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The American Journal of Managed Care July 2019
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Heroin and Healthcare: Patient Characteristics and Healthcare Prior to Overdose
Michele K. Bohm, MPH; Lindsey Bridwell, MPH; Jon E. Zibbell, PhD; and Kun Zhang, PhD
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Heroin and Healthcare: Patient Characteristics and Healthcare Prior to Overdose

Michele K. Bohm, MPH; Lindsey Bridwell, MPH; Jon E. Zibbell, PhD; and Kun Zhang, PhD
An analysis of administrative claims showed increasing rates of heroin overdose among an insured population and opportunities for interventions during healthcare encounters before overdose.

Objectives: To estimate heroin overdose trends among insured individuals and characterize patients and healthcare utilization preceding overdose to inform scale-up of effective prevention and treatment.

Study Design: Retrospective descriptive analysis.

Methods: We analyzed 2010 to 2014 IBM MarketScan Databases and calculated annual heroin overdose rates. For a subset of patients, we describe their comorbidities, where they accessed health services, and select prescription histories prior to their first heroin overdose.

Results: Heroin overdose rates were much lower, but increased faster, among the commercially insured compared with Medicaid enrollees from 2010 to 2014 (270.0% vs 94.3%). By 2012, rates among the commercially insured aged 15 to 24 years reached the overall rates in the Medicaid population. All patients had healthcare encounters in the 6 months prior to their first heroin overdose; two-thirds of commercially insured patients had outpatient visits, whereas two-thirds of Medicaid patients had emergency department visits. One month prior to overdose, 24.5% of Medicaid and 8.6% of commercially insured patients had opioid prescriptions. Fewer Medicaid patients had buprenorphine prescriptions (17.8% vs 27.3%) despite similar rates of known substance-related disorders. A higher proportion of Medicaid patients had non–substance-related comorbidities.

Conclusions: Heroin overdose rates were persistently higher among the Medicaid population than the commercially insured, with the exception of those aged 15 to 24 years. Our findings on healthcare utilization, comorbidities, and where individuals access services could inform interventions at the point of care prior to a first heroin overdose. Outpatient settings are of particular importance for the growing cohort of young, commercially insured patients with opioid use disorders.

Am J Manag Care. 2019;25(7):341-347
Takeaway Points

Healthcare utilization patterns among insured patients who experience heroin overdose highlight opportunities for interventions before the first overdose, noting differences in patient characteristics and healthcare access points by insurance type.
  • Medicaid and commercial insurance pay for approximately half of heroin overdoses, and nearly all insured patients access healthcare services in the 6 months prior to overdose.
  • Outpatient interventions are important for the emerging cohort of young, commercially insured patients with opioid use disorder.
  • Many insured patients who experience heroin overdose have multiple comorbidities, emphasizing the importance of coordinated care, including mental health care, judicious opioid and benzodiazepine prescribing, medication-assisted treatment, provision of naloxone, and prevention of infectious disease transmission.
America’s opioid epidemic continues to grow. The negative health outcomes and healthcare costs associated with the epidemic are well documented,1 with opioid overdose fatalities making up the most acute and reliable measure. In 2014, the CDC reported the highest number of opioid overdose fatalities (28,647) during any previous year on record,2 only to report that this unprecedented number was surpassed with 47,600 opioid overdose deaths by 2017.3

Although the rising number of annual opioid overdose deaths indicates that the opioid epidemic has not yet peaked, the relative contribution of different drug types to the epidemic is changing. In 2015, the CDC reported that the heroin-involved overdose mortality rate was increasing more than overdose deaths involving commonly prescribed opioids (20.6% vs 2.5%).4 As heroin deaths approach the number of prescription opioid deaths, another challenge has emerged from illicitly manufactured fentanyl (IMF).5

The dynamic nature of the opioid overdose epidemic poses continuous challenges to prevention efforts.6 Despite the problem of polysubstance use among heroin users,7 demographic changes in opioid use patterns are also well documented. Younger patients have higher prevalence of heroin use disorders,8 and national reports identify that the largest increases in percentage of individuals with heroin use disorder from 2010 to 2014 are among those aged 18 to 25 years.9 National death data similarly show high heroin overdose rates among younger age groups.3,4 Heroin is frequently adulterated with IMF, and deaths involving synthetic opioids, such as fentanyl, are also highest among younger age groups.3-5

These studies of recent trends in heroin use and mortality are critically important for identifying at-risk groups. However, they do not provide essential information on the underlying patterns in healthcare utilization preceding an overdose or prior prescription opioid use—an important concern given the association between opioid use disorders involving prescription opioids and heroin.7 For this study, we aimed to characterize trends in heroin overdoses treated in healthcare settings for an insured population and to describe healthcare encounters before the overdose, including diagnoses and use of prescription opioids, benzodiazepines, and buprenorphine. Patients treated for heroin overdose in healthcare settings include those who survive the overdose, as well as those for whom the overdose was fatal. We used longitudinal patient-level and payer-specific data to explore these characteristics and identify whether opportunities for preoverdose interventions exist, given that interventions are frequently initiated when an overdose occurs but there may be opportunities to intervene further upstream. These aspects provide insight into the diverging trajectory of the heroin epidemic, including patients’ risk profiles beyond substance use disorders, and may contribute to a more effective prevention strategy.


Data Source

Data for Medicaid and commercially insured enrollees were analyzed separately for 2010 to 2014. We analyzed administrative claims data from IBM MarketScan Research Databases, which are derived from a convenience sample of commercially insured and Medicaid enrollees. Approximately half of the US population is covered by employer-sponsored commercial health plans,10 and the IBM MarketScan Commercial Databases capture data on more than a quarter of these individuals annually from every state in the United States. Approximately 20% of the US population is covered by Medicaid.11 The IBM MarketScan Multi-State Medicaid Databases are derived from 10 to 13 unidentified geographically dispersed states from each of the 4 Census regions, capturing both fee-for-service and managed care data. The numbers of enrollees in our sample for each study year are provided in Table 1. The IBM MarketScan Databases encompass the full continuum of healthcare, including inpatient, outpatient, and emergency department (ED) services, as well as prescriptions dispensed through retail pharmacies.

Of note, Medicaid and commercial health plans cover approximately half of all ED visits and admissions in the United States for heroin overdose (data not shown). Our analysis focuses on those who overdose on heroin and are insured, and we acknowledge that there may be differences between them and those who are uninsured. Although insured individuals who overdose on heroin are not representative of all who overdose on heroin, they are most likely to be affected by reforms in clinical practice and insurance oversight.

Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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