This cohort study evaluates access to medications for opioid use disorder (MOUD), naloxone, and behavioral health care and their association with decreased fatal overdose risk among Medicare beneficiaries with recent nonfatal overdose experience.
Key Points
Question
During the 12 months after a nonfatal drug overdose, what percentage of Medicare beneficiaries receive medications for opioid use disorder (MOUD), naloxone, or behavioral health services, what percentage have a subsequent nonfatal or fatal drug overdose, and how does receipt of these services affect fatal drug overdose risk?
Findings
In this cohort study of 136 762 Medicare beneficiaries with an index nonfatal drug overdose, subsequent nonfatal and fatal drug overdoses were observed. Subsequent nonfatal drug overdose and an opioid use disorder diagnostic code were associated with increased risk for fatal drug overdose, whereas receipt of a naloxone prescription, methadone, or buprenorphine treatment for opioid use disorder as well as behavioral health services were associated with decreased risk.
Meaning
Findings of this study suggest the need to improve access to behavioral health services; MOUD; and overdose-prevention strategies, such as prescribing naloxone and linking individuals to community-based health care settings for ongoing care.
Abstract
Importance
Recognizing and providing services to individuals at highest risk for drug overdose are paramount to addressing the drug overdose crisis.
Objective
To examine receipt of medications for opioid use disorder (MOUD), naloxone, and behavioral health services in the 12 months after an index nonfatal drug overdose and the association between receipt of these interventions and fatal drug overdose.
Design, Setting, and Participants
This cohort study was conducted in the US from January 2020 to December 2021 using claims, demographic, mortality, and other data from the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, and other sources. The cohort comprised Medicare fee-for-service beneficiaries aged 18 years or older with International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes for a nonfatal drug overdose. Data analysis was performed from February to November 2023.
Exposures
Demographic and clinical characteristics, substance use disorder, and psychiatric comorbidities.
Main Outcomes and Measures
Receipt of MOUD, naloxone, and behavioral health services as well as subsequent nonfatal and fatal drug overdoses.
Results
The cohort consisted of 136 762 Medicare beneficiaries (80 140 females [58.6%]; mean (SD) age of 68.2 [15.0] years) who experienced an index nonfatal drug overdose in 2020. The majority of individuals had Hispanic (5.8%), non-Hispanic Black (10.9%), and non-Hispanic White (78.8%) race and ethnicity and lived in metropolitan areas (78.9%). In the 12 months after their index nonfatal drug overdose, 23 815 beneficiaries (17.4%) experienced at least 1 subsequent nonfatal drug overdose and 1323 (1.0%) died of a fatal drug overdose. Opioids were involved in 72.2% of fatal drug overdoses. Among the cohort, 5556 (4.1%) received any MOUD and 8530 (6.2%) filled a naloxone prescription in the 12 months after the index nonfatal drug overdose. Filling a naloxone prescription (adjusted odds ratio [AOR], 0.70; 95% CI, 0.56-0.89), each percentage of days receiving methadone (AOR, 0.98; 95% CI, 0.98-0.99) or buprenorphine (AOR, 0.99; 95% CI, 0.98-0.99), and receiving behavioral health assessment or crisis services (AOR, 0.25; 95% CI, 0.22-0.28) were all associated with reduced adjusted odds of fatal drug overdose in the 12 months after the index nonfatal drug overdose.
Conclusions and Relevance
This cohort study found that, despite their known association with reduced risk of a fatal drug overdose, only a small percentage of Medicare beneficiaries received MOUD or filled a naloxone prescription in the 12 months after a nonfatal drug overdose. Efforts to improve access to behavioral health services; MOUD; and overdose-prevention strategies, such as prescribing naloxone and linking individuals to community-based health care settings for ongoing care, are needed.
Introduction
Over 107 000 lives were lost to drug overdose in the US in 2022.1 Identifying populations at increased risk for drug overdose as well as the clinical and community-based touch points for intervention is a critical step to informing overdose prevention policy, practice, and programmatic strategies.
Prior nonfatal drug overdose is an important factor in subsequent nonfatal and fatal drug overdoses.2,3,4,5,6 Yet, many patients treated for a drug overdose do not receive evidence-based services after their overdose. Larochelle et al7 found that only 30% of patients in Massachusetts who experienced a nonfatal opioid overdose received medications for opioid use disorder (MOUD) in the 12 months after their nonfatal drug overdose. Dunphy et al8 reported that only 4.5% of adults with commercial insurance filled a naloxone prescription after a nonfatal opioid overdose.
Although prior studies2,3,4,5,6,7,8 provide insights into the risks for subsequent drug overdose after a nonfatal overdose as well as missed opportunities to leverage nonfatal overdose as a critical intervention point, these studies typically were limited to data from a single state or small number of states, conducted prior to the COVID-19 pandemic, and conducted before illicitly manufactured fentanyl was widespread in the drug supply. Thus, research using more recent data to account for new policies, care disruptions, and changing health system dynamics during the COVID-19 pandemic, as well as the increasingly toxic drug supply, is essential to inform policymaking.
