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Austin AE, DePadilla L, Niolon P, Stone D, Bacon S. Intersection of adverse childhood experiences, suicide and overdose prevention. Inj Prev 2024:ip-2024-045295. [PMID: 39053926 DOI: 10.1136/ip-2024-045295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 07/11/2024] [Indexed: 07/27/2024]
Abstract
Adverse childhood experiences (ACEs), suicide and overdose are linked across the life course and across generations and share common individual-, interpersonal-, community- and societal-level risk factors. The purpose of this review is to summarise the shared aetiology of these public health issues, synthesise evidence regarding potential community- and societal-level prevention strategies and discuss future research and practice directions.Growing evidence shows the potential for community- and societal-level programmes and policies, including higher minimum wage; expanded Medicaid eligibility; increased earned income tax credits, child tax credits and temporary assistance for needy families benefits; Paid Family Leave; greater availability of affordable housing and rental assistance; and increased participation in the Supplemental Nutrition Assistance Program (SNAP), to contribute to ACEs, suicide and overdose prevention. Considerations for future prevention efforts include (1) expanding the evidence base through rigorous research and evaluation; (2) assessing the implications of prevention strategies for equity; (3) incorporating a relational health perspective; (4) enhancing community capacity to implement, scale and sustain evidenced-informed prevention strategies; and (5) acknowledging that community- and societal-level prevention strategies are longer-term strategies.
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Affiliation(s)
- Anna E Austin
- Centers for Disease Control and Prevention National Center for Injury Prevention and Control, Atlanta, Georgia, USA
| | | | - Phyllis Niolon
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Sarah Bacon
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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2
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Powell D. Educational Attainment and US Drug Overdose Deaths. JAMA HEALTH FORUM 2023; 4:e233274. [PMID: 37801307 PMCID: PMC10559184 DOI: 10.1001/jamahealthforum.2023.3274] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/02/2023] [Indexed: 10/07/2023] Open
Abstract
Importance Educational attainment in the US is associated with life expectancy. As the opioid crisis worsens, it is critical to understand how overdose death rate trends evolve across education groups. Objective To investigate the association between educational attainment and overdose death rates, with emphasis on trends during the COVID-19 pandemic. Design, Setting, and Participants This cross-sectional study used National Vital Statistics System Mortality Multiple Cause-of-Death data describing overdose death rates in the US by educational attainment from January 1, 2000, to December 31, 2021, with a focus on 2018 to 2021. Overdose deaths were aggregated by year and educational level for decedents aged 25 years or older. Exposure Educational attainment, categorized as no high school (HS) diploma, HS diploma (or General Educational Development) but no college, some college but no bachelor's degree, and bachelor's degree or more. Main Outcomes and Measures The main outcomes were rates of all overdose deaths, overdose deaths involving opioids, and overdose deaths involving synthetic opioids. Results Of 912 057 overdose deaths with education information from 2000 to 2021 (mean [SD] age at death, 44.9 [12.3] years; 64.1% male), there were 625 400 deaths (68.6%) among individuals with no college education and 286 657 deaths (31.4%) among those with at least some college. The overdose death rate was 19.9 per 100 000 population. From 2018 to 2021, there were 301 557 overdose deaths, including 58 319 (19.3%) among individuals without an HS diploma, 153 603 (50.9%) among people with an HS diploma, 64 682 (21.4%) among individuals with some college, and 24 953 (8.3%) among individuals with a bachelor's degree. There were 3324 overdose deaths (1.1%) among American Indian or Alaska Native individuals, 2968 (1.0%) among Asian American or Pacific Islander individuals, 49 152 (16.3%) among Black individuals, 31 703 (10.5%) among Hispanic individuals, 211 359 (70.1%) among White individuals, and 3051 (1.0%) among multiracial individuals. From 2018 to 2021, the overdose death rate was 33.4 per 100 000 population, the opioid-related overdose death rate was 24.2 per 100 000 population, and the synthetic opioid overdose death rate was 19.1 per 100 000 population. From 2018 to 2021, the overdose death rate for those without a HS diploma increased by 35.4 per 100 000 population compared with 1.5 per 100 000 population for those with a bachelor's degree. This differential growth was primarily due to increased rates of death involving synthetic opioids. Conclusions and Relevance In this cross-sectional study, lower educational attainment was found to be associated with higher growth in overdose deaths. As the opioid crisis has transitioned to fentanyl and polysubstance use, overdose deaths have become more prevalent in groups with lower socioeconomic status, potentially exacerbating existing life-expectancy disparities.
