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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.
The association between poorer overall health and higher opioid utilization emphasizes the need for clinicians to coordinate care and adopt evidence-based prescribing practices. Judicious opioid prescribing, in accordance with the CDC Guideline for Prescribing Opioids for Chronic Pain,22 would be warranted among our high-risk study group, many of whom had documented histories of substance use disorders. In addition to monitoring illicit drug use, clinicians can use prescription drug monitoring data to check if patients have overlapping opioid and/or benzodiazepine prescriptions. The concurrent use of opioids and benzodiazepines should be avoided per the FDA’s new warnings.22-25

Although nearly half of all patients who overdosed on heroin in this study were previously diagnosed with substance-related disorders, relatively few had prescriptions for buprenorphine, 1 of the 3 medications used in medication-assisted treatment (MAT) for opioid use disorder. These low proportions, especially among Medicaid patients, signal opportunities for improving access to this therapy and potentially preventing overdose. Research has shown that MAT can be effective in the treatment of opioid use disorder and can reduce healthcare utilization.26

Screening and treatment for hepatitis C and HIV is of particular importance for all patients using heroin. Many individuals who report heroin use inject the drug,27 which carries considerable risk for the transmission of bloodborne diseases through needle sharing. In accordance with recommendations from the CDC,28 those who inject drugs should be tested for HIV and hepatitis and vaccinated against viral hepatitis B if not immune. Access to comprehensive syringe services programs is also crucial for individuals who use heroin to mitigate risk of overdose and of bloodborne pathogen transmission. Although a nearly 3-fold greater proportion of the Medicaid population had diagnosed hepatitis (16.8% vs 6.1%), many hepatitis B and C infections remain undiagnosed in the United States. The emerging cohort of young, commercially insured patients with high heroin overdose rates warrants further investigation to determine whether they have hepatitis or other infectious disease rates more similar to the Medicaid population.

Limitations

There are limitations to consider with regard to our results. First, the study may have yielded different results if the analyses were not restricted to the continuously enrolled population. For example, “churning” is common among Medicaid enrollees, whereby individuals fluctuate between states of eligibility and ineligibility, resulting in sporadic coverage.29 It is known that continuously enrolled patients are more likely to have chronic conditions.30-32 A second limitation is the potential effect resulting from Medicaid expansion under the Affordable Care Act. In 2013, rates of substance use disorders among currently uninsured Medicaid-eligible individuals were found to be slightly higher than the rates among current Medicaid enrollees.33 Because we excluded newly eligible Medicaid enrollees, the rates of heroin overdose in our study are likely conservative. A third limitation is that variability in coding practices means that the opioid overdoses we identified could potentially include some heroin overdoses. However, Green et al found high positive predictive values for opioid and heroin overdose codes.12 Fourth, results are not nationally representative and should be interpreted with caution. Finally, due to the nature of claims data, heroin overdoses that did not involve transport to a medical facility, including fatal overdoses, may not have been captured.

CONCLUSIONS

Medicaid and private insurance pay for nearly half of heroin overdoses in the United States. Healthcare encounters for heroin overdose increased significantly from 2010 to 2014 for these groups. Rates among Medicaid enrollees were higher, yet rates increased faster among the commercially insured. Healthcare utilization patterns among insured patients who overdose on heroin suggest that opportunities exist for interventions at the point of care prior to the first overdose. We noted differences in where patients accessed care by insurance coverage type, which can inform targeted and tailored prevention efforts. Outpatient settings are of particular importance for the emerging cohort of young, commercially insured patients aged 15 to 24 years with opioid use disorder. Moreover, many patients in our study had multiple comorbidities in addition to known substance use disorders. This emphasizes the importance of coordinated care for all underlying conditions, judicious prescribing practices in accordance with the CDC’s guideline, referral to or induction on MAT, provision of naloxone, and screening and referral to treatment and prevention resources for viral hepatitis and HIV.

Author Affiliations: Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC (MKB, KZ), Atlanta, GA; Booz Allen Hamilton (LB), Atlanta, GA; Behavioral and Urban Health Program, RTI International (JEZ), Atlanta, GA.

Source of Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the CDC.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (MKB, JEZ, KZ); acquisition of data (MKB); analysis and interpretation of data (MKB, LB, JEZ, KZ); drafting of the manuscript (MKB, LB, JEZ, KZ); critical revision of the manuscript for important intellectual content (MKB, LB, JEZ, KZ); statistical analysis (MKB); administrative, technical, or logistic support (MKB, LB); and supervision (MKB).

Address Correspondence to: Michele K. Bohm, MPH, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC, 4770 Buford Hwy NE, Mailstop F62, Atlanta, GA 30341-3717. Email: mbohm@cdc.gov.
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