To address these research gaps, we conducted a longitudinal cohort study using Medicare data from January 2020 to December 2021. We aimed to examine (1) subsequent rates of nonfatal and fatal drug overdoses; (2) receipt of MOUD (methadone, buprenorphine, and extended-release [ER] naltrexone), naloxone, and behavioral health services in the 12 months after an index nonfatal drug overdose; and (3) the association between receipt of these interventions and fatal drug overdose.
Methods
Data Sources, Cohort Design, and Population
Multiple data sources were used: the Medicare Beneficiary Summary File (MBSF) base; the MBSF Chronic Conditions and Other Chronic or Potentially Disabling Conditions segments; the Long-Term Care Minimum Data Set; Medicare fee-for-service (FFS) and Medicaid claims data files to identify demographic and clinical characteristics and health care use9,10,11,12,13,14,15,16,17,18,19; the MBSF National Death Index segment to identify fatal drug overdoses drawn from the Centers for Disease Control and Prevention National Death Index20; and the American Community Survey 5-year estimates (2016 to 2020) to calculate county-level measures.21 In accordance with the Common Rule, this cohort study was exempt from review and the informed consent requirement because it was not considered human participant research. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
The longitudinal cohort consisted of Medicare FFS beneficiaries aged 18 years or older who experienced a nonfatal drug overdose anytime during 2020 according to at least 1 service claim with an International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code for nonfatal drug overdose (eTable 1 in Supplement 1). To be included in the cohort, beneficiaries had to be continuously enrolled in FFS Medicare Parts A, B, and D from 90 days before to 12 months after their index nonfatal drug overdose or until their death from any cause.
Main Outcomes and Measures
The main outcomes were nonfatal and fatal drug overdoses after the index nonfatal drug overdose. Nonfatal drug overdose was ascertained from an ICD-10-CM code for a drug overdose on a Medicare Part A or B service claim at any point during 2020 (eTable 1 in Supplement 1) and occurring in the emergency department (ED) or outpatient or inpatient hospital settings. Drug overdose deaths were identified from underlying-cause-of-death ICD-10-CM codes X40 to X44 (unintentional), X60 to X64 (intentional), X85 (homicide), or Y10 to Y14 (underdetermined intent) (eTable 1 in Supplement 1) and occurring after the index nonfatal drug overdose.
The MOUD obtained from pharmacies (buprenorphine or ER naltrexone) and prescription medication use for select controlled substances and psychotherapeutics had Medicare Part D or Medicaid pharmacy claims with National Drug Codes (eTable 1 in Supplement 1). Methadone, buprenorphine, or ER naltrexone received from opioid treatment programs (OTPs) had Medicare Part B or Medicaid claims with Healthcare Common Procedure Coding System codes corresponding to receipt of these medications in an OTP (eTable 1 in Supplement 1). Buprenorphine formulations approved for pain and methadone dispensed from pharmacies were excluded because these medications are not used in treatment of opioid use disorder (OUD). Any behavioral health–related service received had a Medicare Part A or B or Medicaid service claim with a behavioral health–related claim code. These services included psychotherapy or counseling; crisis service or detoxification; behavioral health assessment, screening, or diagnosis; and medication management. Medication management services consisted of substance use disorder (SUD) treatment as well as information, support, and medication-specific counseling to patients (eTable 1 in Supplement 1).
Demographic and Clinical Covariates
Sex; age group; race and ethnicity; US Census region; county urban-rural status; Medicare eligibility status; time spent in nursing homes from index nonfatal drug overdose through 12 months after; and SUD, mental health, and chronic medical conditions diagnoses at baseline were identified by ICD-10-CM diagnosis codes or Chronic Conditions Data Warehouse flags in the same year as the index nonfatal drug overdose (eTable 1 in Supplement 1). Race and ethnicity were self-reported to the Social Security Administration and integrated with enrollment in Medicare. Race and ethnicity categories included Hispanic, non-Hispanic American Indian or Alaska Native (hereafter American Indian or Alaska Native), non-Hispanic Asian or Pacific Islander (hereafter Asian or Pacific Islander), non-Hispanic Black (hereafter Black), non-Hispanic White (hereafter White), and other (non-Hispanic Native Hawaiian). Race and ethnicity were assessed due to disparities in nonfatal and fatal drug overdose among different racial and ethnic groups.
Recognizing the changing epidemiologic features of SUD and drug overdose in the US, particularly increased risk of overdose as well as access to and provision of evidence-based services based on social determinants of health, racial and ethnic neighborhood composition, and income inequality,22,23,24 we included these county-level indicators from the American Community Survey: Residential Stability Index, Non-White Dissimilarity Index (racial residential segregation), and Income Inequality Index (eTable 2 in Supplement 1).25
Statistical Analysis
Baseline demographic and clinical characteristics were reported as frequencies and percentages. We examined descriptive statistics for days receiving behavioral health treatments and services, experiencing subsequent nonfatal drug overdose, death from any cause, and fatal drug overdose during the study period. As a sensitivity analysis, we examined subsequent nonfatal and fatal overdoses specifically involving opioids (eTable 1 in Supplement 1).