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3
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Farago F, Blue TR, Smith LR, Witte JC, Gordon M, Taxman FS. Medication-Assisted Treatment in Problem-solving Courts: A National Survey of State and Local Court Coordinators. JOURNAL OF DRUG ISSUES 2023; 53:296-320. [PMID: 38179102 PMCID: PMC10766435 DOI: 10.1177/00220426221109948] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
Problem-solving courts (PSCs) are a critical part of a societal effort to mitigate the opioid epidemic's devastating consequences. This paper reports on a national survey of PSCs (N = 42 state-wide court coordinators; N = 849 local court coordinators) and examines the structural factors that could explain the likelihood of a local PSC authorizing medication-assisted treatment (MAT) and MAT utilization. Results of the analyses indicate that MAT availability at the county level was a significant predictor of the likelihood of local courts authorizing MAT. The court's location in a Medicaid expansion state was also a significant predictor of local courts allowing buprenorphine and methadone, but not naltrexone. Problem-solving courts are in the early stages of supporting the use of medications, even when funding is available through Medicaid expansion policies. Adoption and use of treatment innovations like MAT are affected by coordinators' perceptions of MAT as well as structural factors such as the availability of the medications in the community and funding resources. The study has important implications for researchers, policymakers, and practitioners.
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Affiliation(s)
- Fanni Farago
- Department of Sociology and Anthropology, George Mason
University, Fairfax, VA, USA
| | | | - Lindsay Renee Smith
- Schar School of Policy and Government, Center for Advancing
Correctional Excellence, George Mason University, Fairfax, VA, USA
| | - James C. Witte
- Department of Sociology and Anthropology, George Mason
University, Fairfax, VA, USA
| | | | - Faye S. Taxman
- Schar School of Policy and Government, Center for Advancing
Correctional Excellence, George Mason University, Fairfax, VA, USA
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Alpert A, Evans WN, Lieber EMJ, Powell D. ORIGINS OF THE OPIOID CRISIS AND ITS ENDURING IMPACTS. THE QUARTERLY JOURNAL OF ECONOMICS 2022; 137:1139-1179. [PMID: 35832727 PMCID: PMC9272388 DOI: 10.1093/qje/qjab043] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Overdose deaths involving opioids have increased dramatically since the 1990s, leading to the worst drug overdose epidemic in U.S. history, but there is limited empirical evidence about the initial causes. In this article, we examine the role of the 1996 introduction and marketing of OxyContin as a potential leading cause of the opioid crisis. We leverage cross-state variation in exposure to OxyContin's introduction due to a state policy that substantially limited the drug's early entry and marketing in select states. Recently unsealed court documents involving Purdue Pharma show that state-based triplicate prescription programs posed a major obstacle to sales of OxyContin and suggest that less marketing was targeted to states with these programs. We find that OxyContin distribution was more than 50% lower in "triplicate states" in the years after the drug's launch. Although triplicate states had higher rates of overdose deaths prior to 1996, this relationship flipped shortly after the launch and triplicate states saw substantially slower growth in overdose deaths, continuing even 20 years after OxyContin's introduction. Our results show that the introduction and marketing of OxyContin explain a substantial share of overdose deaths over the past two decades.
