Prescription Opioids 425,247 137.4 156% Oxycodone 182,748 59.1 255% Hydrocodone 115,739 37.4 149% Methadone 76,237 24.6 86% Illicit Drugs 1,171.024 378.5 NR Cocaine 488,101 157.8 NR Heroin 224,706 72.6 NR Marijuana 461,028 149.0 22% Methamphetamine 94,929 30.7 48%
Source: Drug Abuse Warning Network (2010) NR = Not Reported
aRate is per 100,000 population b
Includes all drugs (illicit drugs, alcohol and prescription drugs) and all causes (suicide attempts, abuse, adverse drug reactions, etc)
Characteristics Associated with Prescription Opioid-Related Healthcare Utilization
As seen in Table 1-16, opioid-related ED visits vary by numerous demographic factors. In 2010, ED visits related to all prescription opioids were higher among males and individuals ages 45-54. In addition to having the highest number of opioid-related visits, the rate of increase from 2004- 2010 was highest among individuals ages 45-54. Oxycodone-related ED visits among females were increasing at a similar rate as males, but hydrocodone-related ED visits among males are increasing at a much higher rate than among females.10
Table 1-16. Opioid-Related ED Visits by Gender and Race/Ethnicity, 2010
Opiates (Total) Oxycodone Hydrocodone # of visits Ratea % Changeb # of visits Rate a % Changeb # of visits Rate a % Changeb Gender Male 229,107 150.6 171% 104,028 68.4 257% 55,846 36.7 180% Female 196,020 124.6 140% 78,651 50.0 253% 59,872 38.1 125% Race/Ethnicity White 343,620 NR 186% 155,566 NR 301% 89,330 NR 156% Black 38,400 NR 188% 13,305 NR 406% 12,966 NR 309% Hispanic 18,692 NR 197% 4,194 NR 308% 6,612 NR 349% Other 3,279 NR 471% 1,776 NR NR 659 NR 663% Age Group >21 31,890 36.3 103% 17,420 19.8 204% 8,327 9.5 NR 21-24 51,147 297.7 231% 23,561 137.1 264% 16,066 93.5 276% 25-29 58,825 269.0 244% 23,710 112.2 279% 13,761 65.1 185% 30-34 45,524 231.7 126% 18,994 94.6 193% 14,498 72.2 119% 35-44 82,223 200.8 92% 36,100 88.2 211% 21,744 53.1 68% 45-54 89,328 198.3 153% 36,283 80.6 303% 24,048 53.4 180% 55-64 42,290 114.9 278.8 18,111 49.2 425% 10,168 27.6 385% 65< 24,782 61.3 182% 8,453 20.9 264% 7,118 17.6 241% Source: Drug Abuse Warning Network (2010)
Note: The DAWN database does not calculate rates for race/ethnicity because this information gathered in Emergency Departments is often missing or very limited. NR = Not Reported
aRate is per 100,000 population bPercent change is from 2004 – 2010
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Small differences in the prevalence of ED visits were evident between the commercially insured and Medicaid populations. Braden et al examined data from the TROUP‡‡‡ study and found that 28.2% of Arkansas Medicaid recipients who used prescription opioids continuously for at least 90 days had one or more ED visit within the past year, compared to 24.2% of individuals in the commercially insured population. Approximately 0.4% of the Medicaid group had an ED visit associated with an opioid overdose, compared to 0.2% of the commercially insured group. On the other hand, the type and amount of the prescription opioid was more influential. Braden et al examined the relationship between opioid dosing levels and ED visits in these two populations and found that these variables were more influential. They found that opioid doses between the median (32-35 MED/day) and 120 MED/day were associated with increased ED visits among commercially insured population, but not among the Medicaid population. The data for doses greater than 120 mg/day is noteworthy and clinically important; although not associated with increased ED visits in either population, there was a two-fold increase in the risk for adverse drug events in both the commercially insured and Medicaid populations. Additionally, Braden et al found that comorbidities and substance use and abuse (opioid and non-opioid) were all
associated with increased ED visits among chronic opioid users.98 Hartung and colleagues also found that the type of prescription opioid was an influential factor among prescription opioid- related ED visits. They reviewed Oregon Medicaid claims from 2000-2004 and found that patients prescribed methadone were more likely to have an ED visit compared to those
prescribed oxycodone or morphine. However, patients prescribed methadone or oxycodone were 18% and 23% less likely (respectively) to be hospitalized, compared to individuals prescribed morphine.114
Health Outcomes: Opioid-Related Comorbidities§§§
Presented in Table 1-17 are the prevalence rates of selected comorbidities among both privately insured and Medicaid populations, compared with matched controls. As previously mentioned, White et al reviewed employer claims data from 1998-2002 and found that opioid abusers were more likely to suffer multiple co-morbidities.9 In a similar vein, using data from 2002-2003, McAdam-Marx and colleagues compared the prevalence of comorbidities among a group of Medicaid recipients with an opioid abuse-related diagnosis (abuse, dependence or poisoning) and matched controls and found that 84% of abuse/dependent patients and 52% of controls had at least one of the selected comorbidities. The most prevalent comorbidities among those with an opoid-abuse related diagnosis were psychiatric disorders, non-opoid substance abuse disorders, trauma and hepatitis A, B, or C.18
