodemographic and clinical characteristics associated with receipt of timely treatment as well as with incident and recurrent overdoses were also identified. Results:Among 3791 youths with nonfatal opioid overdose, 2234 (58.9%) were female, and 2491 (65.7%) were non-Hispanic white. The median age was 18 years (interquartile range, 16-20 years). The crude incident opioid overdose rate was 44.1 per 100?000 person-years. Of these 3791 youths, 1001 (26.4%) experienced a heroin overdose; the 2790 (73.6%) remaining youths experienced an overdose involving other opioids. The risk of recurrent overdose among youths with incident heroin involvement was significantly higher than that among youths with other opioid overdose (adjusted hazard ratio, 2.62; 95% CI, 2.14-3.22), and youths with incident heroin overdose experienced recurrent overdose at a crude rate of 20?700 per 100?000 person-years. Of 3606 youths with opioid-related overdose and continuous enrollment for at least 30 days after overdose, 2483 (68.9%) received no addiction treatment within 30 days after incident opioid overdose, whereas only 1056 youths (29.3%) received behavioral health services alone, and 67 youths (1.9%) received pharmacotherapy. Youths with heroin overdose were significantly less likely than youths with other opioid overdose to receive any treatment after their overdose (adjusted odds ratio, 0.64; 95% CI, 0.49-0.83). Conclusions and Relevance:After opioid overdose, less than one-third of youths received timely addiction treatment, and only 1 in 54 youths received recommended evidence-based pharmacotherapy. Interventions are urgently needed to link youths to treatment after overdose, with priority placed on improving access to pharmacotherapy.
Project description:OBJECTIVE:To estimate fatal and nonfatal opioid overdose events in pregnant and postpartum women in Massachusetts, comparing rates in individuals receiving and not receiving pharmacotherapy for opioid use disorder (OUD). METHODS:We conducted a population-based retrospective cohort study using linked administrative and vital statistics databases in Massachusetts to identify women with evidence of OUD who delivered a liveborn neonate in 2012-2014. We described maternal sociodemographic, medical, and substance use characteristics, computed rates of opioid overdose events in the year before and after delivery, and compared overdose rates by receipt of pharmacotherapy with methadone or buprenorphine in the prenatal and postpartum periods. RESULTS:Among 177,876 unique deliveries, 4,154 (2.3%) were to women with evidence of OUD in the year before delivery, who experienced 242 total opioid-related overdose events (231 nonfatal, 11 fatal) in the year before or after delivery. The overall overdose rate was 8.0 per 100,000 person-days. Overdoses were lowest in the third trimester (3.3/100,000 person-days in the third trimester) and then increased in the postpartum period with the highest overdose rate 7-12 months after delivery (12.3/100,000 person-days). Overall, 64.3% of women with evidence of OUD in the year before delivery received any pharmacotherapy in the year before delivery. Women receiving pharmacotherapy had reduced overdose rates in the early postpartum period. CONCLUSION:Pregnant women in Massachusetts have high rates of OUD. The year after delivery is a vulnerable period for women with OUD. Additional longitudinal supports and interventions tailored to women in the first year postpartum are needed to prevent and reduce overdose events.
Project description:Importance:Timely initiation and referral to treatment for patients with opioid use disorder seen in the emergency department is associated with reduced mortality. It is not known how often commercially insured adults obtain follow-up treatment after nonfatal opioid overdose. Objective:To investigate the incidence of follow-up treatment following emergency department discharge after nonfatal opioid overdose and patient characteristics associated with receipt of follow-up treatment. Design, Setting, and Participants:A retrospective cohort study was conducted using an administrative claims database for a large US commercial insurer, from October 1, 2011, to September 30, 2016. Data analysis was performed from May 1, 2019, to September 26, 2019. Adult patients discharged from the emergency department after an index opioid overdose (no overdose in the preceding 90 days) were included. Patients with cancer and without continuous insurance enrollment were excluded. Main Outcomes and Measures:The primary outcome was follow-up treatment in the 90 days following overdose, defined as a combined outcome of claims for treatment encounters or medications for opioid use disorder (buprenorphine and naltrexone). Analysis was stratified by whether patients received treatment for opioid use disorder in the 90 days before the overdose. Logistic regression models were used to identify patient characteristics associated with receipt of follow-up treatment. Marginal effects were used to report the average adjusted probability and absolute risk differences (ARDs) in follow-up for different patient characteristics. Results:A total of 6451 patients were identified with nonfatal opioid overdose; the mean (SD) age was 45.0 (19.3) years, 3267 were women (50.6%), and 4676 patients (72.5%) reported their race as non-Hispanic white. A total of 1069 patients (16.6%; 95% CI, 15.7%-17.5%) obtained follow-up treatment within 90 days after the overdose. In adjusted analysis of patients who did not receive treatment before the overdose, black patients were half as likely to obtain follow-up compared with non-Hispanic white patients (ARD, -5.9%; 95% CI, -8.6% to -3.6%). Women (ARD, -1.7%; 95% CI, -3.3% to -0.5%) and Hispanic patients (ARD, -3.5%; 95% CI, -6.1% to -0.9%) were also less likely to obtain follow-up. For each additional year of age, patients were 0.2% less likely to obtain follow-up (95% CI, -0.3% to -0.1%). Conclusions and Relevance:Efforts to improve the low rate of timely follow-up treatment following opioid overdose may seek to address sex, race/ethnicity, and age disparities.