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Affiliation(s)
- Abby Alpert
- University of Pennsylvania and National Bureau of Economic Research, United States
| | - William N Evans
- University of Notre Dame, National Bureau of Economic Research, and Abdul Latif Jameel Poverty Action Lab, United States
| | - Ethan M J Lieber
- University of Notre Dame and National Bureau of Economic Research, United States
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5
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Auty SG, Griffith KN. Medicaid expansion and drug overdose mortality during the COVID-19 pandemic in the United States. Drug Alcohol Depend 2022; 232:109340. [PMID: 35131533 PMCID: PMC8809643 DOI: 10.1016/j.drugalcdep.2022.109340] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The COVID-19 pandemic caused disruptions in the delivery of health services, which may have adversely affected access to substance use disorder (SUD) treatment services. Medicaid expansion has been previously associated with increased access to SUD services for low-income adults. Thus, the pandemic may have differentially impacted overdose mortality depending on expansion status. This study examined trends in overdose mortality nationally and by state Medicaid expansion status from 2013 to 2020. METHODS State-level data on overdose mortality were obtained from the Centers for Disease Control and Prevention's WONDER database for 2013-2020 (N = 408 state-years). The primary outcomes were drug and opioid overdose deaths per 100,000 residents. The primary exposure was Medicaid expansion status as of January 1st, 2020. Difference-in-difference (DID) models were used to compare changes in outcomes between expansion and non-expansion states after the onset of the COVID-19 pandemic. RESULTS The U.S. experienced 91,799 drug overdose deaths in 2020, a 29.9% relative increase from 2019. Expansion states experienced an adjusted increase of 7.0 drug overdose deaths per 100,000 residents (95% CI 3.3, 10.7) and non-expansion states experienced an increase of 4.3 deaths (95% CI 1.5, 8.2) from 2019 to 2020. Similar trends were observed in opioid overdose deaths. In DID models, Medicaid expansion was not associated with changes in drug (0.9 deaths, 95% CI -2.0, 3.7) or opioid overdose deaths (0.8 deaths, 95% CI -1.8, 3.5). CONCLUSIONS The increase in drug or opioid overdose deaths experienced during the first year of the COVID-19 pandemic was similar in states with and without Medicaid expansion.
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Affiliation(s)
- Samantha G. Auty
- Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, Massachusetts 02118, USA,Correspondence to: 715 Albany Street, Talbot Building, Boston, Massachusetts 02118, USA
| | - Kevin N. Griffith
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Avenue, Nashville, Tennessee 37203, USA,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA 02130, USA
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6
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O'Brien R, Bair EF, Venkataramani AS. Death by Robots? Automation and Working-Age Mortality in the United States. Demography 2022; 59:607-628. [PMID: 35195250 DOI: 10.1215/00703370-9774819] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The decline of manufacturing employment is frequently invoked as a key cause of worsening U.S. population health trends, including rising mortality due to "deaths of despair." Increasing automation-the use of industrial robots to perform tasks previously done by human workers-is one structural force driving the decline of manufacturing jobs and wages. In this study, we examine the impact of automation on age- and sex-specific mortality. Using exogenous variation in automation to support causal inference, we find that increases in automation over the period 1993-2007 led to substantive increases in all-cause mortality for both men and women aged 45-54. Disaggregating by cause, we find evidence that automation is associated with increases in drug overdose deaths, suicide, homicide, and cardiovascular mortality, although patterns differ by age and sex. We further examine heterogeneity in effects by safety net program generosity, labor market policies, and the supply of prescription opioids.