A multilevel logistic regression model was used to examine characteristics associated with experiencing a fatal drug overdose, adjusting for baseline demographic and clinical as well as county-level characteristics. County of residence was included as a level-2 random intercept parameter to adjust for similarity of beneficiaries residing within the same county. Model results were presented using adjusted odds ratios (AORs) and corresponding 95% CIs. To assess the robustness of findings among different subgroups, we ran 3 additional models applied to (1) the sample excluding those with other causes of death (ie, not a fatal drug overdose), (2) only those with dual eligibility (ie, had both Medicare and Medicaid), and (3) only those eligible for Medicare due to disability. Multicollinearity for all models was assessed with variance inflation factors and was not identified in the final models based on variance inflation factor cutoff over 5. Statistical significance was set at 2-sided P < .05. Analyses were conducted from February to November 2023 with SAS Enterprise Guide version 7.1 (SAS Institute Inc) and Stata version 17.0 (StataCorp LLC).
Results
The cohort consisted of 136 762 Medicare FFS beneficiaries who experienced a nonfatal drug overdose in 2020 (Table 1). Of these beneficiaries, 80 140 (58.6%) were females and 56 622 (41.4%) were males, with a mean (SD) age of 68.2 (15.0) years. Additionally, these beneficiaries had American Indian or Alaska Native (0.8%), Asian or Pacific Islander (1.7%), Black (10.9%), Hispanic (5.8%), White (78.8%), and other (2.0%) race and ethnicity. At baseline, 78.9% of beneficiaries were living in metropolitan areas, 66.9% were Medicare eligible due to age, 44.2% had dual eligibility, and 6.9% were receiving care in a nursing home (Table 1).
Table 1. Baseline Demographic and Clinical Characteristics of Medicare Beneficiaries Who Experienced a Nonfatal Overdose .
| Characteristic | No. (%) |
|---|---|
| All beneficiaries | 136 762 (100) |
| Age group, y | |
| 18-44 | 12 635 (9.2) |
| 45-64 | 29 535 (21.6) |
| 65-74 | 45 438 (33.2) |
| ≥75 | 49 154 (35.9) |
| Sex | |
| Female | 80 140 (58.6) |
| Male | 56 622 (41.4) |
| Race and ethnicitya | |
| American Indian or Alaska Native | 1098 (0.8) |
| Asian or Pacific Islander | 2282 (1.7) |
| Black | 15 023 (10.9) |
| Hispanic | 7887 (5.8) |
| White | 107 734 (78.8) |
| Otherb | 2738 (2.0) |
| Dual eligibility status | |
| Medicare only | 76 361 (55.8) |
| Medicare and Medicaid | 60 401 (44.2) |
| Eligibility | |
| Age | 91 495 (66.9) |
| Disability | 38 643 (28.3) |
| With ESKD | 6624 (4.8) |
| In nursing home at baseline | |
| Yes | 9365 (6.9) |
| Time spent in nursing home from baseline to end of study | |
| None | 103 207 (75.5) |
| Quantile 1 | 8423 (6.2) |
| Quantile 2 | 8341 (6.1) |
| Quantile 3 | 8398 (6.1) |
| Quantile 4 | 8393 (6.1) |
| US Census region | |
| Northeast | 26 786 (19.6) |
| Midwest | 33 544 (24.5) |
| South | 49 441 (36.2) |
| West | 26 991 (19.7) |
| County urban-rural status | |
| Metropolitan | 107 894 (78.9) |
| Micropolitan | 25 756 (18.8) |
| Rural | 3112 (2.3) |
| SUD diagnosis | |
| Opioid | 23 555 (17.2) |
| Alcohol | 16 329 (11.9) |
| Tobacco | 39 681 (29.0) |
| Cannabis | 9351 (6.8) |
| Cocaine | 5641 (4.1) |
| Stimulant | 6818 (5.0) |
| Sedative or hypnotic | 6709 (4.9) |
| Other psychoactive substance | 14 151 (10.4) |
| ≥2 Substances | 29 232 (21.4) |
| Mental health diagnosis | |
| Anxiety | 76 688 (56.1) |
| Bipolar disorder | 25 139 (18.4) |
| Major depression | 75 769 (55.4) |
| Personality disorder | 9842 (7.2) |
| ADHD | 7412 (5.4) |
| PTSD | 10 901 (8.0) |
| Schizophrenia or other psychotic disorder | 19 561 (14.3) |
| ≥2 Diagnoses | 67 230 (49.2) |
| Other chronic medical conditions | |
| Cancer | 27 066 (19.8) |
| Diabetes | 54 474 (39.8) |
| Cardiovascular and other circulatory | 116 666 (85.3) |
| Chronic respiratory disease | 53 210 (38.9) |
| Viral hepatitis | 8792 (6.4) |
| HIV | 1554 (1.1) |
| Obesity | 47 388 (34.7) |
| Liver disease cirrhosis and other liver conditionsc | 23 995 (17.6) |
| Acute or chronic pain | 108 291 (79.2) |
| Received MOUD within 90 d prior to index | |
| MOUD | 3617 (2.64) |
| Methadone | 1147 (0.84) |
| Buprenorphine | 2442 (1.79) |
| ER naltrexone | 94 (0.07) |
| Filling prescription within 90 d prior to index | |
| Naloxone | 2843 (2.1) |
| Antidepressants | 63 263 (46.3) |
| Antipsychotics | 30 538 (22.3) |
| Benzodiazepines | 34 740 (25.4) |
| Gabapentinoids | 40 199 (29.4) |
| Nonbenzodiazepine sedatives, tranquilizers, antianxiety medications | 16 102 (11.8) |
| Nonopioid analgesics and antimigraine medications | 31 308 (22.9) |
| Opioid analgesics | 62 589 (45.8) |
| Stimulants | 3080 (2.3) |
| Prescription overlap within 90 d prior to index | |
| Opioid analgesics only | 21 250 (15.5) |
| Benzodiazepines only | 6680 (4.9) |
| Opioid analgesics and benzodiazepines | 17 908 (13.1) |
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; ER, extended-release; ESKD, end-stage kidney disease; MOUD, medications for opioid use disorder; PTSD, posttraumatic stress disorder; SUD, substance use disorder.