Project description:Overdose is the main cause of mortality among heroin users. Many of these overdose-induced deaths can be prevented through the timely administration of naloxone (NLX), a nonselective mu (?)-, kappa (?)-, and delta (?)-opioid receptor antagonist. NLX competitively inhibits opioid-overdose-induced respiratory depression without eliciting any narcotic effect itself. The aim of this study was to investigate the antagonistic action of NLX by comparing its distribution to that of 6-monacetylmorphine (6-MAM), heroin's major metabolite, in a rodent model using mass spectrometric imaging (MSI) in combination with liquid chromatography-tandem mass spectrometry (LC-MS/MS). Male Sprague-Dawley rats (n = 5) received heroin (10 mg kg-1) intraperitoneally, NLX (10 mg kg-1) intranasally, and NLX injected intranasally 5 min after heroin administration. The animals were sacrificed 15 min after dose and brain tissues were harvested. The MSI image analysis showed a region-specific distribution of 6-MAM in the brain regions including the corpus callosum, hippocampal formation, cerebral cortex, corticospinal tracts, caudate putamen, thalamus, globus pallidus, hypothalamus, and basal forebrain regions of the brain. The antagonist had a similar biodistribution throughout the brain in both groups of animals that received NLX or NLX after heroin administration. The MSI analysis demonstrated that the intensity of 6-MAM in these brain regions was reduced following NLX treatment. The decrease in 6-MAM intensity was caused by its displacement by the antagonist and its binding to these receptors in these specific brain regions, consequently enhancing the opioid elimination. These findings will contribute to the evaluation of other narcotic antagonists that might be considered for use in the treatment of drug overdose via MSI.
Project description:Importance:The US opioid epidemic is complex and dynamic, yet relatively little is known regarding its likely future impact and the potential mitigating impact of interventions to address it. Objective:To estimate the future burden of the opioid epidemic and the potential of interventions to address the burden. Design, Setting, and Participants:A decision analytic dynamic Markov model was calibrated using 2010-2018 data from the National Survey on Drug Use and Health, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey, the US Census, and National Epidemiologic Survey on Alcohol and Related Conditions-III. Data on individuals 12 years or older from the US general population or with prescription opioid medical use; prescription opioid nonmedical use; heroin use; prescription, heroin, or combined prescription and heroin opioid use disorder (OUD); 1 of 7 treatment categories; or nonfatal or fatal overdose were examined. The model was designed to project fatal opioid overdoses between 2020 and 2029. Exposures:The model projected prescribing reductions (5% annually), naloxone distribution (assumed 5% reduction in case-fatality), and treatment expansion (assumed 35% increase in uptake annually for 4 years and 50% relapse reduction), with each compared vs status quo. Main Outcomes and Measures:Projected 10-year overdose deaths and prevalence of OUD. Results:Under status quo, 484?429 (95% confidence band, 390?543-576?631) individuals were projected to experience fatal opioid overdose between 2020 and 2029. Projected decreases in deaths were 0.3% with prescribing reductions, 15.4% with naloxone distribution, and 25.3% with treatment expansion; when combined, these interventions were associated with 179?151 fewer overdose deaths (37.0%) over 10 years. Interventions had a smaller association with the prevalence of OUD; for example, the combined intervention was estimated to reduce OUD prevalence by 27.5%, from 2.47 million in 2019 to 1.79 million in 2029. Model projections were most sensitive to assumptions regarding future rates of fatal and nonfatal overdose. Conclusions and Relevance:The findings of this study suggest that the opioid epidemic is likely to continue to cause tens of thousands of deaths annually over the next decade. Aggressive deployment of evidence-based interventions may reduce deaths by at least a third but will likely have less impact for the number of people with OUD.
