Medicaid presently insures about one-fourth of the US population and disproportionately insures about 38 % of non-elderly adults with an opioid use disorder (OUD). Owing to Medicaid's prominent role insuring persons with an OUD and that Medicaid coverage includes pharmaceutical benefits, there has been considerable interest in studying potential prescription opioid misuse among Medicaid beneficiaries and identifying subpopulations at higher risk for misuse and possible progression to an OUD.
The study goals were to explore the associations among prescription opioid misuse, OUD, and co-occurring mental health and other substance use disorders (SUD). We analyzed Illinois Medicaid 2018 claims data for 1102479 adult beneficiaries 18 to 64 years of age. Using algorithms based on previous studies, we first determined either the presence or absence of nine SUDS (including OUD), nine mental health disorders and likely prescription opioid misuse. Then, we subdivided the beneficiary sample into five groups: those who were prescribed opioids and evidenced either no, possible, or probable misuse; those evidencing an OUD; and those evidencing no opioid use or misuse.
Bivariate analyses, upset plots, and multinomial logistic regressions were used to compare the five subgroups on the prevalence of co-occurring SUDS and mental health disorders. Those with an OUD or with probable prescription opioid misuse had the highest prevalence of most co-occurring conditions with beneficiaries with an OUD the most likely to evidence co-occurring SUDS, particularly tobacco use disorder, whereas those with probable misuse had elevated prevalence rates of co-occurring mental health disorders comparable to those with an OUD.
The medical complexity of persons with an OUD or misusing prescription opioids are considered in light of recent attempts to expand buprenorphine provision as a medication for OUD among Medicaid beneficiaries. Additionally, we consider the possibility of gender, co-occurring mental health disorders, and tobacco use disorder as important risk factors for progressing to prescription opioid misuse and an OUD.
Citation: James A. Swartz, Dana Franceschini, Kamryn Scamperle. Mental health and substance use disorder comorbidities among Medicaid beneficiaries: Associations with opioid use disorder and prescription opioid misuse[J]. AIMS Public Health, 2023, 10(3): 658-677. doi: 10.3934/publichealth.2023046
Medicaid presently insures about one-fourth of the US population and disproportionately insures about 38 % of non-elderly adults with an opioid use disorder (OUD). Owing to Medicaid's prominent role insuring persons with an OUD and that Medicaid coverage includes pharmaceutical benefits, there has been considerable interest in studying potential prescription opioid misuse among Medicaid beneficiaries and identifying subpopulations at higher risk for misuse and possible progression to an OUD.
The study goals were to explore the associations among prescription opioid misuse, OUD, and co-occurring mental health and other substance use disorders (SUD). We analyzed Illinois Medicaid 2018 claims data for 1102479 adult beneficiaries 18 to 64 years of age. Using algorithms based on previous studies, we first determined either the presence or absence of nine SUDS (including OUD), nine mental health disorders and likely prescription opioid misuse. Then, we subdivided the beneficiary sample into five groups: those who were prescribed opioids and evidenced either no, possible, or probable misuse; those evidencing an OUD; and those evidencing no opioid use or misuse.
Bivariate analyses, upset plots, and multinomial logistic regressions were used to compare the five subgroups on the prevalence of co-occurring SUDS and mental health disorders. Those with an OUD or with probable prescription opioid misuse had the highest prevalence of most co-occurring conditions with beneficiaries with an OUD the most likely to evidence co-occurring SUDS, particularly tobacco use disorder, whereas those with probable misuse had elevated prevalence rates of co-occurring mental health disorders comparable to those with an OUD.