Race and ethnicity data were self-reported to the Social Security Administration and integrated with enrollment in Medicare.
Other race and ethnicity included non-Hispanic Native Hawaiian.
Excluding hepatitis.
Diagnoses of SUD and psychiatric conditions in the claims data were common. Overall, 21.4% of beneficiaries had SUD for 2 or more substances, 29.0% had tobacco use disorder, 17.2% had OUD, and 11.9% had alcohol use disorder. Psychiatric diagnoses were common, with 49.2% of beneficiaries having 2 or more, 56.1% having anxiety disorder, 55.4% having major depression, and 18.4% having bipolar disorder. Cardiovascular and other circulatory diseases were the most common chronic medical conditions (85.3%) followed by acute or chronic pain (79.2%), diabetes (39.8%), chronic respiratory disease (38.9%), and obesity (34.7%) (Table 1).
Subsequent Nonfatal and Fatal Drug Overdose and All-Cause Mortality After Index Nonfatal Drug Overdose
Among 136 762 beneficiaries in the cohort, 17.4% experienced at least 1 subsequent nonfatal drug overdose in the 12 months after their index nonfatal drug overdose (Table 2). Within that period, 24.7% died of any cause; 3.9% of deaths or 1.0% overall were due to a fatal drug overdose. Other causes of death were those typically found among middle-aged and older adults: cancer (32.4%), cardiovascular disease (19.6%), respiratory diseases (9.0%), and COVID-19 (7.8%). Of the fatal drug overdoses, 72.2% (955) involved opioids.
Table 2. Subsequent Nonfatal Drug Overdose, All-Cause Mortality, and Fatal Drug Overdose Among Medicare Beneficiaries After a Nonfatal Drug Overdose .
| Outcome | No. (%) |
|---|---|
| Study analysis: nonfatal drug overdose population (N = 136 762) | |
| Subsequent nonfatal drug overdose | 23 815 (17.4) |
| Died within study period | 33 800 (24.7) |
| Fatal drug overdose | 1323 (1.0) |
| Opioid-involved fatal drug overdose | 955 (0.7) |
| % Of fatal drug overdose involving opioids | 72.2 |
| Sensitivity analysis: opioid-involved nonfatal drug overdose subpopulation (n = 80 140) | |
| Subsequent nonfatal opioid overdose | 11 386 (14.2) |
| Died within study period | 19 394 (24.2) |
| Fatal drug overdose | 900 (1.1) |
| Opioid-involved fatal drug overdose | 766 (1.0) |
| % Of fatal drug overdose involving opioids | 85.1 |
In sensitivity analyses, 58.6% of the cohort experienced an index nonfatal overdose involving opioids. Among this subset, within 12 months, 14.2% experienced a subsequent opioid-involved nonfatal overdose; 24.2% died from any cause during the study period, 1.1% died from a fatal drug overdose (4.6% of all deaths), and 1.0% died from an opioid-involved overdose (3.9% of all deaths; 85.1% of fatal drug overdoses).
MOUD, Naloxone, Other Substances and Psychotherapeutics, and Behavioral Health Services After Index Nonfatal Drug Overdose
In the 12 months after the index nonfatal drug overdose, 5556 beneficiaries (4.1%) received any MOUD, with 4063 (3.0%) receiving buprenorphine, 1589 (1.2%) receiving methadone, and 234 (0.2%) receiving ER naltrexone (Table 3). The mean (SD) and median (IQR) numbers of days until MOUD initiation after index nonfatal drug overdose were 72.0 (96.4) and 23.0 (6.0-105.0), respectively. Among those who received MOUD, the mean (SD) and median (IQR) percentages of days of receipt were 55.4% (36.3%) and 59.7% (17.8%-93.4%), respectively. The mean and median percentages of MOUD days were highest for methadone followed by buprenorphine and ER naltrexone. Filling a naloxone prescription in the 12 months after an index nonfatal drug overdose was observed among 8530 beneficiaries (6.2%).
