Association of initial opioid prescription duration and an opioid refill by pain diagnosis: Evidence from outpatient settings in ten US health systems.

OBJECTIVE: The Centers for Disease Control and Prevention's 2022 Clinical Practice Guideline for Prescribing Opioids for Pain cautioned that inflexible opioid prescription duration limits may harm patients. Information about the relationship between initial opioid prescription duration and a subsequent refill could inform prescribing policies and practices to optimize patient outcomes. We assessed the association between initial opioid duration and an opioid refill prescription. METHODS: We conducted a retrospective cohort study of adults ≥19 years of age in 10 US health systems between 2013 and 2018 from outpatient care with a diagnosis for back pain without radiculopathy, back pain with radiculopathy, neck pain, joint pain, tendonitis/bursitis, mild musculoskeletal pain, severe musculoskeletal pain, urinary calculus, or headache. Generalized additive models were used to estimate the association between opioid days' supply and a refill prescription. RESULTS: Overall, 220,797 patients were prescribed opioid analgesics upon an outpatient visit for pain. Nearly a quarter (23.5%) of the cohort received an opioid refill prescription during follow-up. The likelihood of a refill generally increased with initial duration for most pain diagnoses. About 1 to 3 fewer patients would receive a refill within 3 months for every 100 patients initially prescribed 3 vs. 7 days of opioids for most pain diagnoses. The lowest likelihood of refill was for a 1-day supply for all pain diagnoses, except for severe musculoskeletal pain (9 days' supply) and headache (3-4 days' supply). CONCLUSIONS: Long-term prescription opioid use increased modestly with initial opioid prescription duration for most but not all pain diagnoses examined.

Prescription Opioid Dose Reductions and Potential Adverse Events: a Multi-site Observational Cohort Study in Diverse US Health Systems.

BACKGROUND: In response to the opioid crisis in the United States, population-level prescribing of opioids has been decreasing; there are concerns, however, that dose reductions are related to potential adverse events. OBJECTIVE: Examine associations between opioid dose reductions and risk of 1-month potential adverse events (emergency department (ED) visits, opioid overdose, benzodiazepine prescription fill, all-cause mortality). DESIGN: This observational cohort study used electronic health record and claims data from eight United States health systems in a prescription opioid registry (Clinical Trials Network-0084). All opioid fills (excluding buprenorphine) between 1/1/2012 and 12/31/2018 were used to identify baseline periods with mean morphine milligram equivalents daily dose of  ≥ 50 during six consecutive months. PATIENTS: We identified 60,040 non-cancer patients with  ≥ one 2-month dose reduction period (600,234 unique dose reduction periods). MAIN MEASURES: Analyses examined associations between dose reduction levels (1- < 15%, 15- < 30%, 30- < 100%, 100% over 2 months) and potential adverse events in the month following a dose reduction using logistic regression analysis, adjusting for patient characteristics. KEY RESULTS: Overall, dose reduction periods involved mean reductions of 18.7%. Compared to reductions of 1- < 15%, dose reductions of 30- < 100% were associated with higher odds of ED visits (OR 1.14, 95% CI 1.10, 1.17), opioid overdose (OR 1.41, 95% CI 1.09-1.81), and all-cause mortality (OR 1.39, 95% CI 1.16-1.67), but lower odds of a benzodiazepine fill (OR 0.83, 95% CI 0.81-0.85). Dose reductions of 15- < 30%, compared to 1- < 15%, were associated with higher odds of ED visits (OR 1.08, 95% CI 1.05-1.11) and lower odds of a benzodiazepine fill (OR 0.93, 95% CI 0.92-0.95), but were not associated with opioid overdose and all-cause mortality. CONCLUSIONS: Larger reductions for patients on opioid therapy may raise risk of potential adverse events in the month after reduction and should be carefully monitored.

Health Care Utilization and Expenditures of Homeless Family Members Before and After Emergency Housing.