Corroborative evidence comes from another study by White et al. From 2003-2007, this group reviewed claims data from both a privately insured sample and Florida Medicaid recipients and found that opioid abusers suffered from psychiatric disorders, non-opioid substance abuse disorders, and other chronic conditions more frequently than non-abusers, regardless of
‡‡‡
The Trends and Risks of Opioid use for Pain (TROUP) study was conducted from 2000-2005. The study compared trends and risks of opioid use, misuse and abuse in two populations – a national commercially insured population (HealthCore Blue Cross and Blue Shield) and the Arkansas Medicaid population
§§§ As comorbidities are both a risk factor for, and outcome of, nonmedical prescription opioid use, misuse and
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insurance type.105 Taken together, these studies provide evidence of the disparate and copious disease burden of opioid abusers compared to controls. The interaction of opioid abuse with
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Table 1-17. Prevalence of Select Comorbidities among Opioid Abusers compared to Nonabusers
Privately Insured 1998-2002a National Medicaid 2002-2003b Privately Insured 2003-2007c Florida Medicaid 2003-2007c Abusers n=740 Controls n=1,266 Abusers N=50,162 Controls N=150,485 Abusers n=4,474 Controls n=4,474 Abusers n=4,467 Controls n=4,467 Psychiatric Disorders 71.1% 8.4% 49.3% 26.1% 74.5% 12.0% 68.5% 23.2% Trauma 36.5% 15.0% 31.2% 19.8% 45.5% 18.2% 45.5% 12.4% Non-Opioid Substance Abuse 50.4% 1.2% 45.1% 8.2% 46.6% 1.5% 59.7% 6.6% Non-Opioid Poisoning 17.6% 0.2% NR NR 17.1% 0.6% 23.1% 0.8% Gastrointestinal Bleeding 8.0% 2.6% 8.6% 6.3% 13.1% 4.5% 16.9% 4.6% Skin Infections/ Abscesses 10.1% 2.5% 12.7% 5.4% 12.4% 4.0% 17.8% 4.1% Sexually Transmitted Disease 8.0% 4.3% 8.6% 7.6% 8.1% 4.0% 9.6% 5.6% Hepatitis A, B or C 6.5% 0.2% 17.1% 2.4% 4.1% 0.2% 12.4% 1.1% Pancreatitis 0.9% 0.05% 1.7% 0.6% 2.5% 0.2% 4.8% 0.4% Chronic Low Back
Pain NR NR NR NR 21.7% 3.2% 24.8% 3.3% Arthritis NR NR 27.3% 19.5% 17.7% 5.1% 18.0% 3.9% Other Back/Neck Disorders NR NR 27.9% 18.1% 14.5% 2.3% 9.8% 1.4% Fibromyalgia NR NR NR NR 3.8% 0.5% 2.8% 0.2% Neuropathic Pain NR NR 9.8% 7.6% 3.2% 0.8% 2.8% 0.7%
Source: aWhite et al (2005). Privately insured population based on administrative claims data for approximately 2 million insured members from 16 large employers.
bMcAdam-Marx et al (2010). Medicaid population based on data from the Medicaid Analytic eXtract (MAX) from the Centers for Medicare and Medicaid
Services (CMS).
cWhite et al (2011). Privately insured population based on administrativeclaims from 40 self-insured Fortune 500 companies. Florida Medicaid population based
on administrative claims for all Medicaid-eligible beneficiaries in the state.
Note: Controls were randomly selected, demographically matched individuals. Abusers were patients with least one claim with an ICD-9 code related to prescription opioid abuse during the study period (304.0, 304.7, 305.5, and 965.0 (excluding 965.01)
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psychiatric disorders, substance abuse, and medical comorbidities will require combined research and policy-making efforts to establish a knowledge base to inform risk-reduction and effective use of evidence based treatment.
Health Outcomes: Opioid-Related Mortality
As seen in Table 1-18, prescription opioid overdose deaths have increased over 250% over the past decade.13 Longitudinal studies have found that nearly 100 opioid-related overdose deaths occur each day in the United States, which is greater than deaths attributable to heroin and cocaine combined.26 In 2008, national mortality data shows that prescription opioid overdose deaths account for over 40% of all drug overdose deaths. Among prescription opioid overdose deaths, methadone-related deaths account for one-third.13 In 2008, the CDC reported that prescription opioid overdose deaths occurred at a rate of nearly 4.8 deaths per 100,000
population;115 in comparison, the methadone-related overdose death rate was approximately 1.5 overdose deaths per 100,000 in the same year.116 Prescription opioid overdose has now surpassed firearms and motor vehicle accidents as the leading cause of unintentional injury or death among 35-54 year olds, and, behind motor vehicle accidents, the second leading cause overall.1,43,105,117 Table 1-18. Deaths Involving Prescription Opioids, 2000-2008
2000 2001 2002 2003 2004 2005 2006 2007 2008