Recreational marijuana laws and the misuse of prescription opioids: Evidence from National Survey on Drug Use and Health microdata.

Several studies have concluded that legalizing medical marijuana can reduce deaths from opioid overdoses. Drawing on micro data from the National Survey on Drug Use and Health, a survey uniquely suited to assessing patterns of substance use, we examine the relationship between recreational marijuana laws (RMLs) and the misuse of prescription opioids. Using a standard difference-in-differences (DD) regression model, we find that RML adoption reduces the likelihood of frequently misusing prescription opioids such as OxyContin, Percocet, and Vicodin. However, using a two-stage procedure designed to account for staggered treatment and dynamic effects, the DD estimate of relationship between RML adoption and the likelihood of frequently misusing prescription opioids becomes positive. Although event study estimates suggest that RML adoption leads to a decrease in the frequency of prescription opioid abuse, this effect appears to dissipate after only 2 or 3 years.

LETTER: Medicaid Expansion and Mental Health Care and Coverage: Reply.

No abstract available.

Care Coordination in Emergency Departments for Children and Adolescents With Behavioral Health Conditions: Assessing the Degree of Regular Follow-up After Psychiatric Emergency Department Visits.

BACKGROUND: Increasing numbers of children are receiving care for behavioral health conditions in emergency departments (EDs). However, studies of mental health-related care coordination between EDs and primary and/or specialty care settings are limited. Such coordination is important because ED care alone may be insufficient for patients' behavioral health needs. METHODS: We analyzed claims during the year 2014 from Truven Health Analytics MarketScan Medicaid and Commercial databases for outpatient services and prescription drugs for youth 2 to 18 years old with continuous enrollment. We applied a standard care coordination measure to insurance claims data in order to examine whether youth received a primary care or specialty follow-up visit within 7 days following an ED visit with a psychiatric diagnosis. We calculated descriptive statistics to evaluate differences in care coordination by enrollees' demographic, insurance, and health-related characteristics. In addition, we constructed a multivariate logistic regression model to detect the factors associated with the receipt of care coordination. RESULTS: The total percentages of children who received care coordination were 45.8% (Medicaid) and 46.6% (private insurance). Regardless of insurance coverage type, children aged 10 to 14 years had increased odds of care coordination compared with youth aged 15 to 18 years. Children aged 2 to 5 years and males had decreased odds of care coordination. CONCLUSIONS: It is of concern that fewer than half of patients received care coordination following an ED visit. Factors such as behavioral health workforce shortages, wait times for an appointment with a provider, and lack of reimbursement for care coordination may help explain these results.

Medicaid Expansion and Health Insurance Coverage and Treatment Utilization among Individuals with a Mental Health Condition.

BACKGROUND: The Affordable Care Act (ACA) gives states the option of expanding Medicaid coverage to low-income individuals; however, not all states have chosen to expand Medicaid. The ACA Medicaid expansions are particularly important for Americans with mental health conditions because they are substantially more likely than other Americans to have low incomes. AIMS OF THE STUDY: We examine the impact of Medicaid expansion on adults who were newly eligible for Medicaid using the 2008-2017 Medical Expenditure Panel Survey (MEPS). METHODS: We use the AHRQ PUBSIM model to identify low-income adults aged 19-64 who were either newly Medicaid eligible if they lived in an expansion state or would have been eligible had their state opted to expand its Medicaid program. We estimate linear probability models within a difference-in-difference framework. An additional interaction term allows us to test for differences among those with serious psychological distress (SPD) or probable depression (PD). Outcomes of interest are insurance coverage by type, behavioral health treatment by service (specifically, any behavioral health treatment, any specialty treatment, any psychotropic medication, any ambulatory treatment outside of an emergency department, and any emergency department treatment), quantities of behavioral health treatment services, and out of pocket spending on healthcare. RESULTS: Our adjusted difference-in-differences estimates indicate Medicaid expansion increased any insurance coverage by 14.2 percentage points and increased Medicaid coverage by 21.2 percentage points. Insurance coverage for individuals with SPD/PD in expansion states increased by an additional 12.9 percentage points. Medicaid expansion did not have an effect on behavioral health treatment for the newly eligible population as a whole or for the subset with SPD/PD. DISCUSSION: Consistent with previous Medicaid expansions, we find that the ACA Medicaid expansions substantially increased insurance rates for the newly Medicaid-eligible population, regardless of mental health status but the overall effect on insurance coverage was stronger among those with SPD/PD. The lack of an effect on treatment use suggests that providing insurance coverage alone may be insufficient to guarantee that people with mental illness will receive the treatment they need. Limitations include that our difference-in-difference estimator may not account for time-varying factors that change contemporaneously with the expansions. Our estimates may also be affected by other provisions of the ACA that went into effect at the same time as the Medicaid expansions. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE AND IMPLICATIONS FOR HEALTH POLICIES: Although the ACA has resulted in increased coverage for low-income individuals, more outreach efforts may be needed to encourage individuals with mental illness to get the treatment they need.