Project description:PURPOSE:Opioid overdose death rates rose 36% from 2015 to 2016 in Missouri, indicating a worsening of the opioid overdose epidemic. To better understand urban and rural differences in nonfatal opioid overdoses treated in Missouri emergency departments, this paper analyzed hospital billing data from emergency departments due to opioid overdose from 2012 to 2016. METHODS:Emergency department records meeting the opioid overdose case definition were aggregated into 6 progressively rural groups using the National Center for Health Statistics (NCHS) urban-rural county classification from 2013. These data were analyzed to determine significant trends amongst and between the geographic groups. FINDINGS:Generally, the magnitude of opioid overdose morbidity decreased as levels of rurality increased, using annual percentage change as the metric of change. Over the study period, Missouri's most urban counties had significantly higher rates of opioid overdose and saw larger percentage increases in rates compared to more rural areas. Statewide, all rural-urban classifications experienced increases in heroin overdose morbidity; however, there was extreme variation in the trajectory of those increases. Heroin overdose rates were much higher in urban areas than rural areas. Conversely, rural and urban areas saw relatively similar patterns for non-heroin opioid overdoses, though overall magnitude of these increases was more modest across all geographic groups. CONCLUSIONS:The results from this analysis can help inform prioritization of strategies and resources to implement activities addressing the opioid overdose epidemic. Using a rich hospital discharge database could allow for further analysis of subpopulations to enhance personalization and customization of care.
Project description:OBJECTIVE:To classify and compare US nationwide opioid-related hospital inpatient discharges over time by discharge type: 1) opioid use disorder (OUD) diagnosis without opioid overdose, detoxification, or rehabilitation services, 2) opioid overdose, 3) OUD diagnosis or opioid overdose with detoxification services, and 4) OUD diagnosis or opioid overdose with rehabilitation services. METHODS:Survey-weighted national analysis of hospital discharges in the Healthcare Cost and Utilization Project National Inpatient Sample yielded age-adjusted annual rates per 100,000 population. Annual percentage change (APC) in the rate of opioid-related discharges by type during 1993-2016 was assessed. RESULTS:The annual rate of hospital discharges documenting OUD without opioid overdose, detoxification, or rehabilitation services quadrupled during 1993-2016, and at an increased rate (8% annually) during 2003-2016. The discharge rate for all types of opioid overdose increased an average 5-9% annually during 1993-2010; discharges for non-heroin overdoses declined 2010-2016 (3-12% annually) while heroin overdose discharges increased sharply (23% annually). The rate of discharges including detoxification services among OUD and overdose patients declined (-4% annually) during 2008-2016 and rehabilitation services (e.g., counselling, pharmacotherapy) among those discharges decreased (-2% annually) during 1993-2016. CONCLUSIONS:Over the past two decades, the rate of both OUD diagnoses and opioid overdoses increased substantially in US hospitals while rates of inpatient detoxification and rehabilitation services identified by diagnosis codes declined. It is critical that inpatients diagnosed with OUD or treated for opioid overdose are linked effectively to substance use disorder treatment at discharge.
Project description:<h4>Background</h4>Since 2010, heroin-related overdoses have risen sharply, coinciding with policies to restrict access to prescription opioids. It is unknown if patients tapered or discontinued off prescription opioids transitioned to riskier heroin use. This study examined opioid prescribing, including long-term opioid therapy (LTOT) and discontinuation, prior to heroin overdose.<h4>Methods</h4>We used retrospective longitudinal data from a national claims database to identify adults with an emergency or inpatient claim for heroin overdose between January 2010 and June 2017. Receipt of opioid prescription, LTOT episodes, and discontinuation of LTOT were measured for the period of one year prior to heroin overdose.<h4>Results</h4>We identified 3183 individuals (53.2% age 18-25; 70.0% male) with a heroin overdose (incidence rate 4.20 per 100k person years). Nearly half (42.3%) received an opioid prescription in the prior 12 months, and 10.9% had an active opioid prescription in the week prior to overdose. LTOT at any time in the 12 months prior to overdose was uncommon (12.8%) among those with heroin overdoses, especially among individuals 18-25 years old (3.5%, P < 0.001). LTOT discontinuation prior to overdose was also relatively uncommon, experienced by 6.7% of individuals aged 46 and over and 2.5% of individuals aged 18-25 years (P < 0.001).<h4>Conclusions</h4>Prior to heroin overdose, prescription opioid use was common, but LTOT discontinuation was uncommon and observed primarily in older individuals with the lowest heroin overdose rates. Further study is needed to determine if these prescribing patterns are associated with increased heroin overdose.
