Heroin and Healthcare: Identifying Opportunities for

#Rx Summit www.NationalRxDrugAbuseSummit.org

Heroin and Healthcare:Identifying Opportunities for

Intervention Prior to OverdoseMichele K. Bohm, MPH, Health Scientist, Centers for Disease Control and Prevention

Lindsey Bridwell, MPH, CHES, Evaluation Fellow, Opioid Overdose Health Systems Team, Centers for Disease Control and Prevention

Alexander Y. Walley, MD, MSc, Associate Professor of Medicine,Boston University School of Medicine

Third-Party Payer Track

Moderator: Amy G. Griffin, JD, Corporate Counsel, Kentucky Employers’ Mutual Insurance

ALTERED FROM LIVE PRESENTATION


Disclosures

Lindsey Bridwell, MPH, CHES, Michele K. Bohm, MPH, Alexander Y. Walley, MD, MSc, and Amy G. Griffin, JD, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.


Disclosures

All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

The following planners/managers have the following to disclose:- Kelly J. Clark, MD, MBA, FASAM, DFAPA –

Consulting fees: Braeburn, Indivior


Learning Objectives

Explain how non-fatal drug overdose trends and healthcare utilization histories can inform prevention.

Describe differences in healthcare utilization patterns by insurance type for heroin overdose.

Identify strategies to support interventions at the point of care prior to the first heroin overdose.


Organization of Session

Heroin and Healthcare: What We Know

Heroin Overdose Trends, Healthcare Utilization, and Diagnoses Prior to Overdose

Heroin and Healthcare: Clinical Perspectives

.


Heroin and Healthcare: What We Know

Lindsey Bridwell, MPH, CHES®

Evaluation FellowCenters for Disease Control and Prevention


Topics

Role of Heroin in the Opioid Overdose Epidemic Heroin and Challenges for Prevention Other Adverse Health Outcomes

- Infectious Disease- Neonatal Abstinence Syndrome

Healthcare Access and Use by Payer Health Status and Comorbidities Gaps in Science


Opioid Overdose Epidemic

Sharp increase in heroin and other synthetic opioid overdose deaths


Heroin and Challenges for Prevention

Polysubstance Use

Rx OPIOIDS



Average annual rates of heroin use per 1,000 people and the percent increase for 2002–2004 and 2011–2013

National Survey on Drug Use and Health, 2002-2013.



Past Year Heroin Use Disorder by Age Group, 2002-2016

2016 National Survey on Drug Use and Health

18-25 year olds have the highest prevalence of heroin use disorder

Year


Adverse Health Outcomes Infectious Disease

* Rate = the number of reported cases of acute hepatitis C per 100,000 population


Adverse Health Outcomes Neonatal Abstinence Syndrome (NAS)

Incidence 1.5 per 1000 hospital

births --1999 6 per 1000 hospital births

– 2013 300% increase

Cost --$1.5 Billion – 2012 Medicaid financially

responsible for 80%

Neonatal abstinence syndrome (NAS) incidence rates — 25 states, 2012–2013

Ko JY, Patrick SW, Tong VT, Patel R, Lind JN, Barfield WD. Incidence of Neonatal Abstinence Syndrome — 28 States, 1999–2013. MMWR Morb Mortal Wkly Rep 2016;65:799–802.


Healthcare Access and Use How Does Healthcare Access Vary by Payer for

Adults in the General Population?

Medicaid and CHIP Payment and Access Commission (2014). Revisiting Emergency Department Use in Medicaid. MACfacts-Key Findings on Medicaid and CHIP.


Healthcare Access and Use

Affordable Care Act (ACA) and People With Substance Use Disorders

- Pre-ACA, slightly higher prevalence of substance use disorders among uninsured individuals who would be eligible for expanded Medicaid in 2014 [compared to traditional Medicaid beneficiaries].¹

- Among people with HUD, the prevalence of uninsured persons declined from 40 per 100 to 28 per 100 (OR= 0.59; CI= 0.39 – 0.89) largely due to Medicaid expansion – but there was no increase in treatment.²

1. Busch, S. H., Meara, E., Huskamp, H. A., & Barry, C. L. (2013). Characteristics of adults with substance use disorders expected to be eligible for Medicaid under the ACA. Psychiatr Serv, 64(6), 520-526. doi:10.1176/appi.ps.201200011

2. Feder KA, Mojtabai R, Krawczyk N, et.al. “Trends in insurance coverage and treatment among persons with opioid use disorders following the Affordable Care Act.” Drug Alcohol Depend. 2017 Aug 9;179:271-274.