OBJECTIVES: To describe longitudinal health service utilization and expenditures for homeless family members before and after entering an emergency shelter. METHODS: We linked Massachusetts emergency housing assistance data with Medicaid claims between July 2008 and June 2015, constructing episodes of health care 12 months before and 12 months after families entered a shelter. We modeled emergency department visits, hospital admissions, and expenditures over the 24-month period separately for children and adults. RESULTS: Emergency department visits, hospital admissions, and expenditures rose steadily before shelter entry and declined gradually afterward, ending, in most cases, near the starting point. Infants, pregnant women, and individuals with depression, anxiety, or substance use disorder had significantly higher rates of all outcomes. Many children's emergency department visits were potentially preventable. CONCLUSIONS: Increased service utilization and expenditures begin months before families become homeless and are potentially preventable with early intervention. Infants are at greater risk. Public Health Implications. Early identification and intervention to prevent homeless episodes, focusing on family members with behavioral health disorders, who are pregnant, or who have young children, may save money and improve family health.

Frequent Emergency Department Visits and Hospitalizations Among Homeless People With Medicaid: Implications for Medicaid Expansion.

OBJECTIVES: We examined factors associated with frequent hospitalizations and emergency department (ED) visits among Medicaid members who were homeless. METHODS: We included 6494 Massachusetts Medicaid members who received services from a health care for the homeless program in 2010. We used negative binomial regression to examine variables associated with frequent utilization. RESULTS: Approximately one third of the study population had at least 1 hospitalization and two thirds had 1 or more ED visits. More than 70% of hospitalizations and ED visits were incurred by only 12% and 21% of these members, respectively. Homeless individuals with co-occurring mental illness and substance use disorders were at greatest risk for frequent hospitalizations and ED visits (e.g., incidence rate ratios [IRRs] = 2.9-13.8 for hospitalizations). Individuals living on the streets also had significantly higher utilization (IRR = 1.5). CONCLUSIONS: Despite having insurance coverage, homeless Medicaid members experienced frequent hospitalizations and ED visits. States could consider provisions under the Patient Protection and Affordable Care Act (e.g., Medicaid expansion and Health Homes) jointly with housing programs to meet the needs of homeless individuals, which may improve the quality and cost effectiveness of care.

Adherence to Buprenorphine Treatment Guidelines in a Medicaid Program.

BACKGROUND: Buprenorphine is the most frequently prescribed medication for treating substance use disorders in the United States, but few studies have evaluated the structure of treatment delivered in real-world settings. The purpose of this study is to investigate adherence to current buprenorphine treatment guidelines using administrative data for Massachusetts Medicaid. METHODS: We identified buprenorphine treatment episodes beginning in 2009 through pharmacy claims. We then used service claims to identify treatment-related physician, behavioral, and laboratory services received in the induction, stabilization, and maintenance phases of these treatment episodes. Rates of service utilization were compared with those recommended in treatment guidelines. RESULTS: A total of 3674 treatment episodes met inclusion criteria, representing 3005 unique Medicaid beneficiaries. Liver enzymes were tested in 47.3% of episodes, but testing for hepatitis C (23.2%), hepatitis B (19.6%), and human immunodeficiency virus (HIV; 13.7%) was less frequent. Adherence to recommended physician visit frequency was 37.6% during induction, 39.7% during stabilization, and 51.2% during maintenance. For behavioral care, adherence rates were 40.0% during induction, 41.2% during stabilization, and 41.0% during maintenance. Rates of toxicology testing met or exceeded recommendations in just over 60% of episodes in the induction (61.1%), stabilization (62.1%), and maintenance (61.4%) phases. Although rates varied by treatment phase, substantial proportions of episodes showed no evidence of physician visits (27.2-42.8%), behavioral care (44.3-60.0%), and toxicology screening (25.3-39.0%). CONCLUSIONS: Our data suggest that there is significant variability in the structure of buprenorphine treatment provided to Massachusetts Medicaid beneficiaries, and that half or less of episodes include physician and behavioral visits at recommended frequencies. The use of administrative data for this type of analysis is limited by the potential for missing or inaccurate data. More research is needed to establish the levels of services most closely associated with positive outcomes to help guide providers in offering the highest-quality care.

Health care utilization patterns of homeless individuals in Boston: preparing for Medicaid expansion under the Affordable Care Act.