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Affiliation(s)
- Rourke O'Brien
- Department of Sociology and Institution for Social and Policy Studies, Yale University, New Haven, CT, USA
| | - Elizabeth F Bair
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Olfson M, Wall MM, Barry CL, Mauro C, Choi CJ, Mojtabai R. Effects of the ACA on Health Care Coverage for Adults With Substance Use Disorders. Psychiatr Serv 2021; 72:905-911. [PMID: 33957766 PMCID: PMC8328862 DOI: 10.1176/appi.ps.202000377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors assessed changes in health care coverage in nationally representative samples of low- and middle-income adults with and without substance use disorders following the 2014 Affordable Care Act marketplace launch and Medicaid expansion. METHODS Data from the 2012-2018 (N=407,985) National Survey on Drug Use and Health identified low- and middle-income nonelderly adults with alcohol, marijuana, cocaine, or heroin use disorders. A sociodemographically adjusted difference-in-differences analysis assessed the trends in Medicaid and individually purchased private insurance between adults with and without substance use disorders. RESULTS Between 2012-2013 and 2015-2016, the percentages without health insurance significantly declined for adults with substance use disorders (from 27.8% to 18.7%) and for those without these disorders (from 22.6% to 14.6%). These trends were related to gains in Medicaid and in individually purchased private insurance but not to gains in employer-based private insurance coverage. Between 2015-2016 and 2017-2018, however, the percentages without health insurance among adults with substance use disorders (18.7% to 18.4%) and without these disorders (14.7% to 14.7%) was little changed. CONCLUSIONS With insurance gains having stalled and the downturn of the U.S. economy, there is renewed urgency to extend health care coverage to middle- and low-income adults with substance use disorders that meets their substance use and general health needs.
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Affiliation(s)
- Mark Olfson
- Vagelos College of Physicians and Surgeons, Columbia University, New York City (Olfson, Wall); New York State Psychiatric Institute, New York City (Olfson, Wall, Mauro, Choi); Departments of Mental Health (Mojtabai and Barry) and Health Policy and Management (Barry), Johns Hopkins Bloomberg School of Public Health, and Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore (Mojtabai)
| | - Melanie M Wall
- Vagelos College of Physicians and Surgeons, Columbia University, New York City (Olfson, Wall); New York State Psychiatric Institute, New York City (Olfson, Wall, Mauro, Choi); Departments of Mental Health (Mojtabai and Barry) and Health Policy and Management (Barry), Johns Hopkins Bloomberg School of Public Health, and Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore (Mojtabai)
| | - Colleen L Barry
- Vagelos College of Physicians and Surgeons, Columbia University, New York City (Olfson, Wall); New York State Psychiatric Institute, New York City (Olfson, Wall, Mauro, Choi); Departments of Mental Health (Mojtabai and Barry) and Health Policy and Management (Barry), Johns Hopkins Bloomberg School of Public Health, and Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore (Mojtabai)
| | - Christine Mauro
- Vagelos College of Physicians and Surgeons, Columbia University, New York City (Olfson, Wall); New York State Psychiatric Institute, New York City (Olfson, Wall, Mauro, Choi); Departments of Mental Health (Mojtabai and Barry) and Health Policy and Management (Barry), Johns Hopkins Bloomberg School of Public Health, and Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore (Mojtabai)
| | - C Jean Choi
- Vagelos College of Physicians and Surgeons, Columbia University, New York City (Olfson, Wall); New York State Psychiatric Institute, New York City (Olfson, Wall, Mauro, Choi); Departments of Mental Health (Mojtabai and Barry) and Health Policy and Management (Barry), Johns Hopkins Bloomberg School of Public Health, and Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore (Mojtabai)
| | - Ramin Mojtabai
- Vagelos College of Physicians and Surgeons, Columbia University, New York City (Olfson, Wall); New York State Psychiatric Institute, New York City (Olfson, Wall, Mauro, Choi); Departments of Mental Health (Mojtabai and Barry) and Health Policy and Management (Barry), Johns Hopkins Bloomberg School of Public Health, and Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore (Mojtabai)
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Abstract