Follow-Up Care After Behavioral Health-Related Hospitalization for Children and Adolescents.

Although the coordination of follow-up behavioral health-related care between hospitals and outpatient behavioral health care settings is important, studies on this topic are few. Claims were selected from Truven Health Analytics' Marketscan databases during 2014 for youth aged 2-18 years who had an inpatient stay with a behavioral health diagnosis. Analyses identified whether youth received a behavioral health follow-up visit within 30 days following a hospitalization. The percentage of children who received post-hospitalization follow-up care was 59.1% (Medicaid) and 59.4% (private insurance). While children less than 15 years old (Medicaid) had increased odds of follow-up care compared with youth aged 15-18 years, children 2-9 years old with commercial insurance had decreased odds of follow-up care. Variations in follow-up care by patient characteristics provide an opportunity to target efforts to increase coordinated care to those who are least likely to receive it.

Characterizing behavioral health-related emergency department utilization among children with Medicaid: Comparing high and low frequency utilizers.

While the frequency of children's behavioral health (BH)-related visits to the emergency department (ED) is rising nationwide, few studies have examined predictors of high rates of ED use. This study examines Florida Medicaid claims (2011-2012) for children age 0-18 who were seen in an emergency department (ED) for behavioral health (BH) conditions. A logistic regression model was used to explore factors associated with frequent ED use and patterns of psychotropic medication utilization. The majority (95%) of patients with at least one BH-related ED visit had three or fewer of these visits, but 5% had four or more. Seventy-four percent of ED visits were not associated with psychotropic medication, including over half (54%) of visits for attention deficit hyperactivity disorder (ADHD). Frequent ED use was higher among older children and those with substance use disorders. The implementation of interventions that reduce non-emergent ED visits through the provision of care coordination, social work services, and/or the use of community health workers as care navigators may address these findings.

The Relationship Between Perceived Unmet Mental Health Care Needs and Suicidal Ideation and Attempt.

This study utilizes data from the National Survey of Drug Use and Health (NSDUH) to analyze the relationship between perceived unmet mental health care needs and suicidal ideation and attempt. Estimates from multivariable logistic regression models suggest that individuals who report perceived unmet mental health care needs have higher probability of experiencing suicidal ideation and attempt. Perceived unmet mental health care need has an important association with suicidal ideation and attempt, and efforts aimed at improving access to care are needed to address this issue.

Utilization of Mental Health Services by Preschool-Aged Children with Private Insurance Coverage.

There is increasing recognition that some preschool-aged children suffer from mental health conditions, but little is known about the treatment they receive. Using the 2014 MarketScan Commercial Claims and Encounters database (N = 1,987,759) the study finds that only a small proportion of preschool-aged children receive any behavioral interventions, including psychotherapy, in conjunction with having a filled psychiatric prescription. Nearly all of the preschool-aged children who had psychotropic prescriptions filled had no other claims for treatment, and among those children who had prescriptions for psychotropic medication filled, the vast majority did not have a mental health diagnosis on a claim.

Inpatient admissions from the ED for adults with injuries: the role of clinical and nonclinical factors.