Table 3. Receipt of Treatment and Behavioral Health Services Among Medicare Beneficiaries After a Nonfatal Drug Overdose .
| Treatment | Medicare beneficiaries, No. (%) | Mean (SD) | Median (IQR) |
|---|---|---|---|
| No. of days in study | 136 762 (100) | 303.2 (119.6) | 365.0 (365.0-365.0) |
| MOUD | |||
| No. of days until first MOUD | 5556 (4.1) | 72.0 (96.4) | 23.0 (6.0-105.0) |
| % Days receiving MOUD | 5556 (4.1) | 55.4 (36.3) | 59.7 (17.8-93.4) |
| % Days receiving methadone | 1589 (1.2) | 63.7 (34.5) | 73.2 (31.5-97.8) |
| % Days receiving buprenorphine | 4063 (3.0) | 49.1 (36.8) | 45.2 (10.7-89.3) |
| % Days receiving ER naltrexone | 234 (0.2) | 31.5 (26.6) | 21.4 (8.2-49.9) |
| Filled naloxone prescription | 8530 (6.2) | 1.2 (0.7) | 1.0 (1.0-1.0) |
| Prescription medication treatment | |||
| % Days receiving antidepressants | 73 047 (53.4) | 63.6 (28.6) | 72.7 (41.9-88.0) |
| % Days receiving antipsychotics | 35 747 (26.1) | 53.0 (33.5) | 58.1 (18.2-85.5) |
| % Days receiving benzodiazepines | 41 270 (30.2) | 44.4 (33.5) | 41.1 (9.9-77.5) |
| % Days receiving gabapentinoids | 47 804 (35.0) | 52.7 (29.6) | 56.4 (24.7-79.2) |
| % Days receiving nonbenzodiazepine sedatives, tranquilizers, or antianxiety medications | 20 153 (14.7) | 43.7 (31.5) | 38.9 (13.4-74.0) |
| % Days receiving nonopioid analgesics and antimigraine medications | 41 232 (30.2) | 31.3 (29.5) | 19.7 (7.7-52.1) |
| % Days receiving opioid analgesics | 72 455 (53.0) | 38.9 (36.0) | 26.3 (3.8-76.4) |
| % Days receiving stimulants | 3717 (2.7) | 53.4 (31.6) | 55.9 (23.3-84.6) |
| Behavioral health services | |||
| % Days receiving any behavioral health service | 121 496 (88.8) | 5.7 (7.6) | 4.1 (2.2-6.9) |
| % Days receiving a behavioral health assessment, screening, or diagnosis | 81 640 (59.7) | 0.8 (1.0) | 0.6 (0.3-0.8) |
| % Days receiving a crisis service | 2863 (2.1) | 1.7 (4.4) | 0.6 (0.3-1.4) |
| % Days receiving detoxification | 464 (0.3) | 2.9 (4.2) | 1.4 (0.6-3.3) |
| % Days receiving medication management | 116 207 (85.0) | 4.0 (4.2) | 3.1 (1.6-5.2) |
| % Days receiving psychotherapy or counseling | 24 602 (18.0) | 4.1 (6.3) | 1.9 (0.6-4.9) |
| % Days receiving treatment or recovery support | 55 909 (40.9) | 3.1 (8.0) | 1.2 (0.6-2.7) |
Abbreviations: ER, extended release; MOUD, medications for opioid use disorder.
Over half of the cohort received antidepressants (53.4%) and opioid analgesics (53.0%) in the 12 months after their index nonfatal drug overdose, while a large minority of the cohort received gabapentinoids (35.0%), benzodiazepines (30.2%), nonopioid analgesics or antimigraine medications (30.2%), and antipsychotics (26.1%) (Table 3). A smaller percentage of beneficiaries received nonbenzodiazepine sedatives, tranquilizers, or antianxiety medications (14.7%) or stimulants (2.7%).
Overall, 88.8% of the cohort received behavioral health services in the 12 months after their index nonfatal drug overdose (Table 3). The most common type of service was medication management (85.0%), followed by behavioral health assessment, screening, or diagnosis (59.7%); treatment or recovery support (40.9%); and psychotherapy or counseling (18.0%). The mean (SD) and median (IQR) percentages of days receiving behavioral health services were 5.7% (7.6%) and 4.1% (2.2%-6.9%). For specific types of behavioral health services, the mean and median percentages of days receiving these services were small.
Characteristics Associated With Fatal Drug Overdose After Index Nonfatal Drug Overdose
Characteristics associated with fatal drug overdose in the 12 months after an index nonfatal drug overdose based on multilevel, multivariable logistic regression analysis are shown in Table 4. Salient characteristics associated with increased adjusted odds for fatal drug overdose included the following: subsequent nonfatal drug overdose (AOR, 1.25; 95% CI, 1.10-1.43), OUD (AOR, 2.58; 95% CI, 2.24-2.96), cocaine use disorder (AOR, 1.44; 95% CI, 1.21-1.70), sedative use disorder (AOR, 1.28; 95% CI, 1.06-1.54), psychoactive SUD (AOR, 1.59; 95% CI, 1.37-1.84), bipolar disorder (AOR, 1.36; 95% CI, 1.17-1.58), major depression (AOR, 1.21; 95% CI, 1.05-1.39), and higher county-level racial residential segregation (AOR, 1.01; 95% CI, 1.00-1.01).