OBJECTIVES: We studied 6494 Boston Health Care for the Homeless Program (BHCHP) patients to understand the disease burden and health care utilization patterns for a group of insured homeless individuals. METHODS: We studied merged BHCHP data and MassHealth eligibility, claims, and encounter data from 2010. MassHealth claims and encounter data provided a comprehensive history of health care utilization and expenditures, as well as associated diagnoses, in both general medical and behavioral health services sectors and across a broad range of health care settings. RESULTS: The burden of disease was high, with the majority of patients experiencing mental illness, substance use disorders, and a number of medical diseases. Hospitalization and emergency room use were frequent and total expenditures were 3.8 times the rate of an average Medicaid recipient. CONCLUSIONS: The Affordable Care Act provides a framework for reforming the health care system to improve the coordination of care and outcomes for vulnerable populations. However, improved health care coverage alone may not be enough. Health care must be integrated with other resources to address the complex challenges presented by inadequate housing, hunger, and unsafe environments.

Quality of Nursing Homes Admitting Working-Age Adults With Serious Mental Illness.

OBJECTIVE: This cross-sectional study examined the association between nursing home quality and admission of working-age persons (ages 22-64 years) with serious mental illness. METHODS: The study used 2015 national Minimum Data Set 3.0 and Nursing Home Compare (NHC) data. A logistic mixed-effects model estimated the likelihood (adjusted odds ratios [AORs] and 95% confidence intervals [CIs]) of a working-age nursing home resident having serious mental illness, by NHC health inspection quality rating. The variance partition coefficient (VPC) was calculated to quantify the variation in serious mental illness attributable to nursing home characteristics. Measures included serious mental illness (i.e., schizophrenia, bipolar disorder, and other psychotic disorders), health inspection quality rating (ranging from one star, below average, to five stars, above average), and other sociodemographic and clinical covariates. RESULTS: Of the 343,783 working-age adults newly admitted to a nursing home in 2015 (N=14,307 facilities), 15.5% had active serious mental illness. The odds of a working-age resident having serious mental illness was lowest among nursing homes of above-average quality, compared with nursing homes of below-average quality (five-star vs. one-star facility, AOR=0.78, 95% CI=0.73-0.84). The calculated VPC from the full model was 0.11. CONCLUSIONS: These findings indicate an association between below-average nursing homes and admission of working-age persons with serious mental illness, suggesting that persons with serious mental illness may experience inequitable access to nursing homes of above-average quality. Access to alternatives to care, integration of mental health services in the community, and improving mental health care in nursing homes may help address this disparity.

Characteristics of Working-Age Adults With Schizophrenia Newly Admitted to Nursing Homes.

OBJECTIVES: Persons aged <65 years account for a considerable proportion of US nursing home residents with schizophrenia. Because they are often excluded from psychiatric and long-term care studies, a contemporary understanding of the characteristics and management of working-age adults (22-64 years old) with schizophrenia living in nursing homes is lacking. This study describes characteristics of working-age adults with schizophrenia admitted to US nursing homes in 2015 and examines variations in these characteristics by age and admission location. Factors associated with length of stay and discharge destination were also explored. DESIGN: This is a cross-sectional study using the Minimum Data Set 3.0 merged to Nursing Home Compare. SETTING AND PARTICIPANTS: This study examines working-age (22-64 years) adults with schizophrenia at admission to a nursing home. METHODS: Descriptive statistics of resident characteristics (sociodemographic, clinical comorbidities, functional status, and treatments) and facility characteristics (ownership, geography, size, and star ratings) were examined overall, stratified by age and by admission location. Generalized estimating equation models were used to explore the associations of age, discharge to the community, and length of stay with relevant resident and facility characteristics. Coefficient estimates, adjusted odds ratios, and 95% CIs are presented. RESULTS: Overall, many of the 28,330 working-age adults with schizophrenia had hypertension, diabetes, and obesity. Those in older age subcategories tended to have physical functional dependencies, cognitive impairments, and clinical comorbidities. Those in younger age subcategories tended to exhibit higher risk of psychiatric symptoms. CONCLUSIONS AND IMPLICATIONS: Nursing home admission is likely inappropriate for many nursing home residents with schizophrenia aged <65 years, especially those in younger age categories. Future psychiatric and long-term care research should include these residents to better understand the role of nursing homes in their care and should explore facility-level characteristics that may impact quality of care.

Development and implementation of a prescription opioid registry across diverse health systems.