INTRODUCTION: Inpatient hospital costs represent nearly a third of heath care spending. The proportion of inpatients visits that originate in the emergency department (ED) has been growing, approaching half of all inpatient admissions. Injury is the most common reason for adult ED visits, representing nearly one-quarter of all ED visits. OBJECTIVE: The objective was to explore the association of clinical and nonclinical factors with the decision to admit ED patients with injury. RESEARCH DESIGN AND PARTICIPANTS: This is a retrospective cohort study of injury-related ED encounters by adults in select states in 2009. We limited the study to ED visits of persons with moderately severe injuries. We used logistic regression to calculate the marginal effects, estimating 4 equations to account for different risk patterns for older and younger adults, and types of injuries. Regression models controlled for comorbidities, injury characteristics, demographic characteristics, and state fixed effects. RESULTS: Injury location, type, and mechanism and comorbidities had large effects on hospitalization rates as expected. We found higher inpatient admission rates by level of trauma center designation and hospital size, but findings differed by age and type of injury. For younger adults, patients with private insurance and patients who traveled more than 30 miles were more likely to be admitted. CONCLUSIONS: There is great variation in inpatient admission decisions for moderately injured patients in the ED. Decisions appear to be dominated by clinical factors such as injury characteristics and comorbidities; however, nonclinical factors, such as type of insurance, hospital size, and trauma center designation, also play an important role.

Admit or transfer? The role of insurance in high-transfer-rate medical conditions in the emergency department.

STUDY OBJECTIVE: We study the association of payer status with odds of transfer compared with admission from the emergency department (ED) for multiple diagnoses with a high percentage of transfers. METHODS: This was a retrospective study of adult ED encounters using the Healthcare Cost and Utilization Project 2010 Nationwide Emergency Department Sample. We used the Clinical Classification Software to identify disease categories with 5% or more encounters resulting in transfer (27 categories; 3.7 million encounters based on survey weights). We sorted encounters by condition into 12 groups according to expected medical or surgical specialist needs. We used logistic regression to assess the role of payer status on odds of transfer compared with admission and report adjusted odds ratios (ORs). RESULTS: Among high-transfer conditions in 2010, uninsured patients had double the odds of transfer compared with privately insured patients (OR 2.12; 95% confidence interval [CI] 1.72 to 2.62). Medicaid patients were also more likely to be transferred (OR 1.2; 95% CI 1.04 to 1.38). Uninsured patients had higher odds of transfer in all specialist categories (significant in 9 of 12). The categories with the highest odds of transfer for the uninsured included nephrology (OR 2.44; 95% CI 1.07 to 5.55), psychiatry (OR 2.26; 95% CI 1.65 to 3.25), and hematology-oncology (OR 2.21; 95% CI 1.50 to 3.25); the highest for Medicaid were general surgery (OR 1.61; 95% CI 1.09 to 1.83), hematology-oncology (OR 1.55; 95% CI 1.05 to 2.30), and vascular surgery (OR 1.55; 95% CI 1.02 to 2.28). CONCLUSION: Insurance status appears to play a role in ED disposition (transfer versus admission) for many high-transfer conditions.

State-level policies and receipt of CDC-informed opioid thresholds among commercially insured new chronic opioid users.

OBJECTIVES: To evaluate the association of state-level policies on receipt of opioid regimens informed by Centers for Disease Control and Prevention (CDC) morphine milligram equivalent (MME)/day recommendations. DESIGN: A retrospective cohort study of new chronic opioid users (NCOUs). SETTING: Commercially insured plans across the United States using IQVIA PharMetrics® Plus for Academics database with new chronic use between January 2014 and March 2015. PARTICIPANTS: NCOUs with ≥60-day coverage of opioids within a 90-day period with ≥30-day opioid-free period prior to the date of the first qualifying opioid prescription. INTERVENTIONS: State-level policies including Prescription Drug Monitoring Program (PDMP) robustness and cannabis policies involving the presence of medical dispensaries and state-wide decriminalization. MAIN OUTCOME MEASURES: NCOUs were placed in three-tiered risk-based average MME/day thresholds: low (>0 to <50), medium (≥50 to <90), and high (≥90). Multinomial logistic regression was used to estimate the association of state-level policies with the thresholds while adjusting for relevant patient-specific factors. RESULTS: NCOUs in states with medium or high PDMP robustness had lower odds of receiving medium (adjusted odds ratio [AOR] 0.74; 95 percent confidence interval [CI]: 0.62-0.69) and high (AOR 0.74; 95 percent CI: 0.59-0.92) thresholds. With respect to cannabis policies, NCOUs in states with medical cannabis dispensaries had lower odds of receiving high (AOR 0.75; 95 percent CI: 0.60-0.93) thresholds, while cannabis decriminalization had higher odds of receiving high (AOR 1.24; 95 percent CI: 1.04-1.49) thresholds. CONCLUSION: States with highly robust PDMPs and medical cannabis dispensaries had lower odds of receiving higher opioid thresholds, while cannabis decriminalization correlated with higher odds of receiving high opioid thresholds.