The medical complexity of persons with an OUD or misusing prescription opioids are considered in light of recent attempts to expand buprenorphine provision as a medication for OUD among Medicaid beneficiaries. Additionally, we consider the possibility of gender, co-occurring mental health disorders, and tobacco use disorder as important risk factors for progressing to prescription opioid misuse and an OUD.
| [1] | Center for Medicaid and CHIP ServicesApril 2022 Medicaid and CHIP enrollment trends snapshot (2022). Available from: https://www.medicaid.gov/sites/default/files/2022-07/april-2022-medicaid-chip-enrollment-trend-snapshot_0.pdf. |
| [2] | Saunders H, Rudowitz R (2022) Demographics and health insurance coverage of nonelderly adults With mental illness and substance use disorders in 2020. Washington, DC: Kaiser Family Foundation. Available from: https://www.kff.org/medicaid/issue-brief/demographics-and-health-insurance-coverage-of-nonelderly-adults-with-mental-illness-and-substance-use-disorders-in-2020/. |
| [3] |
Saloner B, Li W, Bandara SN, et al. (2022) Trends In the use of treatment for substance use disorders, 2010–19. Health Aff (Millwood) 41: 696-702. https://doi.org/10.1377/hlthaff.2021.01767 
|
| [4] |
Becker WC, Fiellin DA (2020) When epidemics collide: Coronavirus disease 2019 (COVID-19) and the opioid crisis. Ann Intern Med 173: 59-60. https://doi.org/10.7326/M20-1210
|
| [5] | (2019) U.S. Department of Health and Human Services Centers for Medicare & Medicaid ServicesSubstance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act: Section 1003 Demonstration project to increase substance use provider capacity. U.S.: Departmemt of Health and Human Services Centers for Medicare & Medicaid Services. Available from: https://www.medicaid.gov/medicaid/benefits/behavioral-health-services/substance-use-disorder-prevention-promotes-opioid-recovery-and-treatment-for-patients-and-communities-support-act-section-1003/index.html. |
| [6] | Swartz JA, Franceschini D, Scamperle K, et al. (2022) Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) enrolled in Illinois Medicaid managed care-final project report. Chicago, IL: Illinois Department of Healthcare and Family Services. |
| [7] |
Manichikanti L, Helm S, Fellows B, et al. (2012) Opioid epidemic in the United States. Pain Physician 15: ES9-E38. https://doi.org/10.36076/ppj.2012/15/ES9
|
| [8] | Swartz JA (2012) Substance use in America: A documentary and reference guide. Santa Barbara, CA: ABC-CLIO. |
| [9] |
Ciccarone D (2019) The triple wave epidemic: Supply and demand drivers of the US opioid overdose crisis. Int J Drug Policy 71: 183-188. https://doi.org/10.1016/j.drugpo.2019.01.010
|
| [10] | Gardner EA, McGrath SA, Dowling G, et al. (2022) The opioid crisis: Prevalence and markets of opioids. Forsenic Science Review 34: 43-70. |
| [11] |
Compton WM, Jones CM, Baldwin GT (2016) Relationship between nonmedical prescription-opioid use and heroin Use. N Engl J Med 374: 154-163. https://doi.org/10.1056/NEJMra1508490
|
| [12] |
Bettinger JJ, Amarquaye W, Fudin J, et al. (2022) Misinterpretation of the “overdose crisis” continues to fuel misunderstanding of the role of prescription opioids. J Pain Res 15: 949-958. https://doi.org/10.2147/JPR.S367753
|
| [13] |
Fenton JJ, Magnan E, Tseregounis IE, et al. (2022) Long-term risk of overdose or mental health crisis after opioid dose tapering. JAMA Netw Open 5: e2216726. https://doi.org/10.1001/jamanetworkopen.2022.16726
|
| [14] |
Peachman RR (2023) Will the new CDC opioid guidelines help correct the course in pain care. JAMA 329: 111-113. https://doi.org/10.1001/jama.2022.22284
|
| [15] |
Mark TL, Parish W (2019) Opioid medication discontinuation and risk of adverse opioid-related health care events. J Subst Abuse Treat 103: 58-63. https://doi.org/10.1016/j.jsat.2019.05.001
|