Objective: Develop and implement a prescription opioid registry in 10 diverse health systems across the US and describe trends in prescribed opioids between 2012 and 2018. Materials and Methods: Using electronic health record and claims data, we identified patients who had an outpatient fill for any prescription opioid, and/or an opioid use disorder diagnosis, between January 1, 2012 and December 31, 2018. The registry contains distributed files of prescription opioids, benzodiazepines and other select medications, opioid antagonists, clinical diagnoses, procedures, health services utilization, and health plan membership. Rates of outpatient opioid fills over the study period, standardized to health system demographic distributions, are described by age, gender, and race/ethnicity among members without cancer. Results: The registry includes 6 249 710 patients and over 40 million outpatient opioid fills. For the combined registry population, opioid fills declined from a high of 0.718 per member-year in 2013 to 0.478 in 2018, and morphine milligram equivalents (MMEs) per fill declined from 985 MMEs per fill in 2012 to 758 MMEs in 2018. MMEs per member declined from 692 MMEs per member in 2012 to 362 MMEs per member in 2018. Conclusion: This study established a population-based opioid registry across 10 diverse health systems that can be used to address questions related to opioid use. Initial analyses showed large reductions in overall opioid use per member among the combined health systems. The registry will be used in future studies to answer a broad range of other critical public health issues relating to prescription opioid use.

Twelve-month diagnosed prevalence of behavioral health disorders among elderly medicare and medicaid members.

OBJECTIVES: We examined the 12-month diagnosed prevalence of behavioral health disorders (BHDs) and dementia among elderly Medicare and Medicaid members in Massachusetts by primary payment source group (dual eligible, Medicare only, and Medicaid only) and age group (65-74 years, 75-84 years, and 85 years and older). DESIGN: A retrospective cross-sectional study. SETTING: Medicare and Medicaid programs. PARTICIPANTS: Massachusetts Medicare or Medicaid enrollees age 65 and older as of January 1, 2005, (N = 679,182). MEASUREMENTS: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes recorded on Medicare and Medicaid claims were used to identify the BHDs. RESULTS: The 12-month diagnosed prevalence was 19.4% for any BHD and 11.2% for dementia. The most common BHDs by disease category were major depression (severe mental illness [SMI]), other depression (other mental illness [OMI]), and alcohol abuse or dependence (subtance use disorder [SUD]). Dual eligibles had a considerably higher diagnosed prevalence of any BHD (38.8%), compared with 16.1% in the Medicare only group. The 12-month diagnosed prevalence of SMI, OMI, and dementia was higher in the older-age groups. Co-occurring SUD was higher for younger dual eligibiles. Dementia and mental illness co-occurred at much higher rates for dual eligibles than for either of the single-insurance groups. This combination increased with age in all three groups. CONCLUSIONS: The 12-month prevalence of BHDs and dementia among elderly dual eligibles was disproportionately higher than other elderly Medicare or Medicaid members. However, access barriers to behavioral health services for this vulnerable population could be significant because Medicare and Medicaid payment limitations resulted in financial disincentives for providing these services.

Beyond health plans: behavioral health disorders and quality of diabetes and asthma care for Medicaid beneficiaries.

BACKGROUND: Most health insurance plans monitor ambulatory care quality using the Healthcare Effectiveness Data and Information Set (HEDIS), publicly reporting results at the plan level. Plan-level comparisons obscure the influence of patients served or settings where care is delivered. Mental illness, substance abuse, and other physical comorbidities, particularly prevalent among Medicaid beneficiaries, can impact adherence to recommended care. We analyzed individual-level HEDIS measures for diabetes and asthma from 5 Medicaid managed care plans to understand how these factors contribute to quality. METHODS: We used claims and medical records to study HEDIS measures for persistent asthma (n = 9103) and diabetes (n = 1790) among beneficiaries enrolled in Massachusetts' Medicaid program during 2004 and 2005. Logistic regression models included patient-level demographic and health factors, provider type, region, and managed care plan. RESULTS: Alcohol and drug use disorders and emergency department use were associated with lower quality care for most measures. Glycemic control was better for patients with diabetes and severe mental illness. Patients with higher illness burden and with more frequent ambulatory visits received higher quality care for both conditions. Younger adults received recommended care less often than older adults. Quality varied across plans. CONCLUSIONS: Additional efforts to improve quality of care for asthma and diabetes for Medicaid beneficiaries are needed for individuals with substance use disorders and young adults. Although evidence of higher quality for patients with multiple conditions is encouraging, improving quality for comparatively healthier individuals might also produce significant long-term benefits.

Racial/ethnic disparities in mental health treatment in six Medicaid programs.