Table 4. Characteristics Associated With Fatal Drug Overdose Among 136 127 Medicare Beneficiaries After a Nonfatal Overdose.
| Characteristic | AOR (95% CI)a |
|---|---|
| Subsequent nonfatal drug overdose | |
| No | 1 [Reference] |
| Yes | 1.25 (1.10-1.43)b |
| Baseline age group, y | |
| 18-44 | 1 [Reference] |
| 45-64 | 0.94 (0.81-1.09) |
| 65-74 | 0.37 (0.30-0.46)b |
| ≥75 | 0.16 (0.12-0.21)b |
| Baseline sex | |
| Female | 0.88 (0.78-0.99)b |
| Male | 1 [Reference] |
| Baseline race and ethnicityc | |
| American Indian or Alaska Native | 0.52 (0.25-1.06) |
| Asian or Pacific Islander | 0.94 (0.57-1.55) |
| Black | 0.76 (0.63-0.91)b |
| Hispanic | 0.80 (0.63-1.00) |
| White | 1 [Reference] |
| Otherd | 0.41 (0.13-1.29) |
| Baseline dual eligibility status | |
| Medicare only | 1 [Reference] |
| Medicare and Medicaid | 1.27 (1.08-1.48)b |
| Baseline nursing home residence | |
| Not in nursing home | 1 [Reference] |
| In nursing home | 1.35 (0.81-2.26) |
| Time spent in nursing home from baseline to end of study | |
| None | 1 [Reference] |
| Quartile 1 | 0.31 (0.20-0.48)b |
| Quartile 2 | 0.30 (0.19-0.47)b |
| Quartile 3 | 0.29 (0.19-0.45)b |
| Quartile 4 | 0.06 (0.02-0.15)b |
| Baseline US Census region | |
| Northeast | 1 [Reference] |
| Midwest | 0.94 (0.78-1.13) |
| South | 0.86 (0.72-1.02) |
| West | 1.02 (0.83-1.27) |
| Baseline county urban-rural status | |
| Metropolitan | 1 [Reference] |
| Micropolitan | 0.75 (0.63-0.89)b |
| Rural | 0.52 (0.29-0.95)b |
| Baseline substance use disorder diagnosise | |
| Opioid | 2.58 (2.24-2.96)b |
| Alcohol | 1.11 (0.96-1.28) |
| Tobacco | 1.42 (1.23-1.64)b |
| Cannabis | 0.79 (0.67-0.94)b |
| Cocaine | 1.44 (1.21-1.70)b |
| Stimulant | 1.07 (0.91-1.27) |
| Sedative or hypnotic | 1.28 (1.06-1.54)b |
| Other psychoactive substance | 1.59 (1.37-1.84)b |
| Baseline mental health diagnosise | |
| Anxiety | 1.08 (0.93-1.25) |
| Bipolar disorder | 1.36 (1.17-1.58)b |
| Major depression | 1.21 (1.05-1.39)b |
| Personality disorder | 1.11 (0.92-1.34) |
| Attention-deficit/hyperactivity disorder | 0.91 (0.74-1.12) |
| Posttraumatic stress disorder | 1.08 (0.91-1.28) |
| Schizophrenia or other psychotic disorder | 0.99 (0.84-1.16) |
| Baseline other chronic medical conditionse | |
| Cancer | 0.45 (0.35-0.57)b |
| Diabetes | 0.77 (0.67-0.88)b |
| Cardiovascular and other circulatory | 1.22 (1.05-1.41)b |
| Chronic respiratory disease | 0.93 (0.82-1.05) |
| Viral hepatitis | 1.26 (1.08-1.47)b |
| HIV | 0.96 (0.68-1.36) |
| Obesity | 1.04 (0.91-1.19) |
| Liver disease cirrhosis and other liver conditionsf | 1.15 (0.99-1.32) |
| Acute or chronic pain | 0.96 (0.84-1.11) |
| Naloxone prescription filled during study period | |
| No | 1 [Reference] |
| Yes | 0.70 (0.56-0.89)b |
| % Days in study prescribed medication | |
| Methadoneg | 0.98 (0.98-0.99)b |
| Buprenorphineg | 0.99 (0.98-0.99)b |
| Extended-release naltrexoneg | 1.01 (0.99-1.03) |
| Antidepressants | 0.99 (0.99-0.99)b |
| Antipsychotics | 0.99 (0.99-1.00)b |
| Gabapentinoids | 1.00 (0.99-1.01) |
| Nonbenzodiazepine sedatives, tranquilizers, or antianxiety medications | 1.00 (0.99-1.01) |
| Nonopioid analgesics and antimigraine medications | 1.00 (1.00-1.01)b |
| Stimulant | 1.00 (0.99-1.01) |
| Benzodiazepines | 1.00 (0.99-1.00) |
| Opioid analgesics | 0.99 (0.99-1.00) |
| Overlapping opioid analgesics | 0.99 (0.99-1.00) |
| Overlapping benzodiazepines | 1.00 (0.99-1.01) |
| Overlapping opioid analgesics and benzodiazepines | 1.00 (0.99-1.01) |
| Received a behavioral health assessment or crisis service | |
| No | 1 [Reference] |
| Yes | 0.25 (0.22-0.28)b |
| % Days in study receiving behavioral health services | |
| Medication management services | 0.98 (0.96-1.00) |
| Treatment or recovery support services | 0.99 (0.97-1.00) |
| County characteristics | |
| Residential stability | 1.07 (0.98-1.16) |
| Racial residential segregation | 1.01 (1.00-1.01)b |
| Income inequality | 1.38 (0.13-14.25) |
Abbreviation: AOR, adjusted odds ratio.