Health Status and Comorbidities

Medicaid and CHIP Payment and Access Commission (MACPAC). 2012b. Section B: Access to care for non-elderly adults. In Report to the Congress on Medicaid and CHIP. June 2012. Washington, DC: MACPAC.

In general, Medicaid enrollees have a higher prevalence of comorbidities and poorer health status compared to enrollees with Employee Sponsored Insurance (ESI) and the uninsured.


Gap in the Science ap in the Literature and Science Characteristics and trends of non-fatal heroin

overdose by payer

Do not know…•Patterns of healthcare utilization prior to overdose

•Diagnoses preceding overdose•Prescription opioid use prior to overdose


Heroin Overdose Trends, Healthcare Utilization, and Diagnoses

Prior to Overdose for Medicaid and Commercial Enrollees,

2010-2014

Michele K. BohmCenters for Disease Control and Prevention

April 3, 2018


Overview

Study Objective Background Data Source and Measures Results Implications

.


Study Objective

Characterize non-fatal heroin overdose (OD) trends among the insured, including healthcare utilization preceding overdose and prior use of prescription opioids, benzodiazepines and buprenorphine in order to inform prevention strategies for the population at risk of heroin OD.


Background

Project POINT-Indiana

“We’re now treating a heroin patient in the ED much as we would treat a heart attack or

stroke patient.” Dr. Charles Miramonti

Local Syringe Services Programs


Health Insurance Coverage U.S. Population

Employer-sponsoredInsurance

Medicaid


Q: Who Pays for Heroin ED Visits and Hospitalizations?

A: 50% Medicaid and Private Insurance

National Inpatient Sample (NIS) and National Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality.

Medicaid26%

Private Insurance

19%Medicare

6%

Uninsured45%

Other4%

2013 ED VISITS HEROIN OVERDOSE

Medicaid30%

Private Insurance

20%Medicare

9%

Uninsured35%

Other6%

2013 HOSPITAL DISCHARGESHEROIN OVERDOSE


Data Source and MeasuresData Source and Measures


Data SourceMarketScan® Medicaid & Commercial Claims

Convenience Sample but strength in size of databases- Commercially-insured: >25% of all U.S. employer-sponsored

healthcare beneficiaries- Medicaid-insured patients: 10-13 de-identified states

Full continuum of care- Inpatient, outpatient, ED, retail pharmacy- ICD-9-CM, CPT, NDC

Analyzed data 2010-2014- Ages 15-64 years


Measures OVERDOSE

- Heroin OD rates by year, payer, gender, age• ICD-9-CM 965.01 (poisoning by heroin) and E850.0

(accidental)- Opioid (other than heroin) OD rates by year and payer

COMORBIDITIES AND HEALTHCARE PRIOR TO OVERDOSE- Non-heroin OD or buprenorphine RX- Any healthcare utilization by setting--office, ED, inpatient (6

months)- Comorbidities per HCUP Clinical Classifications for

diagnoses (6 months)

PRESCRIPTIONS- Opioids, benzodiazepines, buprenorphine (1, 3, 6 months

prior to OD)


Results


Key FindingsHeroin OD Rates, 2010-2014

Gender: Generally higher among males

Age: Distribution varied by payer

Increases: Greatest for females

By 2012, rates among commercial enrollees 15-24 years=Overall rates in Medicaid population

Truven Health Analytics MarketScan®--United States, 2010-2014


Limitations of Study

Continuously enrolled more likely to have chronic conditions ACA Medicaid expansion

- SUD higher among uninsured, expanded Medicaid-eligible - Excluded all new-to-Medicaid enrollees=conservative rates

Variability in coding Not nationally-representative/generalizable to entire U.S.

population. Claims do not capture: Heroin OD without transport to facility,

fatal OD, uninsured, prescriptions paid out-of-pocket


Summary of Results Nonfatal heroin overdose trends, 2010-2014, reflect heroin use

and OD mortality1-2

Commercially-insured account for increasing burden from heroin OD

Multiple medical and mental healthcare needs among insured who overdose on heroin. - Higher opioid prescribing reflects painful comorbidities in

Medicaid - High benzo prescribing and co-prescribing with opioids

reflects mental health issues (2016 FDA Warning on combined use)

Insured patients with impending heroin overdose were not lost to follow-up.

