Abstract
This study uses Medicaid data to compare prescription opioid use, duration of opioid use, and rates of medication-assisted treatment (buprenorphine, methadone, or naltrexone) among enrollees before and after an overdose event.
For every fatal opioid overdose, there are approximately 30 nonfatal overdoses. Nonfatal overdoses that receive medical attention represent intervention opportunities for clinicians to mitigate risk by reducing opioid prescribing or advocating addiction treatment. Studies evaluating commercially insured patients suggest these potential interventions are underutilized. For example, a 2000-2012 study reported high rates of opioid prescribing for patients even after they had sustained a nonfatal opioid overdose. Another study of patients with opioid use disorder (OUD) showed low rates of buprenorphine treatment after hospitalization for overdose. However, little is known about how opioid prescribing and medication-assisted treatment (MAT) changes from before to after overdose among Medicaid enrollees, who have a 3-times higher risk of opioid overdose. We used data from a large Medicaid program to compare (1) prescription opioid use, (2) duration of opioid use, and (3) rates of MAT (buprenorphine, methadone, or naltrexone) among enrollees before and after an overdose event.
Methods
This study was deemed exempt by the University of Pittsburgh institutional review board. We conducted a retrospective cohort analysis using 2008-2013 claims data for all Pennsylvania Medicaid enrollees aged 12 to 64 years with a heroin or prescription opioid overdose who were identified using International Classification of Diseases, Ninth Revision, codes (965.00-965.02, 965.09, E.850.1-E.850.2) in inpatient, outpatient, and professional claims. We included patients with 6 months of continuous enrollment in Medicaid before and after the overdose claim (limiting our analyses to nonfatal opioid overdoses). We measured all nonparenteral prescription opioid use in pharmacy claims. We used Current Procedural Terminology codes (H0020, J1230) in professional claims to capture methadone dispensed for OUD in an opioid treatment program (as opposed to prescriptions for pain management). We used National Drug Codes in pharmacy claims to identify OUD-approved buprenorphine and naltrexone. We used a logistic regression model with generalized estimating equations for correlated data to estimate differences from before to after overdose in prescription opioid use (any use and receipt of ≥90 cumulative days duration) and differences in receiving MAT (overall and each medication separately). Analyses were stratified by overdose type (prescription opioid vs heroin) and conducted using SAS (SAS Institute), version 9.4, and STATA (StataCorp), version 14. We considered 2-sided P values less than .05 to be statistically significant and reported 95% CIs for differences of proportions.
Results
Of the 13 670 patients with an overdose event, 6013 (44%) were continuously enrolled 6 months before and after overdose (2068 with a heroin overdose and 3945 with a prescription opioid overdose). Among enrollees with a heroin overdose or a prescription opioid overdose, the mean ages were 32.6 years and 35.5 years; 48.4% and 61.6% were female; and 82.7% and 50.9% had a OUD diagnosis, respectively (Table 1). Any filled opioid prescription decreased after overdose from 43.2% to 39.7% after heroin overdose (difference, −3.5 percentage points [95% CI, −5.9 to −1.1], P = .005), and from 66.1% before to 59.6% after prescription opioid overdose (difference, −6.5 percentage points [95% CI −8.0 to −5.0], P < .001) (Table 2). The percentage of enrollees with 90 days or more duration of prescription opioids decreased in the heroin group (from 10.5% to 9.0%; difference, −1.5 percentage points [95% CI, −2.7 to −0.3], P = .01) and the prescription opioid group (from 32.5% to 28.3%; difference, −4.1 percentage points [95% CI −5.3 to −3.0], P < .001). MAT increased after heroin overdose from 29.5% to 33.0% (difference, 3.6 percentage points [95% CI, 1.4 to 5.8], P = .002) and after prescription opioid overdose from 13.5% to 15.1% (difference, 1.6 percentage points [95% CI, 0.7 to 2.5], P = .001).