Models adjusted for all variables in the table and use of all medications in the table within 90 days prior to index date.
P < .05.
Race and ethnicity data were self-reported to the Social Security Administration and integrated with enrollment in Medicare.
Other race and ethnicity included non-Hispanic Native Hawaiian.
Reference group was without the diagnosis or condition.
Excluding hepatitis.
An additional model was run using any receipt of methadone, any receipt of buprenorphine, and any receipt of extended-release naltrexone. In this model, the AOR was 0.42 (95% CI, 0.26-0.66) for methadone, 0.48 (95% CI, 0.36-0.64) for buprenorphine, and 1.12 (95% CI, 0.54-2.30) for extended-release naltrexone.
Salient characteristics associated with lower adjusted odds of fatal drug overdose included the following: cannabis use disorder (AOR, 0.79; 95% CI, 0.67-0.94), filling a naloxone prescription (AOR, 0.70; 95% CI, 0.56-0.89), percentage of days (ie, each additional day) receiving methadone (AOR, 0.98; 95% CI, 0.98-0.99) or buprenorphine (AOR, 0.99; 95% CI, 0.98-0.99), percentage of days receiving antidepressants (AOR, 0.99; 95% CI, 0.99-0.99) or antipsychotics (AOR, 0.99; 95% CI, 0.99-1.00); and receiving behavioral health assessment or crisis services (AOR, 0.25; 95% CI, 0.22-0.28) during the study period. When coded as any receipt of methadone, buprenorphine, or ER naltrexone after the index nonfatal drug overdose rather than percentage of days receiving the medication, the AOR was 0.42 (95% CI, 0.26-0.66) for methadone, 0.48 (95% CI, 0.36-0.64) for buprenorphine, and 1.12 (95% CI, 0.54-2.30) for ER naltrexone.
Findings of the sensitivity analysis of the subset of beneficiaries with an index nonfatal drug overdose that involved opioids were similar to the results of the main multivariable model (eTable 3 in Supplement 1). Similarly, subgroup models among the cohort that excluded those who died from other causes, who were dually eligible, and who were Medicare eligible due to disability yielded findings similar to the main analysis (eTable 4 in Supplement 1).
Discussion
To our knowledge, this longitudinal cohort study is the first to examine linked clinical and drug-overdose mortality data in a national cohort of Medicare beneficiaries during the COVID-19 pandemic in 2020 through the end of 2021, when drug overdose deaths in the US increased substantially.1,26 In the 12 months after experiencing a nonfatal drug overdose in 2020, 17.4% of the cohort experienced a subsequent nonfatal drug overdose and approximately 1.0% died of an overdose. Despite MOUD and naloxone being associated with reduced risk of a fatal drug overdose, only 4.1% of individuals received MOUD and only 6.2% filled a naloxone prescription over the 12-month follow-up. While a larger percentage of beneficiaries received behavioral health services, the majority received these services for less than a week. These findings underscore the need to increase the uptake of evidence-based care after a nonfatal drug overdose.
The findings are generally consistent with previous research on postoverdose treatment using pre–COVID-19 data.3,7,27,28 Using 2008 to 2016 Medicare data of adults aged 18 to 64 years eligible for Medicare due to disability, Samples and colleagues29 found that in the 12 months after a nonfatal opioid-involved overdose, 4.6% received buprenorphine treatment, which is similar to the 4.1% who received MOUD (primarily buprenorphine) in the present study. Barnett and colleagues30 analyzed Medicare data of Black, Hispanic, and White beneficiaries from 2016 to 2019 and found that 21.3% and 3.3% of their cohort received buprenorphine or naltrexone, respectively, in the 180 days after an index OUD-related event. The higher prevalence of MOUD receipt in the Barnett and colleagues30 study was likely due to the difference in the study population. Approximately one-third of the index events in their cohort were due to nonfatal opioid-involved overdose, with 43.5% of index events due to injection drug use–related infections with hospitalization and 25.7% associated with prior inpatient treatment or detoxification.30 Nevertheless, a consistent finding across these studies, including the present research, was that receipt of MOUD was associated with reduced risk of drug overdose, yet only a minority of patients received these life-saving medications.