Project description:STUDY OBJECTIVE:Persons with substance use disorders frequently utilize emergency department (ED) services, creating an opportunity for intervention and referral to addiction treatment and harm-reduction services. However, EDs may not have the appropriate tools to distinguish which patients are at greatest risk for negative outcomes. We link hospital ED and medical examiner mortality databases in one state to identify individual-level risk factors associated with overdose death among ED patients with substance-related encounters. METHODS:This retrospective cohort study linked Maryland statewide ED hospital claims records for adults with nonfatal overdose or substance use disorder encounters in 2014 to 2015 with medical examiner mortality records in 2015 to 2016. Logistic regression was used to identify factors in hospital records associated with risk of opioid overdose death. Predicted probabilities for overdose death were calculated for hypothetical patients with different combinations of overdose and substance use diagnostic histories. RESULTS:A total of 139,252 patients had substance-related ED encounters in 2014 to 2015. Of these patients, 963 later experienced an opioid overdose death, indicating a case fatality rate of 69.2 per 10,000 patients, 6 times higher than that of patients who used the ED for any cause. Factors most strongly associated with death included having both an opioid and another substance use disorder (adjusted odds ratio 2.88; 95% confidence interval 2.04 to 4.07), having greater than or equal to 3 previous nonfatal overdoses (adjusted odds ratio 2.89; 95% confidence interval 1.54 to 5.43), and having a previous nonfatal overdose involving heroin (adjusted odds ratio 2.24; 95% confidence interval 1.64 to 3.05). CONCLUSION:These results highlight important differences in overdose risk among patients receiving care in EDs for substance-related conditions. The findings demonstrate the potential utility of incorporating routine data from patient records to assess risk of future negative outcomes and identify primary targets for initiation and linkage to lifesaving care.
Project description:Most research examining buprenorphine has been conducted with heroin users. Few studies have examined buprenorphine pharmacotherapy for prescription opioid users. Data were from a randomized controlled trial of behavioral treatment provided for 16weeks on a platform of buprenorphine pharmacotherapy and medication management. We compared heroin (H, n=54), prescription opioid (PO, n=54) and combination heroin+prescription opioid (POH, n=71) users to test the hypothesis that PO users will have better treatment outcomes compared with heroin users. The PO group provided more opioid-negative urine drug screens over the combined treatment period (PO:70%, POH:40%, H:38%, p<0.001) and at the end of the combined treatment period (PO:65%, POH:31%, H:33%, p<0.001). Retention was lowest in the H group (PO:80%, POH:65%, H:57%, p=0.039). There was no significant difference in buprenorphine dose between the groups. PO users appear to have better outcomes in buprenorphine pharmacotherapy compared to those reporting any heroin use, confirming that buprenorphine pharmacotherapy is effective in PO users.
Project description:To address the opioid overdose epidemic in the United States, states have implemented policies to reduce inappropriate opioid prescribing. These policies could affect the coincident heroin overdose epidemic by either driving the substitution of heroin for opioids or reducing simultaneous use of both substances. We used IMS Health's National Prescription Audit and government mortality data to examine the effect of these policies on opioid prescribing and on prescription opioid and heroin overdose death rates in the United States during 2006-13. The analysis revealed that combined implementation of mandated provider review of state-run prescription drug monitoring program data and pain clinic laws reduced opioid amounts prescribed by 8 percent and prescription opioid overdose death rates by 12 percent. We also observed relatively large but statistically insignificant reductions in heroin overdose death rates after implementation of these policies. This combination of policies was effective, but broader approaches to address these coincident epidemics are needed.