OBJECTIVE The authors examined changes in buprenorphine treatment following Medicaid expansion, including the contribution of Medicaid-financed prescriptions. METHODS Buprenorphine pharmacy claims for patients were identified in the 2012-2018 IQVIA Longitudinal Prescription Data (LRx) data set, including 79.8% of U.S. retail prescriptions in 2012, increasing to 92.0% in 2018. A cohort analysis was used to assess the mean number of patients in a yearly quarter filling one or more buprenorphine prescriptions during preexpansion (2012-2013) and postexpansion (2014-2018) periods in expansion and nonexpansion states. Interrupted time-series analysis estimated associations of Medicaid expansion period with change in Medicaid-financed treatment. Separate analyses evaluated changes in duration and dose of new treatment episodes focused on mean quarterly number of patients treated with buprenorphine and proportions of new treatment episodes ≥180 days long and with ≥16 mg/day. RESULTS Between preexpansion and postexpansion, the mean quarterly number of patients taking buprenorphine increased by 93,300 in expansion states and by 84,960 in nonexpansion states. Corresponding changes for Medicaid-financed patients were 28,760 and 4,050, respectively. The fastest growth in Medicaid-financed treatment occurred among patients ages 25-44. Among new Medicaid-financed treatment episodes, little change was found in the proportion reaching the 180-day threshold, and declines were observed in the proportion receiving ≥16 mg/day. CONCLUSIONS The findings are consistent with previous research indicating that Medicaid expansion has increased Medicaid-financed buprenorphine treatment. However, because of offsetting changes in other payment groups, the overall increase in expansion states was similar to the increase in nonexpansion states.
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Affiliation(s)
- Mark Olfson
- Vagelos College of Physicians and Surgeons and Mailman School of Public Health, Columbia University, New York City (Olfson); School of Management, Yale University, New Haven, Connecticut (Zhang, King); Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Mojtabai)
| | - Victoria Shu Zhang
- Vagelos College of Physicians and Surgeons and Mailman School of Public Health, Columbia University, New York City (Olfson); School of Management, Yale University, New Haven, Connecticut (Zhang, King); Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Mojtabai)
| | - Marissa King
- Vagelos College of Physicians and Surgeons and Mailman School of Public Health, Columbia University, New York City (Olfson); School of Management, Yale University, New Haven, Connecticut (Zhang, King); Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Mojtabai)
| | - Ramin Mojtabai
- Vagelos College of Physicians and Surgeons and Mailman School of Public Health, Columbia University, New York City (Olfson); School of Management, Yale University, New Haven, Connecticut (Zhang, King); Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Mojtabai)
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Griffith KN, Feyman Y, Auty SG, Crable EL, Levengood TW. Implications of county-level variation in U.S. opioid distribution. Drug Alcohol Depend 2021; 219:108501. [PMID: 33421805 PMCID: PMC8115932 DOI: 10.1016/j.drugalcdep.2020.108501] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 12/06/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Prescription opioids accounted for the majority of opioid-related deaths in the United States prior to 2010, and continue to contribute to opioid misuse and mortality. We used a novel dataset to investigate the distributional patterns of prescription opioids, whether opioid pill volume was associated with opioid-related mortality, and whether early state Medicaid expansions were associated with either pill volume or opioid-related mortality. METHODS Data on opioid shipments to retail pharmacies for 2006-2013 were obtained from the U.S. Drug Enforcement Administration, and opioid-related deaths (ORDs) were obtained from the Centers for Disease Control and Prevention. We first compared characteristics of counties in the highest and lowest quartiles for per capita pill volume (PCPV). We used adjusted difference-in-differences regression models to identify factors associated with PCPV or ORDs, and whether early state Medicaid expansions were associated with either outcome. All models were estimated as linear regressions with standard errors clustered by county, and weighted by county population. RESULTS We found large geographic variations in opioid distribution, and this variation appears to be driven by differences in demographics, healthcare access, and healthcare supply. In adjusted models, a one-pill increase in PCPV was associated with a 0.20 increase in ORDs per 100,000 population (95 % CI 0.11-0.30). Early Medicaid expansions were associated with lower PCPV (-2.20, 95 % CI -2.97 to -1.43). CONCLUSIONS Our findings validate the relationship between PCPV and ORDs, identify important environmental drivers of the opioid epidemic, and suggest early state Medicaid expansions were beneficial in reducing opioid pill volume.
