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The American Journal of Managed Care July 2019
Changing Demographics Among Populations Prescribed HCV Treatment, 2013-2017
Naoky Tsai, MD; Bruce Bacon, MD; Michael Curry, MD; Steven L. Flamm, MD; Scott Milligan, PhD; Nicole Wick, AS; Zobair Younossi, MD; and Nezam Afdhal, MD
Precision Medicines Need Precision Patient Assistance Programs
A. Mark Fendrick, MD; and Jason D. Buxbaum, MHSA
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Robert W. Dubois, MD, PhD
Real-Time Video Detection of Falls in Dementia Care Facility and Reduced Emergency Care
Glen L. Xiong, MD; Eleonore Bayen, MD, PhD; Shirley Nickels, BS; Raghav Subramaniam, MS, BS; Pulkit Agrawal, PhD; Julien Jacquemot, MSc, BSc; Alexandre M. Bayen, PhD; Bruce Miller, MD; and George Netscher, MS, BS
Impact of a Co-pay Accumulator Adjustment Program on Specialty Drug Adherence
Bruce W. Sherman, MD; Andrew J. Epstein, PhD; Brian Meissner, PharmD, PhD; and Manish Mittal, 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
Number of Manufacturers and Generic Drug Pricing From 2005 to 2017
Inmaculada Hernandez, PharmD, PhD; Chester B. Good, MD, MPH; Walid F. Gellad, MD, MPH; Natasha Parekh, MD, MS; Meiqi He, MS; and William H. Shrank, MD, MSHS
Insurers’ Perspectives on MA Value-Based Insurance Design Model
Dmitry Khodyakov, PhD; Christine Buttorff, PhD; Kathryn Bouskill, PhD; Courtney Armstrong, MPH; Sai Ma, PhD; Erin Audrey Taylor, PhD; and Christine Eibner, PhD
Healthcare Network Analysis of Patients With Diabetes and Their Physicians
James Davis, PhD; Eunjung Lim, PhD; Deborah A. Taira, ScD; and John Chen, PhD
What Are the Potential Savings From Steering Patients to Lower-Priced Providers? A Static Analysis
Sunita M. Desai, PhD; Laura A. Hatfield, PhD; Andrew L. Hicks, MS; Michael E. Chernew, PhD; Ateev Mehrotra, MD, MPH; and Anna D. Sinaiko, PhD, MPP
Physician Satisfaction With Health Plans: Results From a National Survey
Natasha Parekh, MD, MS; Sheryl Savage; Amy Helwig, MD, MS; Patrick Alger, BS; Ilinca D. Metes, BS; Sandra McAnallen, MA, BSN; and William H. Shrank, MD, MSHS
Evaluation of Interdisciplinary Geriatric Transitions of Care on Readmission Rates
Nada M. Farhat, PharmD; Sarah E. Vordenberg, PharmD, MPH; Vincent D. Marshall, MS; Theodore T. Suh, MD, PhD, MHS; and Tami L. Remington, PharmD

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.
Healthcare Utilization, Prescriptions, and Diagnoses Prior to Overdose

Nearly all enrollees with heroin overdose had at least 1 healthcare encounter in the 6 months prior to their first overdose, including approximately 1 in 4 having an inpatient admission (Table 213). A higher proportion of commercially insured (64.7%) than Medicaid (36.6%) patients had outpatient visits, whereas the opposite was true for ED visits (35.5% vs 62.1%). A consistently higher proportion of Medicaid patients were prescribed opioids prior to their heroin overdose. For instance, within 1 month of the overdose, 24.5% of Medicaid patients and 8.6% of commercially insured patients had prescriptions for opioids, which is a nearly 3-fold difference. Additionally, a higher proportion of Medicaid patients were prescribed benzodiazepines. Specifically, 29.0% of Medicaid and 14.5% of commercially insured patients received benzodiazepine prescriptions within 1 month of the overdose. More enrollees on Medicaid (14.5% vs 3.9%) were also prescribed both benzodiazepines and opioids within 1 month of overdose. Prescriptions for buprenorphine indicated for the treatment of opioid use disorder were prescribed less frequently for Medicaid patients than commercially insured patients (17.8% vs 27.3%) preceding the overdose.

