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Heroin and Healthcare: Patient Characteristics and Healthcare Prior to Overdose
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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.

IBM MarketScan provides access to data on enrollees who have prescription drug coverage. All analyses were restricted to enrollees aged 15 to 64 years, as there are few heroin overdoses in younger adolescents and children, and the number of enrollees 65 years or older drops off considerably as they transition to Medicare. When calculating annual rates, we included only individuals continuously enrolled throughout a given calendar year. For 2014 Medicaid data, we included only individuals who were continuously enrolled in both 2013 and 2014. This kept our sample consistent by reducing the impact of a large increase in MarketScan Medicaid enrollees in 2014 due in part to Medicaid expansion under the Affordable Care Act.

Measures and Analyses

Overdose rates. Within each calendar year, we identified enrollees with at least 1 inpatient, outpatient, or ED claim with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis of 965.01 (poisoning by heroin) or E850.0 (accidental poisoning by heroin). We then stratified our study population by gender and age categories to calculate heroin overdose rates by demographic characteristics. Distinct from the diagnostic codes for heroin overdose, we also calculated opioid (other than heroin) overdose rates (eAppendix [available at]) for each year to compare with heroin overdose trends. In 2017, Green et al reported that ICD-9-CM codes for opioid-related poisoning had a very high predictive value, suggesting that they can be used to monitor overdose rates.12

Healthcare utilization, prescriptions, and diagnoses prior to overdose. We next conducted additional analyses on a subset of patients experiencing heroin overdose. We examined diagnoses, healthcare utilization, and select controlled substance prescriptions among patients experiencing heroin overdose who had 18 months of continuous enrollment prior to their first heroin overdose in the study period. Eighteen months provided a retrospective period with no heroin overdose, such that the index heroin overdose event we examined was regarded as the “first heroin overdose” for our study purposes. We had access to data from 2009 but not 2008, so we excluded patients with a heroin overdose occurring in the first 6 months of 2010.

We then assessed the proportion of patients with at least 1 ED visit, inpatient admission, or outpatient visit in the 6 months prior to the impending overdose to highlight opportunities for screening, intervention, or referral during such encounters. Encounters in the 14 days prior to the overdose were not considered to avoid capturing claims that may have been related to the first heroin overdose and to focus on missed opportunities that would have allowed a reasonable amount of time for intervention prior to the index event. We also determined the proportion of patients filling a prescription for buprenorphine indicated for the treatment of opioid use disorder anytime up to 3 days before the overdose. We next determined the proportion of patients with prescriptions for opioids in the 6 months, 3 months, and 1 month prior to the overdose, and repeated this for benzodiazepines. Lastly, we identified common diagnoses in the 6 months prior to the heroin overdose using categories from the Healthcare Cost and Utilization Project Clinical Classifications Software for ICD-9-CM.13 Diagnoses included those received in the course of inpatient admissions or during outpatient or ED visits.


Overdose Rates

Heroin overdose rates were lower than opioid (other than heroin) overdose rates but increased over time. We observed much higher heroin overdose rates among the Medicaid population compared with the commercially insured population, but rates increased faster among the commercially insured from 2010 to 2014 (Table 1). Heroin overdose rates increased 270.0% among the commercially insured—from 1.9 to 7.1 per 100,000 enrollees—during the study period. Among the Medicaid population, these rates increased 94.3% during the same time period—from 15.7 to 30.5 per 100,000 enrollees. In contrast, opioid (other than heroin) overdose rates remained fairly stable, although much higher than heroin overdose rates.

Heroin overdose rates were consistently higher among male than female enrollees, irrespective of health insurance type. In 2014, the rates of heroin overdose among male and female enrollees were 10.5 and 4.1 per 100,000 commercial enrollees, respectively, and 34.9 and 28.0 per 100,000 Medicaid enrollees, respectively. The highest heroin overdose rates among the commercially insured were in the youngest age group—those aged 15 to 24 years (30.3 per 100,000 in 2014)—whereas among the Medicaid population, this age group had the lowest rates (14.0 per 100,000 in 2014). In 2012, heroin overdose rates among the commercially insured aged 15 to 24 years were similar to the overall rates of heroin overdose in the Medicaid population. Among the commercially insured, heroin overdose rates declined as age category increased, whereas rates remained steady among Medicaid enrollees aged 35 to 64 years.

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