Mental Health Conditions and Substance Use Disorders among Youth Subsequently Diagnosed with Opioid Use Disorder or Opioid Poisoning

Abstract

Purpose:

This study examined receipt of services for mental health conditions and non-opioid substance use disorders (SUDs) among privately insured adolescents and young adults (i.e. youth) with subsequent clinically diagnosed opioid use disorder (OUD) or opioid poisoning.

Methods:

Among individuals aged 12 to 25 years (N=4,926), healthcare service utilization claims for the two years prior to a newly clinically diagnosed OUD or opioid poisoning were assessed for mental health and non-opioid SUD service visits.

Results:

Over half (60.6%) of the youth with clinically diagnosed OUD or opioid poisoning received mental health or non-opioid SUD services in the two years prior to the opioid poisoning or OUD diagnosis.

Conclusion:

Many adolescents and young adults with clinically diagnosed OUD or opioid poisoning interacted with the healthcare system to receive services for mental health conditions and non-opioid SUDs prior to the OUD or opioid poisoning being diagnosed. Opportunities exist to design better intervention strategies to prevent OUD or opioid poisoning among adolescents and young adults.

Introduction:

Opioid misuse, which frequently begins in adolescence,¹ is a leading cause of unintentional injury and death among adolescents and young adults (i.e. youth).² Previous studies have documented a significant association of mental health conditions and non-opioid substance use disorders (SUDs) with long-term use of prescription opioid analgesics for chronic pain,^3,4 and high rates of co-occurring mental health conditions and non-opioid SUDs among youth with opioid use disorder (OUD),⁵ but there is a paucity of studies examining the frequency with which youth have received treatment for mental health conditions and non-opioid SUDs before being identified with a new OUD or opioid poisoning diagnosis. To address this gap in the literature, this study examines receipt of health services for mental health conditions or non-opioid SUDs in a commercially insured youth population in the two years prior to a clinically diagnosed OUD or opioid poisoning.

Methods:

Using 2015 to 2017 IBM® MarketScan® Commercial Claims and Encounters data, a national claims database consisting of commercially insured individuals in the United States, we identified individuals aged 12 to 25 years with a clinical diagnosis of OUD or opioid poisoning in 2017 using International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for opioid abuse, opioid dependence, or poisoning by opium, methadone, heroin, other opioids and related narcotics as specified in the ICD (diagnosis codes are listed in the Appendix). Since our focus is on newly diagnosed OUD or opioid poisoning, we excluded any youth who had an OUD or opioid poisoning diagnosis in the previous two years or those for whom the new diagnosis was for opioid use disorder in remission. We also excluded any youth who had not been continuously enrolled for the two years prior to their OUD or opioid poisoning diagnosis.

Using International Classification of Diseases, Tenth Revision (ICD-10) and Ninth Revision (ICD-9) codes, we identified individuals with a primary or secondary diagnosis of a mental health condition or a non-opioid SUD (defined as any substance dependence, misuse or poisoning diagnosis) in the two years prior to the OUD or opioid poisoning diagnosis (specific codes are listed in the Appendix). We specifically identified the presence of depression, anxiety and attention deficit/hyperactivity disorder because of the potential association between these mental health conditions and substance use disorders.^6–8 The resultant sample was categorized as having received services for mental health conditions or non-opioid SUDs versus those not receiving such services. Chi-square tests were used to assess differences between the two groups. The Penn State College of Medicine Institutional Review Board approved this study.

Results:

We identified 16,860 youth aged 12 to 25 years clinically diagnosed with OUD or opioid poisoning in 2017, and 4,926 (29.2%) met our inclusion criteria. Most of our sample (89.6%; n=4,413) were diagnosed with OUD only, 435 (8.8%) were diagnosed with opioid poisoning only and a small portion (1.6%; n=78) were diagnosed with both OUD and opioid poisoning.

A majority of our sample (60.6%; n=2,984) had received services for a mental health condition or non-opioid SUD in the two years prior to their clinically diagnosed OUD or opioid poisoning. Depression and anxiety diagnoses were very common, appearing in almost half of our sample (42.1% and 45.2%, respectively) and more than half (56.9%) received diagnoses for non-opioid SUDs (Table). A higher percentage of younger youth (those aged 12–17) received diagnoses for a mental health condition or non-opioid substance use disorder prior to a clinically diagnosed OUD or opioid poisoning than older youth (those aged 18–25) (74.6% versus 59.2%), and a higher proportion of females received diagnoses for a mental health condition or non-opioid SUD prior to a clinically diagnosed OUD or opioid poisoning than males (66.8% versus 56.7%).

Table 1.