Table 1. Characteristics of Patients With Heroin or Prescription Opioid Overdose Events, 2008-2013.
| Heroin Overdose, No. (%) (n = 2068)a |
Prescription Opioid Overdose, No. (%) (n = 3945)a |
|
|---|---|---|
| Age, mean (SD), y | 32.6 (10.8) | 35.5 (12.4) |
| 12-17 | 37 (1.8) | 251 (6.4) |
| 18-29 | 981 (47.4) | 1210 (30.7) |
| 30-39 | 503 (24.3) | 950 (24.1) |
| 40-49 | 338 (16.3) | 880 (22.3) |
| 50-64 | 209 (10.1) | 654 (16.6) |
| Female | 1001 (48.4) | 2431 (61.6) |
| Race/ethnicityb | ||
| White | 1677 (81.1) | 2958 (75.0) |
| Black | 184 (8.9) | 677 (17.2) |
| Hispanic | 164 (7.9) | 220 (5.6) |
| Other | 43 (2.1) | 90 (2.3) |
| Type of eligibility | ||
| Supplemental Security Income | 374 (18.1) | 1042 (26.4) |
| Temporary Assistance for Needy Families | 464 (22.4) | 979 (24.8) |
| General Assistance | 635 (30.7) | 713 (18.1) |
| Other | 595 (28.8) | 1211 (30.7) |
| Opioid use disorder diagnosis | 1710 (82.7) | 2009 (50.9) |
Includes enrollees with an overdose event receiving medical attention for which International Classification of Diseases, Ninth Revision, codes (965.00-965.02, 965.09, E.850.1, E.850.2) were recorded. Enrollees with 6 months of continuous enrollment before and after the overdose event were included.
Race/ethnicity was self-identified at the time of Medicaid enrollment based on categories defined by Medicaid. Race/ethnicity was assessed in this study because previous literature shows racial/ethnic differences in outcomes (opioid use and overdose).
Table 2. Medication Use Patterns Before and After Heroin or Opioid Overdose Events, 2008-2013.
| Characteristics | Heroin Overdose (n = 2068)a | Prescription Opioid Overdose (n = 3945) | ||||||
|---|---|---|---|---|---|---|---|---|
| Before Overdose, No. of Patients (%) | After Overdose, No. of Patients (%)a | Estimated Difference (95% CI), Percentage Pointsb | P Value | Before Overdose, No. of Patients (%) | After Overdose, No. of Patients (%) | Estimated Difference (95% CI), Percentage Pointsb | P Value | |
| Any prescription opioid use | 894 (43.2) | 822 (39.7) | −3.5 (−5.9 to −1.1) | .005 | 2609 (66.1) | 2353 (59.6) | −6.5 (−8.0 to −5.0) | <.001 |
| Prescription opioid duration ≥90 d | 218 (10.5) | 187 (9.0) | −1.5 (−2.7 to −0.3) | .01 | 1280 (32.4) | 1117 (28.3) | −4.1 (−5.3 to −3.0) | <.001 |
| Any medication-assisted treatmentc | 609 (29.4) | 683 (33.0) | 3.6 (1.4 to 5.8) | .002 | 531 (13.5) | 594 (15.1) | 1.6 (0.7 to 2.5) | .001 |
| Buprenorphine | 397 (19.2) | 419 (20.3) | 1.1 (−0.8 to 2.9) | .27 | 215 (5.4) | 265 (6.7) | 1.3 (0.5 to 2.0) | .001 |
| Methadone | 215 (10.4) | 261 (12.6) | 2.2 (0.7 to 3.8) | .005 | 324 (8.2) | 328 (8.3) | 0.1 (−0.5 to 0.7) | .75 |
| Naltrexone | 49 (2.4) | 61 (3.0) | 0.6 (−0.2 to 1.4) | .16 | 17 (0.4) | 31 (0.8) | 0.4 (0.0 to 0.7) | .04 |
Includes enrollees with an overdose event receiving medical attention for which International Classification of Diseases, Ninth Revision, codes (965.00-965.02, 965.09, E.850.1, E.850.2) were recorded. Enrollees with 6 months of continuous enrollment before and after the overdose event were included. Among enrollees with more than 1 overdose event during the 6-year study period, only the first overdose in this sample was included.
The differences in before to after overdose measurements were estimated using a logistic regression model that accounted for correlated data.
Medication-assisted treatment was measured using medical claims (for methadone) and pharmacy claims (for buprenorphine and naltrexone). Patients could use more than 1 medication-assisted treatment.
Discussion
Despite receiving medical attention for an overdose, these patients in Pennsylvania Medicaid continued to have persistently high prescription opioid use, with only slight increases in MAT engagement, signaling a relatively weak health system response to a life-threatening event. Several interventions have been shown to reduce overdose risk, including trigger notifications to clinicians for patients treated for overdose and emergency department–initiated naloxone education and distribution. Study limitations include the focus on 1 state, more stable Medicaid coverage due to the continuous enrollment criteria, and use of claims data, which only track overdoses receiving medical attention, may have limited sensitivity to detect overdoses, and may underestimate opioid use by only tracking prescriptions filled.
Section Editor: Jody W. Zylke, MD, Deputy Editor.
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