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Affiliation(s)
- Kevin N Griffith
- Department of Health Policy, Vanderbilt University Medical Center, 2525 West End Ave., Suite 1200, Nashville, TN 37203, USA; Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Bldg. 9, 150 S. Huntington Ave., Boston, MA 02130, USA.
| | - Yevgeniy Feyman
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Bldg. 9, 150 S. Huntington Ave., Boston, MA 02130, USA; Department of Health Law, Policy & Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA
| | - Samantha G Auty
- Department of Health Law, Policy & Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA
| | - Erika L Crable
- Department of Health Law, Policy & Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA
| | - Timothy W Levengood
- Department of Health Law, Policy & Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA
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10
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Coupet E, Werner RM, Polsky D, Karp D, Delgado MK. Impact of the Young Adult Dependent Coverage Expansion on Opioid Overdoses and Deaths: a Quasi-Experimental Study. J Gen Intern Med 2020; 35:1783-1788. [PMID: 31898130 PMCID: PMC7280374 DOI: 10.1007/s11606-019-05605-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/27/2019] [Accepted: 12/05/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Several policymakers have suggested that the Affordable Care Act (ACA) has fueled the opioid epidemic by subsidizing opioid pain medications. These claims have supported numerous efforts to repeal the ACA. OBJECTIVE To determine the effect of the ACA's young adult dependent coverage insurance expansion on emergency department (ED) encounters and out-of-hospital deaths from opioid overdose. DESIGN Difference-in-differences analyses comparing ED encounters and out-of-hospital deaths before (2009) and after (2011-2013) the ACA young adult dependent coverage expansion. We further stratified by prescription opioid, non-prescription opioid, and methadone overdoses. PARTICIPANTS Adults aged 23-25 years old and 27-29 years old who presented to the ED or died prior to reaching the hospital from opioid overdose. MAIN MEASURES Rate of ED encounters and deaths for opioid overdose per 100,000 U.S. adults. KEY RESULTS There were 108,253 ED encounters from opioid overdose in total. The expansion was not associated with a significant change in the ED encounter rates for opioid overdoses of all types (2.04 per 100,000 adults [95% CI - 0.75 to 4.82]), prescription opioids (0.60 per 100,000 adults [95% CI - 1.98 to 0.77]), or methadone (0.29 per 100,000 adults [95% CI - 0.78 to 0.21]). There was a slight increase in the rate of non-prescription opioid overdoses (1.91 per 100,000 adults [95% CI 0.13-3.71]). The expansion was not associated with a significant change in the out-of-hospital mortality rates for opioid overdoses of all types (0.49 per 100,000 adults [95% CI - 0.80 to 1.78]). CONCLUSIONS Our findings do not support claims that the ACA has fueled the prescription opioid epidemic. However, the expansion was associated with an increase in the rate of ED encounters for non-prescription opioid overdoses such as heroin, although almost all were non-fatal. Future research is warranted to understand the role of private insurance in providing access to treatment in this population.
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Affiliation(s)
- Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, Yale University, 464 Congress Avenue, Suite 260, New Haven, CT, 06519, USA.
- Yale Drug Use, Addiction, and HIV Research Scholars (DAHRS) Program, New Haven, USA.