1. Hedegaard, H., Chen, L. H., & Warner, M. (2015). Drug-poisoning deaths involving heroin: United States, 2000-2013. NCHS Data Brief(190), 1-8. 2. Jones, C. M., Logan, J., Gladden, R. M., & Bohm, M. K. (2015). Vital Signs: Demographic and Substance Use Trends Among Heroin Users - United States, 2002-2013. MMWR Morb Mortal Wkly Rep, 64(26), 719-725.


Implications


Young Commercially-Insured Heroin OD rates in line with overall Medicaid population

- Dependents of primary insured3

- Emerging cohort? Office-based settings High OD rates in young commercially-insured, BUT opioid

prescribing lower in commercially-insured - Young people more likely obtain Rx opioids from

friends/family1

- Individuals entering treatment now more frequently reporting heroin as their opioid of initiation as opposed to prescription opioids.2

1. Lipari, R. N., & Hughes, A (2017). How people obtain the prescription pain relievers they misuse. The CBHSQ Report: January 12, 2017. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD.2. Cicero, T. J., Ellis, M. S., & Kasper, Z. A. (2017). Increased use of heroin as an initiating opioid of abuse. Addict Behav, 74, 63-66. doi:10.1016/j.addbeh.2017.05.0303. The authors analyzed the MarketScan data and found that most enrollees aged 15 to 24 years were dependents of the primary insured member.


Beyond Opioid OD PreventionTreat impending OD as you would a

patient at risk for heart attack.

Opioid Misuse

Neonatal Abstinence Syndrome

Infectious Complications

CDC Guideline for Prescribing Opioids for Chronic Pain

Prescription Drug Monitoring Program (PDMP)

Medication Assisted Treatment (MAT)

Overdose Education and Naloxone Distribution (OEND)

No need to wait for heroin OD to intervene!

Federal funds can support COMPREHENSIVE Syringe Services Programs in certain jurisdictions.

SSPs prevent overdoses by distributing naloxone and teaching people who inject drugs to avoid and reverse overdose.

Third Party Payers: Note that SSPs save healthcare dollars by preventing infectious complications which are expensive to treat.

People who inject drugs should be tested for HIV, viral hepatitis and STDs, and vaccinated against hepatitis B if not immune.


Neonatal Abstinence Syndrome In addition to MAT, ensure

access to family planning and preconception care for womenwho use opioids. - Among women with OUD, 86%

of pregnancies are unintended.1

- CDC recommends healthcare providers support family planning services: preconception services, pregnancy intention screening, and contraceptive counseling.2

1. Heil SH, Jones HE, Arria A, et al. Unintended pregnancy in opioid-abusing women. J Subst Abuse Treat 2011;40:199–202. 2. Gavin L, Moskosky S, Carter M, et al. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep 2014;63(No. RR-4).3. https://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndrome

3

https://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndrome


Opportunities for Pre-Overdose Interventions

Healthcare utilization patterns prior to first heroin overdose signal opportunities for pre-overdose interventions tailored to where patients access care (not necessarily ED).

Analyze more recent, granular data (third-party payer, ACO, etc.) to inform initiatives and innovate.

Integrate care with systematic coordination of medical (pain), social, and psychological health:- Judicious prescribing per CDC Guidelines- PDMP- MAT- Naloxone- Screen and treat HCV, HIV, other infections- SSP- Family planning- Reproductive health- Mental health


Acknowledgments

Lindsey BridwellKun ZhangJon Zibbell

Questions or comments: [email protected]


Heroin and Healthcare: Clinical Perspectives

Alexander Y. Walley, MD, MSc

Associate Professor of Medicine and Director of Addiction Medicine Fellowship

Clinical Addiction Research and Education Unit, Boston Medical Center/ Boston University School of Medicine

Medical DirectorOpioid Overdose Prevention Pilot Program, Massachusetts

Department of Public Health


Touchpoints: Identifying people at high risk for overdose and interact with systems before they overdose

People who present for opioid detoxification People have a non-fatal overdose People hospitalized for medical or mental health

conditions related to opioid use People with opioid use disorder who are

incarcerated People who are prescribed opioids for pain


415.6%10.4%10.7%10.8%11.0%11.5%

12.4%12.5%12.8%13.4%

14.6%15.5%

17.1%20.4%20.6%

29.6%31.1%31.6%

33.8%38.8%

Other

Renal

Neurosurgery

Gyn

Heme / Onc

General Surgery

Cards CHF

Family Medicine

Hospitalist

Internal Medicine

Adult discharges with billed substance use code during visitPercentage of annual discharges

Source: Internal BMC admission / billing data; May 2014-June 2015.

