Adolescents Who Overdose on Opioids Not Getting Treatment
JANUARY 10, 2020
Rachel Alinsky, MD, MPH
Rachel Alinsky, MD, MPH, from the general pediatrics and adolescent medicine division at Johns Hopkins School of Medicine, and a team of US-based investigators analyzed more than 4 million Medicaid-enrolled adolescents between 13–22 years old to assess the characteristics and percentage of those who experienced nonfatal opioid overdose and received timely evidence-based treatment. Most patients did not receive timely addiction treatment after overdose and only 1 in 54 received pharmacotherapy with buprenorphine, naltrexone, or methadone.
Interventions are needed to help adolescents get treatment after overdose and improved access to evidence-based pharmacotherapy is needed, the investigators suggested.
Alinsky and colleagues used the 2009–2015 Truven-IBM Watson Health MarketScan Medicaid claims database from 16 deidentified states. The team included data from 4,039,216 Medicaid-enrolled adolescents. Those who received a primary or secondary diagnosis of opioid poisoning were included.
Overall, 3791 adolescents (0.1%) experienced a nonfatal opioid overdose between January 2009–September 2015—an incidence rate of 44.1 per 100,000 person-years. The median age of those who overdosed was 18 years old (interquartile range, 16–20 years old).
Younger children with opioid use disorder were nine-times more likely to receive pharmacotherapy (95% CI, 3.95–20.7) and nearly two-times more likely to receive behavioral health services (95% CI, 1.34–2.25) than those who were not diagnosed with opioid use disorder.
Those who overdosed on heroin were significantly less likely to receive any treatment after their overdose (aOR, .64; 95% CI, .49–.83) than those with other opioid overdose.
After 3 months, 8.1% of adolescents with incident heroin overdose and 2% of those with other opioid overdose experienced recurrent overdose. Only 1 in 54 received timely pharmacotherapy treatment and less than one-third received behavioral health services.
Among those who experienced an overdose, 2234 were female (58.9%) and 470 were pregnant (21%). A majority (65.7%) of the adolescents who overdosed were non-Hispanic white. Fewer than 20% of adolescents who overdosed received a diagnosis of opioid use disorder.
Additional characteristics linked to overdose also included comorbid acute or chronic pain conditions; depression; self-harm; anxiety; attention-deficit/hyperactivity disorder; alcohol use disorder; and other substance use disorders.
More than 1000 overdoses (26.4%) involved heroin, while 2790 (73.6%) were from other opioids. Overdoses from heroin were more common in the later calendar years and more often treated in the emergency department (80.2%) than inpatient settings (19.8%).
Adolescents who experienced heroin overdose were more likely than those who experienced other opioid overdose to be at least 18 years old, to be non-Hispanic white race or ethnicity (76.7% vs 61.8%; P <.001); to have previously received addiction treatment or to have received an opioid use disorder diagnosis (49.7% vs 8.2%; P <.001); alcohol use disorder (25.2% vs 16.5%; P <.001); or other substance use disorders (70.3% vs 37.3%; P <.001).
If an adolescent who overdosed on a different opioid, they were more likely than those with heroin overdose to have pain conditions; depression (67.7% vs 44.0%; P <.001); self-harm (40.8% vs 17.6%; P <.001); anxiety (51.1% vs 38.7%; P <.001); attention-deficit/hyperactivity disorder (22.2% vs 15.2%; P <.001); or previously received an opioid prescription (26.3% vs 11.6%; P <.001).
After the analysis of the characteristics, the investigators limited the sample to 3606 adolescents with continuous enrollment for at least 30 days after overdose. Those who overdosed from heroin had a more than seven-fold higher unadjusted recurrent overdose crude rate (heroin, 20,770 per 100,000 person-years vs other opioids, 2855 per 100,000 person-years; P <.001).
Among the 3606 adolescents, nearly 2500 (68.9%) did not receive addiction treatment within 30 days after the initial overdose. Fewer than 30% only received behavioral health services, while 1.9% received pharmacotherapy, either alone or in conjunction with behavioral health services.
Younger adolescents had lower unadjusted rates of pharmacotherapy treatment (13–15 years old, 0.5%; 16–17 years old, 0.8%; 18–20 years old, 1.8%; 21–22 years old, 4.2%). The same was seen for racial and ethnic minorities (Hispanic, 0%; non-Hispanic black, 0.2%; non-Hispanic white, 2.3%).
In the adjusted model, younger adolescents were more likely to receive any timely treatment due to higher rates of behavioral health services. Those with anxiety, depression, or self-harm were more likely to receive behavioral health services but not pharmacotherapy.
The findings reflect the high risk of opioid overdose among adolescents and characterized factors associated with opioid overdose in adolescents enrolled in Medicaid. Further, the study emphasizes the unmet need for addiction treatment for youths after an overdose. Timely receipt of pharmacotherapy for adults is associates with decreased mortality, and there is an urgent need to address the treatment gap for adolescents, the study investigators wrote.
Additional research should evaluate population-level effects of timely addiction treatment in reducing recurrent overdose and the effectiveness of programs to help adolescents get care after an overdose.
The study, “Receipt of Addiction Treatment After Opioid Overdose Among Medicaid-Enrolled Adolescents and Young Adults,” was published online in the journal JAMA Pediatrics.
Reducing Disparities in the Delivery of Healthcare to Patients with Lupus: A Q&A with Sam Lim, MD, Consortium Chair of the Lupus Initiative