In one of the first looks at privately insured patients with opioid problems, researchers paint a grim picture: Medical services for people with opioid dependence diagnoses skyrocketed more than 3,000 percent between 2007 and 2014.
The study considers a huge cohort of people who have either job-based insurance or buy coverage on their own. Its findings illustrate that the opioid problem is “in the general mainstream,” said Robin Gelburd, president of Fair Health, a nonprofit databank corporation focused on health care cost transparency and insurance information. “Is the health system preparing for this tsunami of services?” she said.
The researchers used de-identified claims data from insurers representing 150 million patients, looking for diagnosis codes related to opioid dependency and abuse, adverse effects of heroin use, and problems caused by the misuse or abuse of other types of opiates. While heroin is a street drug, other opiates are often prescription medications.
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They found that much of the increase in opioid dependence occurred since 2011, a period marked by increased attention to the problem and a growing drumbeat by advocates calling on doctors to reduce the number of opioid prescriptions.
[Year-over-year opioid results during the time period 2007-2014. Opioid dependence and abuse include heroin dependence and abuse; opioid overdose excludes heroin overdose.]
Year-over-year opioid results from 2007 to 2014. (Courtesy of Fair Health)
Younger patients — 19 to 35 — were most likely to be diagnosed as opioid dependent compared to other age groups. Dependence is defined by symptoms such as increased tolerance, withdrawal or unsuccessful attempts to quit.
Those younger patients were also more likely than older ones to overdose on heroin. The reverse was true, however, for overdoses related to other types of opioids. People in their mid-40s to mid-50s were more likely to suffer this consequence.
The primary diagnosis of opioid dependency kicks off a number of medical services, including office visits, lab tests and other related treatments. The report found that the number of such services rendered to patients with a dependency diagnosis went from about 217,000 in 2007 to about 7 million in 2014.
The scope of the increase found by Fair Health stunned even those already familiar with the problem.
“A 3,000 percent increase is enormous,” said Andrew Kolodny, senior scientist at the Heller School for Social Policy and Management at Brandeis University. He did not work on the study.
Such a sharp rise over a short period of time is a classic definition of an epidemic, he said, and one that points out that much more effort is needed to prevent future cases and treat people who already have addiction problems.
Still, experts caution that research based solely on claims data, while common, is a good way to track the use of health services, but may not paint a complete picture. The accuracy of claims codes — which are used for billing — may be poor, for example. In this case, increased attention to the opioid problem may have also resulted in an increased use of the code. Some research studies also pair claims data with medical record information — the doctors’ notes — to provide additional information. This study did not.
Other findings from the report include:
Across all age groups, men were more likely than women to be diagnosed with dependency. That gap narrowed among patients in their 40s and 50s, with women representing 45 percent of those diagnosed.
Women were more likely than men to experience an overdose.
The ratio of opioid dependence to other substance abuse problems varied by state. Rhode Island had the highest while Maine and Montana the lowest.
[Distribution of opioid dependence diagnoses compared to other substance abuse and dependence diagnoses from 2007 to 2014.]
Distribution of opioid dependence diagnoses compared to other substance abuse and dependence diagnoses from 2007 to 2014. (Courtesy of Fair Health)
Kolodny is among those who say the increase in addiction is directly tied to the run-up in opioids prescribed by doctors in the past decade. Some of those who develop dependency problems are the patients who get the prescriptions. But many also obtain the drugs illicitly, from a friend, family member or dealer.
Younger people, said Kolodny, may start with prescription medications, but then turn to street drugs like heroin because they have “a harder time maintaining their opioid supply by visiting doctors.”
Older patients, he said, are less likely to turn to street drugs because they have an easier time getting refills from their doctors.
[Heroin overdoses compared to opioid overdoses excluding heroin, by age, from 2009 to 2014.]
Heroin overdoses compared to opioid overdoses excluding heroin, by age, from 2009 to 2014. (Courtesy of Fair Health)
Data from IMS Health, which tracks prescription drug sales, shows the number of prescriptions for opioid-based drugs have ticked down, falling 11.8 percent from 2012 to 2015. That decline, however, followed a huge increase: The number of opioid prescriptions more than doubled between 2000 and 2012, when more than 282 million prescriptions were written.
“In the past couple of years, we’ve seen policymakers realize that overprescribing is fueling the crisis,” said Kolodny. “Before that, the focus of federal policymakers was almost exclusively on trying to stop non-medical use” of opioids.
In 2014, federal health officials reclassified certain drugs containing the opioid hydrocodone, including Vicodin, making refills harder to get.
In mid-July, President Barack Obama signed the Comprehensive Addition and Recovery Act of 2016, which aims to make prevention and treatment more widely available.
Supporters say the legislation will help but criticized lawmakers for not including more funding.
Other efforts to combat the rise in opioid abuse have involved states.
Most have begun prescription monitoring programs, which aim to identify and track people who are “doctor shopping,” in order to get multiple prescriptions for narcotics. Pharmacists or physicians can check those databases to see if a particular patient already has a prescription for narcotics before dispensing another.
In 2001, only 16 states had laws allowing such programs. By 2012, 41 states were operating one, according to a report by the Pew Charitable Trusts.
“There’s some evidence that those are helpful in reducing prescribing,” said Allan Coukell, senior director for health programs at Pew.
He added that more effort is needed to provide treatment options for people seeking help.
“The reality is, even in states that have done that, demand is far in excess of what they can provide.”
The new data from Fair Health, he said, shows the scope of the problem.
“What this tells you is this is not limited to a problem of the poor and unemployed,” he said. “This is a problem that is cutting right across society.”
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