▪ Across all adult discharges, 17.5% had a primary or secondary substance use code billed during their hospitalization

▪ Likely undercounts true demand, as substance use is not always coded when it is not primary


0%10%20%30%40%50%60%70%80%90%

100%

-12 -9 -6 -3 0 3 6 9 12

% re

ceiv

ing

med

icatio

n

Months from index overdose

Buprenorphine

Methadone

Naltrexone

Larochelle et al. Presented at CPDD and AMERSA 2017 - Under review


0%

2%

4%

6%

8%

10%

-12 -9 -6 -3 0 3 6 9 12% re

ceiv

ing

med

icatio

n


Buprenorphine

Methadone

Naltrexone


%Months Received (median [IQR])

Any MOUD 30%Buprenorphine 17% 4 [2,8]Methadone 12% 5 [2,9]Naltrexone 6% 1 [1,2]


Opioid and benzodiazepine prescriptions before and after overdose

0%

5%

10%

15%

20%

-12 -9 -6 -3 0 3 6 9 12

% re

ceiv

ing

med

icatio

n


Rx OpioidBenzodiazepineAny MOUD

Presented at CPDD and AMERSA 2017 - Study under review


0%

1%

2%

3%

4%

5%

0 1 2 3 4 5 6 7 8 9 10 11 12Cum

ulat

ive in

ciden

ce o

f al

l-cau

se d

eath

Months From Overdose

Naltrexone

None

BuprenorphineMethadone



Morgan JR, Schackman BR, Leff JA, Linas BP, Walley AY. Injectable naltrexone, oral naltrexone, and buprenorphine utilization and discontinuation among individuals treated for opioid use disorder in a United States commercially insured population. JSAT. 2017 Jul 3.

2010-14 claims database of >200 million commercially insured in US 4-fold-increase in OUD dx

- 0.12% 0.48% BUT, proportion treated

decreased- 25% 16%


Make MAT opt out, instead of opt in- Convert detox programs into MAT induction programs- Continue and initiate MAT for hospitalized/ED patients

with complications of OUD• Especially post-overdose

- Continue and initiate MAT for incarcerated people with OUD

Offer overdose prevention to everyone with risk and their networks- People who are prescribed opioids and benzos- Make overdose prevention part of addiction treatment- Medical and mental health patients who use opioids- Incarcerated

Intervention strategies at the point of care prior to the first heroin overdose


A comprehensive public health response to address overdoses related to IMF 1. Fentanyl should be included on standard toxicology screens 2. Adapt existing harm reduction strategies, such as direct observation of anyone using

illicit opioids, and ensuring bystanders are equipped with naloxone3. Enhanced access and linkage to medication for opioid use disorders

“So, now what they [people selling illicit drugs] are doing is they’re cutting the heroin with the fentanyl to make it stronger. And the dope [heroin] is so strong with the fentanyl in it, that you get the whole dose of the fentanyl at once rather than being time-released [like the patch]. And that’s why people are dying—plain and simple. You know, they [people using illicit drugs] are doing the whole bag [of heroin mixed with fentanyl] and they don’t realize that they can’t handle it; their body can't handle it.” -- Overdose bystander


Go further upstream! Engage people who do not touch systems and integrate

overdose prevention- Syringe service programs- Drug consumption spaces- Integrate HIV, HCV testing outreach with overdose

prevention- Housing First programs that integrate overdose

prevention- Post-overdose public health-public safety outreach- Pre-arrest treatment and harm reduction- Hot-spotting: Public health-public safety surveillance and

rapid response

Intervention strategies at the point of care prior to the first heroin overdose


[email protected]


Monthly receipt of medication [Through discontinuation]

0%

1%

2%

3%

4%

5%

0 1 2 3 4 5 6 7 8 9 10 11 12

Cum

ulat

ive in

ciden

ce o

f al

l-cau

se d

eath

Months From Overdose

NaltrexoneNone

Buprenorphine

Methadone

Presented at CPDD and AMERSA 2017 - Study under review


Heroin and Healthcare:Identifying Opportunities for

Intervention Prior to OverdoseMichele K. Bohm, MPH, Health Scientist, Centers for Disease Control and Prevention

Lindsey Bridwell, MPH, CHES, Evaluation Fellow, Opioid Overdose Health Systems Team, Centers for Disease Control and Prevention

Alexander Y. Walley, MD, MSc, Associate Professor of Medicine,Boston University School of Medicine

Third Party Payer Track

Moderator: Amy G. Griffin, JD, Corporate Counsel, Kentucky Employers’ Mutual Insurance

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Heroin and Healthcare: Identifying Opportunities for