Characteristics of Adolescents and Young Adults Diagnosed with Opioid Poisoning or OUD and Receipt of Health Services

Characteristic	Receipt of Mental Health or Other Substance Use Disorder Services in Previous 2 Years		p-value
	Yes (n=2984)	No (n=1942)
Age at OUD diagnosis or opioid poisoning, n (%)*
12 to 17 (n=452)	337 (74.6)	115 (25.4)	<.001
18 to 25 (n=4474)	2647 (59.2)	1827 (40.8)
Sex, (%)*
Male (n= 3051)	1731 (56.7)	1320 (43.3)	<.001
Female (n= 1875)	1253 (66.8)	622 (33.2)
Pre-Existing Diagnoses, n (%) **
Attention Deficit/Hyperactive Disorder	685 (23.0)	NA	NA
Anxiety	1350 (45.2)	NA	NA
Depression	1255 (42.1)	NA	NA
Other Mental Health Conditions†	1294 (43.4)	NA	NA
Non-opioid Substance Use Disorders‡	1698 (56.9)	NA	NA
Alcohol	613 (20.5)	NA	NA
Cannabis	724 (24.3)	NA	NA
Nicotine/Tobacco	755 (25.3)	NA	NA

^*Percentages reported as row percentages

^**Percentages reported as column percentages

^†Most common diagnoses include: other mood disorders e.g. bipolar disorder (22.6%), and reaction to severe stress, and adjustment disorders (17.6%)

^‡Most common diagnoses include: alcohol, cannabis, tobacco/nicotine and other psychoactive substance use disorders (16.1%)

Abbreviation: OUD= opioid use disorder; NA= not applicable

Discussion:

More than half of adolescents and young adults had received health services for mental health conditions or non-opioid SUDs prior to their clinically diagnosed OUD or opioid poisoning. This is consistent with a prior study showing individuals with mental health conditions are at higher risk for OUD³ but that study examined mental health conditions among adolescents and young adults during a 6 month window only, whereas we looked over a longer period (two years). In addition, the prior study was limited to youth diagnosed with chronic pain, while our study included any youth with a clinically diagnosed OUD or opioid poisoning.

Our finding that many youth with OUD or opioid poisoning had engaged in the healthcare system and received diagnoses of mental health conditions and non-opioid SUDs in the previous two years suggests the opportunity for a range of interventions. These could include more active efforts by health providers to identify youth with opioid poisoning, OUD or those misusing opioids, implementing harm reduction interventions such as more aggressive educational efforts on overdose prevention/opioid misuse with youth and their families, engaging family members in treatment plans,⁹ and increased naloxone access and distribution¹⁰ for youth who screen positive for active opioid use. Unfortunately, pediatricians often fail to identify risky substance use and dependence when based solely on clinical impression.¹¹ The American Academy of Pediatrics recommends screening, brief intervention and referral to treatment (SBIRT) to screen for substance use disorders¹² but while SBIRT has been shown to be effective in identifying unhealthy alcohol use in adults,^13,14 evidence of its efficacy in identifying opioid misuse in youth is inconsistent.⁹ More research is needed to identify effective strategies for screening for opioid misuse and dependence in primary care settings.⁹ Providing screening and early interventions will be especially important and beneficial for adolescents aged 12–17 years, as our results showed that more people in this age group were treated for mental health conditions or non-opioid SUDs prior to their clinically diagnosed OUD or opioid poisoning compared to those in the 18–25 year group (74.6% vs. 59.2%). Since opioid misuse frequently begins in adolescence, taking advantage of opportunities to intervene early for this at-risk population could greatly reduce the chances of future opioid misuse among adolescents.

In addition, prior research has shown that females are more likely than males to be diagnosed with major depression or anxiety disorder prior to the onset of a substance use diagnosis.¹⁵ Our finding that more females received services for a mental health condition prior to their OUD or opioid poisoning diagnosis is indicative of the need for sex-specific interventions among youth at risk of developing SUDs.

Our findings must be considered within the context of the study’s limitations. These include being limited to privately-insured youth and the lack of clinical detail in claims data. We also acknowledge that while two years is a long wash-out period to identify new OUD or opioid poisoning diagnoses, some youth might have been previously diagnosed with OUD or opioid poisoning or did not seek care initially. Despite these limitations, our results highlight the need for more effective screening and interventions for youth at risk for OUD or opioid poisoning. Future research might also investigate other characteristics associated with youth developing OUD and the barriers to treatments with the ultimate goal of developing better screening and early identification tools for this vulnerable population. Examining the clinical settings that youth who develop OUD frequently visit may also help inform youth-specific interventions and their implementations.

Abbreviations:

OUD

opioid use disorder

SUD

substance use disorder

ICD-10

International Classification of Diseases, Tenth Revision

ICD-9

International Classification of Diseases, Ninth Revision