Short-term healthcare resource utilization associated with receipt of CDC-informed opioid thresholds among commercially insured new chronic opioid users.

OBJECTIVE: To evaluate the impact of recent changes to the Centers for Disease Control and Prevention (CDC) morphine milligram equivalent (MME)/day threshold recommendations on healthcare utilization. DESIGN: A retrospective cohort study of new chronic opioid users (NCOUs). SETTING: Commercially insured plans across the United States using IQVIA PharMetrics® Plus for Academics database with new use between January 2014 and March 2015. PATIENTS: NCOUs with ≥60-day coverage of opioids within a 90-day period with ≥30-day opioid-free period prior to the date of the first qualifying opioid -prescription. INTERVENTIONS: NCOU categorized by the CDC three-tiered risk-based average MME/day thresholds: low (>0 to <50), medium (≥50 to <90), and high (≥90). MAIN OUTCOME MEASURES: Multivariable logistic regression was used to calculate adjusted odds of incurring an acute care encounter (ACE) (all-cause and opioid-related) between the thresholds (adjusted odds, 95 percent confidence interval). RESULTS: In adjusted analyses, when compared to low threshold, there was no difference in the odds of all-cause ACE across the medium (1.01, 0.94-1.28) and high (1.01, 0.84-1.22) thresholds. When compared to low threshold, a statistically insignificant increase was observed when evaluating opioid-related ACE among medium (1.86, 0.86-4.02) and high (1.51, 0.65-3.52) thresholds. CONCLUSIONS: There was no difference in odds of an all-cause or opioid-related ACE associated with the thresholds. Early-intervention programs and policies exploring reduction of MME/day among NCOUs may not result in short-term reduction in all-cause or opioid-related ACEs. Further assessment of potential long-term reduction in ACEs among this cohort may be insightful.

Impact of the fall 2009 influenza A(H1N1)pdm09 pandemic on US hospitals.

BACKGROUND: Understanding how hospitals functioned during the 2009 influenza A(H1N1)pdm09 pandemic may improve future public health emergency response, but information about its impact on US hospitals remains largely unknown. RESEARCH DESIGN: We matched hospital and emergency department (ED) discharge data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project with community-level influenza-like illness activity during each hospital's pandemic period in fall 2009 compared with a corresponding calendar baseline period. We compared inpatient mortality for sentinel conditions at high-surge versus nonsurge hospitals. RESULTS: US hospitals experienced a doubling of pneumonia and influenza ED visits during fall 2009 compared with prior years, along with an 18% increase in overall ED visits. Although no significant increase in total inpatient admissions occurred overall, approximately 10% of all study hospitals experienced high surge, associated with higher acute myocardial infarction and stroke case fatality rates. These hospitals had similar characteristics to other US hospitals except that they had higher mortality for acute cardiac illnesses before the pandemic. After adjusting for 2008 case fatality rates, the association between high-surge hospitals and increased mortality for acute myocardial infarction and stroke patients persisted. CONCLUSIONS: The fall 2009 pandemic period substantially impacted US hospitals, mostly through increased ED visits. For a small proportion of hospitals that experienced a high surge in inpatient admissions, increased mortality from selected clinical conditions was associated with both prepandemic outcomes and surge, highlighting the linkage between daily hospital operations and disaster preparedness.

Changes in the Street Prices of Prescription Opioids During the COVID-19 Pandemic.