Little is known about ethnic and racial disparities in mental health care among Medicaid beneficiaries. The association between ethnicity and race and the utilization of mental health care was explored in six Medicaid programs. The analysis distinguished between different settings of care, including community-based, outpatient hospital, inpatient, and emergency departments (EDs). Racial and ethnic disparities in mental health care were observed across state Medicaid programs. Hispanic and African American beneficiaries with mental illness were much less likely than Whites to be treated in community-based settings. African Americans were more likely to receive mental health treatment in inpatient, ED, and outpatient hospital settings in some states. The implications of these findings and possible initiatives to enhance community-based mental health care among African American and Hispanic Medicaid beneficiaries are discussed.

Infants Exposed To Homelessness: Health, Health Care Use, And Health Spending From Birth To Age Six.

Homeless infants are known to have poor birth outcomes, but the longitudinal impact of homelessness on health, health care use, and health spending during the early years of life has received little attention. Linking Massachusetts emergency shelter enrollment records for the period 2008-15 with Medicaid claims, we compared 5,762 infants who experienced a homeless episode with a group of 5,553 infants matched on sex, race/ethnicity, location, and birth month. Infants born during a period of unstable housing resulting in homelessness had higher rates of low birthweight, respiratory problems, fever, and other common conditions; longer neonatal intensive care unit stays; more emergency department visits; and higher annual spending. Differences in most health conditions persisted for two to three years. Asthma diagnoses, emergency department visits, and spending were significantly higher through age six. While screening and access to health care can be improved for homeless infants, long-term solutions require a broader focus on housing and income.

Homelessness Contributes To Pregnancy Complications.

Homelessness during pregnancy poses significant health risks for mothers and infants. As health care providers increase their emphasis on social determinants of health, it is important to understand how unstable housing contributes to complications during pregnancy. We linked data about emergency shelter enrollees with Massachusetts Medicaid claims for the period January 1, 2008-June 30, 2015 to compare health care use and pregnancy complications for 9,124 women who used emergency shelter with those for 8,757 similar women who did not. Rates of mental illness and substance use disorders were significantly higher among homeless women. Adjusted odds of having nine pregnancy complications were also significantly higher for homeless women and remained substantially unchanged after we adjusted for behavioral health disorders. Emergency shelter users also had fewer ambulatory care visits and more months without billable care and were more likely to visit an emergency department. Homelessness and behavioral health disorders appear to be independent factors contributing to pregnancy complications and should be addressed simultaneously.

Case selection for a Medicaid chronic care management program.

Medicaid agencies are beginning to turn to care management to reduce costs and improve health care quality. One challenge is selecting members at risk of costly, preventable service utilization. Using claims data from the State of Vermont, we compare the ability of three pre-existing health risk predictive models to predict the top 10 percent of members with chronic conditions: Chronic Illness and Disability Payment System (CDPS), Diagnostic Cost Groups (DCG), and Adjusted Clinical Groups Predictive Model (ACG-PM). We find that the ACG-PM model performs best. However, for predicting the very highest-cost members (e.g, the 99th percentile), the DCG model is preferred.

Correlates of specialty substance use treatment among adults with opioid use disorders.

AIMS: To identify factors associated with the receipt of specialty substance use treatment among adults with opioid use disorders (OUD). DESIGN: Cross-sectional study based on 2010-2014 National Surveys on Drug Use and Health (NSDUH). SETTING AND PARTICIPANTS: Adults with a past-year OUD (n = 2488). The sample is representative of non-institutionalized US adults. MEASUREMENTS: Past-year OUD was determined using DSM-IV criteria. Past-year specialty substance use treatment was defined as receiving treatment for drug use at any of the following locations: rehabilitation facilities, hospitals (inpatient only), outpatient mental health centers, private doctors' offices, or methadone clinics. Multivariable logistic regression models were used to measure the independent association between potential correlates and specialty substance use treatment receipt. FINDINGS: Of adults with an OUD, 8.3% received past-year specialty substance use treatment. In a fully adjusted logistic regression model, the following factors were associated with increased odds of receiving specialty substance use treatment: ≥ 35 years old (adjusted Odds Ratio (aOR) = 2.55, 95% Confidence Interval (CI) = 1.04-6.26); unemployment (aOR = 1.92, 95% CI = 1.02-3.61); not in the labor force (aOR = 2.16, 95% CI = 1.15-4.06); never been married (aOR = 2.14, 95% CI = 1.04-4.39); arrested in past 12 months (aOR = 4.43, 95% CI = 2.45-7.99); opioid dependence (aOR = 3.82, 95% CI = 2.06-7.10); alcohol use disorder (aOR = 2.44, 95% CI = 1.44-4.11); and another drug use disorder (aOR = 3.22, 95% CI = 1.95-5.32). Living in a non-metropolitan county (aOR = 0.29, 95% CI = 0.12-0.68) and fair/poor health (aOR = 0.38, 95% CI = 0.17-0.86) were associated with decreased odds of receiving specialty substance use treatment. CONCLUSIONS: These findings suggest a need for the following efforts: strategies to increase individuals' recognition of their need for OUD treatment, expansion of insurance coverage for substance use treatment, expansion of earlier intervention services, adoption of a chronic care approach to substance use treatment, and an expansion of treatment capacity for rural communities.