Table 213 lists the categories of diagnoses received by patients in the 6 months prior to their heroin overdose. Similar proportions of both Medicaid and commercially insured populations were diagnosed with substance-related disorders other than alcohol and tobacco (approximately 49%) (see eAppendix for codes for opioid overdose and substance-related disorders) and with alcohol-related disorders specifically (approximately 14%). However, for all other diagnoses, the proportion receiving the diagnosis was higher among the Medicaid than commercially insured patients. Notably, there were approximately 3-fold higher proportions of Medicaid patients than commercially insured patients with diagnoses of nonspecific chest pain, other nervous system disorders, and hepatitis (all forms of viral hepatitis and chronic hepatitis associated with liver disease and cirrhosis).


We found increasing trends in heroin overdose rates that reflect previously reported increases in heroin use and heroin-related overdose deaths.7,14 During the study period of 2010 to 2014, opioid (other than heroin) overdose rates remained stable, whereas heroin overdose rates increased steadily among most demographic groups year to year; however, we acknowledge that these increases were relative to initially small heroin overdose rates. Our findings that men, young adults, and Medicaid enrollees had the highest rates of heroin overdose are consistent with prior research.3,7-9 Our inclusion of nonfatal overdoses and demographic stratifications by payer type provide additional insight into the trajectory of the heroin epidemic. Among the commercially insured population, the highest heroin overdose rates were among those aged 15 to 24 years. During 2012 to 2014, this is the only age group among the commercially insured whose rates were similar to those of their Medicaid counterparts and the overall rates among the Medicaid population. This may represent an emerging cohort of commercially insured individuals with high prevalence of heroin use. In comparison, the same age group with Medicaid insurance had the lowest heroin overdose rates among all Medicaid age groups in every year. All other Medicaid age groups (ages 25-64 years) had consistently high heroin overdose rates, signaling persistent substance use disorder prevalence.15,16 Although rates of heroin overdose are currently lower among the commercially insured, their numbers may account for a substantial burden from heroin overdose given that more than half of the US population is covered by employer-sponsored commercial health plans.10

Healthcare utilization patterns prior to heroin overdoses indicate that nearly all enrollees had at least 1 healthcare encounter (all diagnoses) in the 6 months prior to their first overdose; the majority of commercially insured patients (64.7%) received healthcare through outpatient visits, whereas most Medicaid patients (62.1%) accessed the ED. This is consistent with what we know about insurance type and healthcare access in general.17 Healthcare utilization patterns prior to heroin overdoses confirm that these high-risk insured patients are not “lost to follow-up” or absent from healthcare settings. This emphasizes the importance of the healthcare system’s role in preventing overdoses by offering brief interventions, coordinating medical and mental health services, and linking patients to appropriate care, such as substance use disorder treatment. Differences in patient healthcare utilization patterns based on payer type have implications for prevention efforts aimed at those at risk for heroin overdose. This knowledge allows for the development of targeted evidence-based strategies specific to the healthcare settings where these populations are most likely to access care. Although EDs are frequent sites of interventions related to substance use disorders, outpatient settings could be explored to better target young, commercially insured patients at risk for overdose.

Prescribing patterns prior to overdose show that opioid prescribing was higher among the Medicaid population, which could be related to high rates of comorbidities known to cause pain. A greater proportion of Medicaid patients had diagnoses of mood, anxiety, or nervous system disorders; connective tissue disease; joint disorders; back problems; lower respiratory diseases; and hepatitis. High prevalence of comorbidities in our population is consistent with Medicaid populations in general, but nonetheless underscores the importance of screening to ensure that all underlying conditions are appropriately treated. Given that the highest heroin overdose rate in the commercially insured population was among those aged 15 to 24 years, the finding of a relatively lower proportion of commercially insured with opioid prescriptions could be due to adolescents and young adults being more likely than other age groups to obtain prescription opioids from a friend or relative.18 Another explanation could relate to individuals now more frequently reporting heroin as their opioid of initiation.19 Additionally, a higher proportion of the Medicaid population received both opioid and benzodiazepine prescriptions prior to heroin overdose. We found higher benzodiazepine prescribing than opioid prescribing, which is the opposite of what is true for opioid and benzodiazepine prescribing prevalence in the general population20,21 and likely reflects more mental health conditions in our study population.

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