OBJECTIVE: This study analyzed changes in prescription opioid street prices during the COVID-19 pandemic. METHODS: Crowdsourced prescription opioid street prices were obtained from the Researched Abuse, Diversion and Addiction-Related Surveillance System StreetRx Program. Percentage changes in street price per milligram of different opioids between April and December 2020 compared with the same months in 2019 were calculated by using linear regression. RESULTS: Street prices of high-potency drugs hydromorphone and oxycodone increased 23% and 12% per milligram, respectively. Prices of low-potency drugs hydrocodone and morphine increased 9% and 12% per milligram, respectively. Changes in prices of medications for opioid use disorder were not statistically significant. CONCLUSIONS: Decreased access to opioid analgesics during the pandemic combined with contributors to opioid demand may have led to increases in street prices of prescription opioids. Measures taken to increase access to medications for opioid use disorder were not associated with changes in those drugs' street prices.

Outcomes Associated with Treatment with and Without Medications for Opioid Use Disorder.

There is limited research on outcomes for patients who start treatment for opioid use disorder (OUD) with only psychosocial treatment compared to those who initiate treatment with either medications for OUD (MOUD) or the combination of psychosocial treatment and MOUD. Cox proportional hazards regression was used on a database of individuals with commercial health insurance or Medicare Advantage to estimate the associations of treatment type with opioid overdose and self-harm (separately). Logistic regression was used to estimate the association of treatment type with prescription opioid fill following treatment initiation. Relative to patients who initiated treatment with only psychosocial treatment, patients who also initiated treatment with MOUD had lower risk of having an overdose inpatient or emergency department (ED) encounter, a self-harm inpatient or ED encounter, and a prescription opioid filled following treatment initiation. Starting treatment with MOUD was associated with better patient outcomes than initiating treatment with only psychosocial treatment.

Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay.

BACKGROUND: Policymakers are exploring ways to reduce readmission rates. Much attention has been given to readmissions for conditions such as heart failure, acute myocardial infarction, and pneumonia, but little attention has been given to readmissions of patients with injury-related index admissions. METHODS: This analysis is a retrospective cohort study of elderly persons who are admitted to a community hospital for a principal diagnosis of injury. We use 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases from 11 States. With logistic regression we identify factors associated with a 30-day, all-cause inpatient readmission. Factors include: patient characteristics, injury characteristics, clinical experiences during the hospital stay, and hospital characteristics. RESULTS: About 1 in 7 elderly patients with an injury-related admission were readmitted in 30 days (13.7%). We found that severe injuries had higher predicted readmission rates. Patients receiving transfusions, experiencing a Patient Safety Indicator event, and with infections had higher readmission rates. Patients discharged to nursing homes or home health care had higher readmission rates compared with patients discharged to the community. CONCLUSIONS: This study expands evidence for the influence of injury characteristics on readmission rates. It also provides evidence about hospital experiences that affect readmissions. These findings suggest that a focus on preventing complications during the hospital stay may help reduce hospital-specific readmissions for patients with injury-related conditions. It also suggests that a strategy to reduce readmission rates should not only focus on hospitals but also nursing homes and home health care.

Duration of patients' visits to the hospital emergency department.

BACKGROUND: Length of stay is an important indicator of quality of care in Emergency Departments (ED). This study explores the duration of patients' visits to the ED for which they are treated and released (T&R). METHODS: Retrospective data analysis and multivariate regression analysis were conducted to investigate the duration of T&R ED visits. Duration for each visit was computed by taking the difference between admission and discharge times. The Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) for 2008 were used in the analysis. RESULTS: The mean duration of T&R ED visit was 195.7 minutes. The average duration of ED visits increased from 8 a.m. until noon, then decreased until midnight at which we observed an approximately 70-minute spike in average duration. We found a substantial difference in mean duration of ED visits (over 90 minutes) between Mondays and other weekdays during the transition time from the evening of the day before to the early morning hours. Black / African American patients had a 21.4-minute longer mean duration of visits compared to white patients. The mean duration of visits at teaching hospitals was substantially longer than at non-teaching hospitals (243.8 versus 175.6 minutes). Hospitals with large bed size were associated with longer duration of visits (222.2 minutes) when compared to hospitals with small bed size (172.4 minutes) or those with medium bed size (166.5 minutes). The risk-adjusted results show that mean duration of visits on Mondays are longer by about 4 and 9 percents when compared to mean duration of visits on non-Monday workdays and weekends, respectively. CONCLUSIONS: The duration of T&R ED visits varied significantly by admission hour, day of the week, patient volume, patient characteristics, hospital characteristics and area characteristics.