Screening mammography among nursing home residents in the United States: Current guidelines and practice.

OBJECTIVE: United States (US) guidelines regarding when to stop routine breast cancer screening remain unclear. No national studies to-date have evaluated the use of screening mammography among US long-stay nursing home residents. This cross-sectional study was designed to identify prevalence, predictors, and geographic variation of screening mammography among that population in the context of current US guidelines. MATERIALS AND METHODS: Screening mammography prevalence, identified with Physician/Supplier Part B claims and stratified by guideline age classification (65-74, ≥75 years), was estimated for all women aged ≥65 years residing in US Medicare- and Medicaid- certified nursing homes (≥1 year) with an annual Minimum Data Set (MDS) 3.0 assessment, continuous Medicare Part B enrollment, and no clinical indication for screening mammography as of 2011 (n = 389,821). The associations between resident- and regional- level factors, and screening mammography, were estimated by crude and adjusted prevalence ratios from robust Poisson regressions clustered by facility. RESULTS: Women on average were 85.4 (standard deviation ±8.1) years old, 77.9% were disabled, and 76.3% cognitively impaired. Screening mammography prevalence was 7.1% among those aged 65-74 years (95% Confidence Interval (CI): 6.8%-7.3%) and 1.7% among those ≥75 years (95% CI, 1.7%-1.8%), with geographic variation observed. Predictors of screening in both age groups included race, cognitive impairment, frailty, hospice, and some comorbidities. CONCLUSIONS: These results shed light on the current screening mammography practices in US nursing homes. Thoughtful consideration about individual screening recommendations and the implementation of more clear guidelines for this special population are warranted to prevent overscreening.

Treatment for co-occurring mental and substance use disorders in five state Medicaid programs.

OBJECTIVES: This study described the locations and patterns of psychiatric and substance abuse treatment for Medicaid beneficiaries with co-occurring mental and substance use disorders in five states. METHODS: Medicaid beneficiaries aged 21 to 65 with psychiatric or substance use disorders were identified with claims and encounter records. Groups were further divided into those with and those without a diagnosed substance use disorder. Adjusted odds of treatment in community-based settings, inpatient facilities, emergency departments, and hospital outpatient departments were calculated. RESULTS: A total of 92,355 persons had a psychiatric disorder, 34,158 had a substance use disorder, and 14,256 had co-occurring psychiatric and substance use disorders. In all five states, beneficiaries with severe mental illness (schizophrenia, bipolar disorder, or major depression) and a substance use disorder had higher odds of inpatient, emergency department, and hospital-based outpatient psychiatric treatment, compared with those with severe mental illness alone. In four of five states, both severe and less severe mental illness and a co-occurring substance use disorder were associated with lower odds of community-based treatment compared with those with the respective mental illness alone. Compared with those with less severe mental illness alone, individuals with less severe psychiatric disorders and a co-occurring substance use disorder had higher odds of inpatient treatment in all states and of emergency department use in three of five states. Odds of inpatient and outpatient hospital use and emergency department use for substance abuse treatment were higher for persons with severe mental illness and a co-occurring substance use disorder in most states, compared with odds for those with a substance use disorder alone. CONCLUSIONS: Heavy inpatient and emergency department use by Medicaid beneficiaries with co-occurring substance use disorders is a consistent cross-state problem. Co-occurring disorders may decrease the likelihood of community-based treatment for those with less severe mental disorders and for those with severe mental illness, suggesting that policies focusing only on these settings may miss a significant proportion of people with these co-occurring disorders.