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
| | - Rachel M Werner
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, USA
| | - Daniel Polsky
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- Department of Health Economics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - David Karp
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - M Kit Delgado
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, USA
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11
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Affiliation(s)
- Atheendar S. Venkataramani
- Department of Medical Ethics and Health PolicyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPennsylvania
| | - Alexander C. Tsai
- Center for Global HealthMassachusetts General HospitalBostonMassachusetts
- Harvard Medical SchoolBostonMassachusetts
- Mbarara University of Science and TechnologyMbararaUganda
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12
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Kravitz-Wirtz N, Davis CS, Ponicki WR, Rivera-Aguirre A, Marshall BDL, Martins SS, Cerdá M. Association of Medicaid Expansion With Opioid Overdose Mortality in the United States. JAMA Netw Open 2020; 3:e1919066. [PMID: 31922561 PMCID: PMC6991255 DOI: 10.1001/jamanetworkopen.2019.19066] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The Patient Protection and Affordable Care Act (ACA) permits states to expand Medicaid coverage for most low-income adults to 138% of the federal poverty level and requires the provision of mental health and substance use disorder services on parity with other medical and surgical services. Uptake of substance use disorder services with medications for opioid use disorder has increased more in Medicaid expansion states than in nonexpansion states, but whether ACA-related Medicaid expansion is associated with county-level opioid overdose mortality has not been examined. OBJECTIVE To examine whether Medicaid expansion is associated with county × year counts of opioid overdose deaths overall and by class of opioid. DESIGN, SETTING, AND PARTICIPANTS This serial cross-sectional study used data from 3109 counties within 49 states and the District of Columbia from January 1, 2001, to December 31, 2017 (N = 3109 counties × 17 years = 52 853 county-years). Overdose deaths were modeled using hierarchical Bayesian Poisson models. Analyses were performed from April 1, 2018, to July 31, 2019. EXPOSURES The primary exposure was state adoption of Medicaid expansion under the ACA, measured as the proportion of each calendar year during which a given state had Medicaid expansion in effect. By the end of study observation in 2017, a total of 32 states and the District of Columbia had expanded Medicaid eligibility. MAIN OUTCOMES AND MEASURES The outcomes of interest were annual county-level mortality from overdoses involving any opioid, natural and semisynthetic opioids, methadone, heroin, and synthetic opioids other than methadone, derived from the National Vital Statistics System multiple-cause-of-death files. A secondary analysis examined fatal overdoses involving all drugs. RESULTS There were 383 091 opioid overdose fatalities across observed US counties during the study period, with a mean (SD) of 7.25 (27.45) deaths per county (range, 0-1145 deaths per county). Adoption of Medicaid expansion was associated with a 6% lower rate of total opioid overdose deaths compared with the rate in nonexpansion states (relative rate [RR], 0.94; 95% credible interval [CrI], 0.91-0.98). Counties in expansion states had an 11% lower rate of death involving heroin (RR, 0.89; 95% CrI, 0.84-0.94) and a 10% lower rate of death involving synthetic opioids other than methadone (RR, 0.90; 95% CrI, 0.84-0.96) compared with counties in nonexpansion states. An 11% increase was observed in methadone-related overdose mortality in expansion states (RR, 1.11; 95% CrI, 1.04-1.19). An association between Medicaid expansion and deaths involving natural and semisynthetic opioids was not well supported (RR, 1.03; 95% CrI, 0.98-1.08). CONCLUSIONS AND RELEVANCE Medicaid expansion was associated with reductions in total opioid overdose deaths, particularly deaths involving heroin and synthetic opioids other than methadone, but increases in methadone-related mortality. As states invest more resources in addressing the opioid overdose epidemic, attention should be paid to the role that Medicaid expansion may play in reducing opioid overdose mortality, in part through greater access to medications for opioid use disorder.
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Affiliation(s)
- Nicole Kravitz-Wirtz
- Violence Prevention Research Program, Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento
| | | | - William R. Ponicki
- Prevention Research Center, Pacific Institute for Research and Evaluation, Berkeley, California
| | - Ariadne Rivera-Aguirre
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University School of Medicine, New York
| | - Brandon D. L. Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Silvia S. Martins
- Mailman School of Public Health, Department of Epidemiology, Columbia University, New York, New York
| | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University School of Medicine, New York
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