Factors Associated With Initial Treatment Choice, Engagement, and Discontinuation for Patients With Opioid Use Disorder.

OBJECTIVE: Pharmacotherapy for opioid use disorder is effective but underused from a clinical perspective, and average treatment duration is shorter than current recommendations. In this analysis, the authors examined factors associated with initiation of, engagement in, and duration of treatment among patients with opioid use disorder. METHODS: Using the OptumLabs Data Warehouse (a large, national, deidentified database of commercial or Medicare Advantage plan enrollees), the authors identified a sample of 204,225 patients with opioid use disorder between July 1, 2010, and April 1, 2019. Factors associated with initial treatment type were identified with multinomial logistic regression. The odds of treatment engagement, defined as two claims for treatment and a treatment episode of ≥30 days, were estimated with logistic regression. The hazard ratios for treatment discontinuation were estimated with a Cox proportional hazards model. RESULTS: Treatment initiation with pharmacotherapy (alone or in combination with psychosocial therapy) was associated with higher odds of treatment engagement and a lower hazard of treatment discontinuation. Patients with certain behavioral health conditions (e.g., anxiety or mood disorders) had higher odds of initiating treatment with pharmacotherapy and engaging in treatment and a lower hazard of discontinuing treatment. Patients with certain painful general health conditions (e.g., fibromyalgia or musculoskeletal disorders) had lower odds of initiating and engaging in treatment. CONCLUSIONS: Treatment initiation with pharmacotherapy was associated with treatment engagement and duration. Previous contact with behavioral health treatment may support initiating, engaging in, and remaining in treatment. Patients with painful conditions may benefit from provider support in initiating treatment for opioid use disorder.

Impact of Mental Health Treatment on Suicide Attempts.

This paper analyzes the impact of mental health treatment on suicide attempts. While prior work demonstrates the effectiveness of mental health treatment at reducing suicide risk, few studies examine nationally representative populations or use broad measures of access to mental health services. A methodological problem can arise in studies of mental health treatment and suicidal behavior because a suicide attempt can result in the use of more mental health services. Using nationally representative survey data combined with national estimates of provider availability, this paper employs a methodological correction to address that potential problem of reverse causation. This paper uses measures of the density of health care providers in an area as statistical instruments for use of mental health treatment in an analysis of the impact of mental health treatment on suicide attempts. This study finds that mental health treatment significantly reduces suicide attempts.

Medical Marijuana Laws, Marijuana Use, and Opioid-Related Outcomes among Women in the United States.

BACKGROUND: In the context of the opioid epidemic, a limited but growing body of literature has found state medical marijuana laws (MMLs) to be associated with lower levels of opioid prescribing. However, robust evidence linking state MMLs with individual-level opioid-related outcomes is lacking, particularly among women. This finding is especially true for pregnant and parenting women, who have been disproportionately affected by the opioid crisis. METHODS: Using data drawn from the 2002-2014 National Survey on Drug Use and Heath, the study uses a difference-in-differences estimation strategy to compare opioid-related outcomes (opioid misuse initiation, opioid misuse in the past month and past year, and opioid use disorder) among all women, pregnant women, and parenting women in states with and without MMLs (before and after implementation). The study also investigates the impact of MMLs on marijuana use and marijuana use disorder. RESULTS: The findings indicate that MMLs were not associated with opioid misuse, opioid misuse initiation, or opioid use disorder among all women, pregnant women, and parenting women. These laws were, however, positively correlated with marijuana use and marijuana use disorder among all women and women with children. In addition, MMLs were associated with an increase in the frequency of opioid misuse for pregnant women and a decrease in the frequency of opioid misuse for parenting women. CONCLUSIONS: This finding suggests that, although medical marijuana may be viewed by some as a substitute for opioid analgesics, MMLs may not be an effective policy tool to tackle the opioid epidemic among women, especially pregnant and parenting women.