Due to the recency of the data we used, which covered the COVID-19 pandemic and the current synthetic drug crisis in the US, the study findings have particular clinical and research relevance. We examined the full complement of MOUD, whether received from pharmacies in the community, in office-based settings, or through OTPs as well as nonpharmacological psychosocial services available to individuals after a drug overdose. Findings highlight that the time after a nonfatal drug overdose presents a critical opportunity to connect people to medical and behavioral health care.
Making drug-overdose education and naloxone distribution a standard part of ED care for nonfatal drug overdoses and SUD-related ED visits could be an important first step.26 In addition, EDs can partner with health systems, community-based health care and social service practitioners, and recovery and peer-support organizations to link overdose survivors and high-risk individuals to care and services for OUD, co-occurring SUD and mental disorder, and chronic medical conditions. Examples include strategies that initiate buprenorphine in EDs, MOUD and SUD bridge clinics, and postoverdose treatment linkages (both within EDs and outside these settings).31,32,33,34,35,36
Importantly, this study examined only nonfatal drug overdoses treated in health care settings, yet research shows that some drug overdoses occurring in the community and those responded to by emergency medical services do not lead to transport to an ED.37,38 Therefore, emergency medical services and other community-based strategies can play a vital role in broader postoverdose support, including follow-up, outreach, education, and linkage to care.37,38,39,40,41
The clinical characteristics of the Medicare cohort in this study underscore the importance of advancing efforts to integrate SUD, mental health, and physical health care services and supports. Many patients had co-occurring SUD and mental health conditions, acute and/or chronic pain, and multiple chronic conditions. Findings of this and other studies that demonstrate benefits associated with receiving treatment for co-occurring psychiatric disorders suggest the importance of these interventions.42 Medicare payment policy proposals were introduced recently to advance integrated and coordinated care for people with frequently co-occurring conditions.43
Limitations
This study population comprised Medicare FFS beneficiaries; thus, the findings might not generalize to other populations, including those with Medicaid, Medicare Advantage, and employer-sponsored insurance as well as uninsured individuals, among whom access to MOUD appears to vary systematically compared with consistent access to all 3 MOUDs in Medicare FFS.44,45 We relied on ICD-10-CM codes to identify nonfatal drug overdoses, clinical conditions, and provision of services; thus, the findings may underestimate nonfatal drug overdoses; clinical diagnoses, such as SUD, OUD, and psychiatric diagnoses; and services or medications that were not coded in the claims data. Consistent with other studies using claims data,7,8,37 we assumed that medications were used as dispensed. In addition, quality of mortality data is dependent on proper and thorough death investigation and accurate completion of death certificates, which can vary by state from year to year.46 Lethal drug overdoses occurred in a low percentage of people in this cohort. Because trying to estimate the occurrence of rare events at the individual level is difficult,47 population-based approaches that address the risk and protective factors identified in this analysis may be useful. Given the study’s observational nature, we cannot draw causal inferences from its findings.
Conclusions
This cohort study showed that, despite the association of MOUD with reduced risk of a fatal drug overdose, only a small percentage of Medicare beneficiaries received MOUD or filled a naloxone prescription in the 12 months after a nonfatal drug overdose. Efforts to improve the provision of life-saving behavioral health services; MOUD; and overdose-prevention strategies, such as prescribing naloxone in the ED and other health care settings as well as linking individuals to community-based practitioners for ongoing care, are urgently needed to address historically high rates of drug overdose in the US.
eTable 1. Definitions, National Drug Codes, Diagnosis Codes, and Procedure Codes Used for Defining Medication Utilization, Medically Treated Overdose, Fatal Drug Overdose, Behavioral Health Services, Condition Diagnoses
eTable 2. American Community Survey County-Level Measures
eTable 3. Characteristics Associated With Fatal Opioid-Involved Overdose Among Medicare Beneficiaries in the 12 Months After Experiencing a Nonfatal Overdose Involving Opioids
eTable 4. Characteristics Associated With Fatal Drug Overdose Among Medicare Beneficiaries in the 12 Months After Experiencing a Nonfatal Overdose: 1) Among the Sample With Those Who Died From Other Causes of Death Removed; 2) Only Among Those Who Are Dual Eligible; and 3) Only Among Those Who Are Eligible for Medicare Due to Disability
Data Sharing Statement
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Definitions, National Drug Codes, Diagnosis Codes, and Procedure Codes Used for Defining Medication Utilization, Medically Treated Overdose, Fatal Drug Overdose, Behavioral Health Services, Condition Diagnoses
eTable 2. American Community Survey County-Level Measures
eTable 3. Characteristics Associated With Fatal Opioid-Involved Overdose Among Medicare Beneficiaries in the 12 Months After Experiencing a Nonfatal Overdose Involving Opioids
eTable 4. Characteristics Associated With Fatal Drug Overdose Among Medicare Beneficiaries in the 12 Months After Experiencing a Nonfatal Overdose: 1) Among the Sample With Those Who Died From Other Causes of Death Removed; 2) Only Among Those Who Are Dual Eligible; and 3) Only Among Those Who Are Eligible for Medicare Due to Disability
Data Sharing Statement
