An analysis of Medicaid data from 2001–2007 paints a picture of missed opportunity in offering more comprehensive care that might have averted numerous opioid-related deaths. While the study’s lead author acknowledges that the study period predates a fentanyl crisis that has since changed the face of the opioid overdose threat, he believes some trends seen in the study, such as overdose risk among chronic pain patients recently initiating prescription opioids, remain prominent today.

Commenting on a key takeaway from this research, Mark Olfson, M.D., M.P.H., professor of psychiatry at Columbia University Medical Center, told ADAW, “It’s clear that the great majority of people are presenting for care in the months preceding their death.”

Published online Nov. 28 in the American Journal of Psychiatry, the study points to several factors that could have contributed to the heightened overdose risk in the Medicaid population, from the presence of dangerous prescription combinations of opioids and benzodiazepines to an overall absence of care integration between addiction service providers and other health professionals.

Olfson also points out, however, that there can be too narrow a focus on data around fatal overdose. He says analyses that are now underway, using the same data set, are examining patients who experienced a nonfatal overdose in order to identify prominent risk factors for later death from overdose or other causes.

Details of study

The study sought to outline health service utilization among Medicaid beneficiaries — a group at high risk of death from opioid overdose — in the month and year prior to an opioid-related death. Data from 45 states covering the 2001–2007 period were examined, with the research team looking only at individuals ages 64 and under at the time of death. The drugs contributing to the deaths that were examined in the analysis included heroin, prescription opioids, other natural and semisynthetic opioids, and synthetic opioids other than methadone.

The researchers compared outpatient service visit patterns and alcohol and drug use disorder diagnoses between individuals with and without chronic pain not associated with cancer. They also looked at pharmacy claims data for filled prescriptions for opioids, benzodiazepines, antidepressants, antipsychotics and mood stabilizers in the month and year before death.

The researchers identified 13,089 opioid-related deaths in the data set, with most victims being non-Hispanic whites between the ages of 35 and 54. While 42.2 percent of the victims had been diagnosed with a substance use disorder in the 12 months preceding their death, only 12.3 percent received such a diagnosis in the last month of life, and only 4.2 percent received an opioid use disorder diagnosis. Many of the overdose victims were engaging in polysubstance use, Olfson said.

Around two-thirds of the fatal overdose victims filled an opioid prescription during the last 12 months of their life, and around half filled prescriptions for both an opioid and a benzodiazepine. More than one-third of the victims filled an opioid prescription in the last month of life. Study authors wrote that “those with chronic pain diagnoses were significantly more likely to fill prescriptions for opioids, benzodiazepines, and both opioids and benzodiazepines, as well as antidepressants, antipsychotics and mood stabilizers during both time periods.”

The researchers also found that in the 12 months prior to death, 8.1 percent of fatal overdose victims with a chronic pain diagnosis experienced a nonfatal opioid overdose. Those numbers make it clear that while it is important to identify treatment opportunities for overdose survivors, doing that alone will not have a far-enough reach across the population of at-risk individuals.

The prevalence of substance use disorder diagnoses and filled prescriptions in the population with chronic pain “may provide opportunities for detection of overdose risk and early intervention,” Olfson and colleagues wrote. They added that the clinical management of chronic pain should incorporate a detailed mental health history and periodic assessments to mitigate potential risk of opioid overdose.

The researchers added that it appeared from the data that most victims who had received a substance use disorder diagnosis in the month prior to death had received no substance use services in the last 30 days of life. It was beyond the scope of this analysis to determine whether that lack of services was more of a reflection of coverage and access deficiencies or other barriers to care.

The researchers cited as a limitation of the study the fact that the data are from a period before fentanyl and its analogs altered patterns in opioid-related deaths. Olfson acknowledges that pain-related deaths likely were more prominent during the 2000–2007 period than they would be when looking at current data, which would reflect a rising number of deaths from heroin and synthetics.

More comprehensive care

Olfson says that based on the morbidity and mortality risks that the population with chronic pain faces, the linking of electronic records to allow for closer communication among health providers (which has been happening in more health systems) could serve to benefit these patients. He said the magnitude of the difference between health care usage patterns for persons with and without chronic pain in the study was somewhat surprising.

He now is examining data for individuals in this Medicaid data set who survived an opioid overdose, in order to attempt to identify risk factors for later death from overdose or other causes. “Many of these patients have other medical vulnerabilities,” said Olfson.

He also hopes to be able, as part of this overall work, to analyze similar but more recent data that would reflect more timely trends.

Bottom Line…

Medicaid data from 2001–2007 illustrate the need for more coordinated care to avert risk of fatal opioid overdose, especially in the subpopulation with a chronic pain diagnosis.