| [16] | Spencer MR, Minino AM, Warner M (2022) Drug overdose deaths in the United States, 2001–2021. NCHS Data Brief, no. 457. Hyattsville, MD: National Center for Health Statistics. Available from: https://www.cdc.gov/nchs/products/databriefs/db457.html. |
| [17] |
Cepeda JA, Astemborski J, Kirk GD, et al. (2019) Rising role of prescription drugs as a portal to injection drug use and associated mortality in Baltimore, Maryland. PLoS One 14: e0213357. https://doi.org/10.1371/journal.pone.021335
|
| [18] |
Cicero TJ, Ellis MS, Surratt HL, et al. (2014) The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry 71: 821-826. https://doi.org/10.1001/jamapsychiatry.2014.366
|
| [19] |
Ciccarone D (2021) The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis. Curr Opin Psychiatry 34: 344-350. https://doi.org/10.1097/YCO.0000000000000717
|
| [20] |
Dilokthornsakul P, Moore G, Campbell JD, et al. (2016) Risk factors of prescription opioid overdose among Colorado Medicaid beneficiaries. J Pain 17: 436-443. https://doi.org/10.1016/j.jpain.2015.12.006
|
| [21] |
Fernandes JC, Campana D, Harwell TS, et al. (2015) High mortality rate of unintentional poisoning due to prescription opioids in adults enrolled in Medicaid compared to those not enrolled in Medicaid in Montana. Drug Alcohol Depend 153: 346-349. https://doi.org/10.1016/j.drugalcdep.2015.05.032
|
| [22] |
Sharp A, Jones A, Sherwood J, et al. (2018) Impact of Medicaid expansion on access to opioid analgesic medications and medication-assisted treatment. Am J Public Health 108: 642-648. https://doi.org/10.2105/AJPH.2018.304338
|
| [23] |
Swartz JA, Beltran SJ (2019) Prescription opioid availability and opioid overdose-related mortality rates in Medicaid expansion and non-expansion states. Addiction 114: 2016-2025. https://doi.org/10.1111/add.14741
|
| [24] |
Cochran G, Gordon AJ, Lo-Ciganic WH, et al. (2017) An examination of claims-based predictors of overdose from a large Medicaid program. Med Care 55: 291-298. https://doi.org/10.1097/MLR.0000000000000676
|
| [25] |
Callison K, Karletsos D, Walker B (2022) Opioid prescribing restrictions and opioid use among the Louisiana Medicaid population. Int J Drug Policy 107: 103770. https://doi.org/10.1016/j.drugpo.2022.103770
|
| [26] | (2020) Office of Inspector GeneralOpioids in Medicaid: Concerns about opioid use among beneficiaries in six Appalachian states in 2018 (OEI–05–19–00410). Washington, DC: U.S. Department of Health and Human Services. Available from: https://oig.hhs.gov/oei/reports/OEI-05-19-00410.pdf. |
| [27] |
Santo T, Campbell G, Gisev N, et al. (2022) Prevalence of mental disorders among people with opioid use disorder: A systematic review and meta-analysis. Drug Alcohol Depend 238: 109551. https://doi.org/10.1016/j.drugalcdep.2022.109551
|
| [28] |
Volkow ND, Jones EB, Einstein EB, et al. (2019) Prevention and treatment of opioid misuse and addiction: A review. JAMA Psychiatry 76: 208-216. https://doi.org/10.1001/jamapsychiatry.2018.3126
|
| [29] |
Rosoff DB, Smith GD, Lohoff FW (2021) Prescription opioid use and risk for major depressive disorder and anxiety and stress-related disorders: A multivariable mendelian randomization analysis. JAMA Psychiatry 78: 151-160. https://doi.org/10.1001/jamapsychiatry.2020.3554
|
| [30] |
Jones CM, McCance-Katz EF (2019) Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug Alcohol Depend 197: 78-82. https://doi.org/10.1016/j.drugalcdep.2018.12.030
|
| [31] |
Mahoney JJ, Winstanley EL, Lander LR, et al. (2021) High prevalence of co-occurring substance use in individuals with opioid use disorder. Addict Behav 114: 106752. https://doi.org/10.1016/j.addbeh.2020.106752
|
| [32] |
Davis MA, Lin LA, Liu H, et al. (2017) Prescription opioid use among adults with mental health disorders in the United States. J Am Board Fam Med 30: 407-417. https://doi.org/10.3122/jabfm.2017.04.170112
|
| [33] | Seal KH, Shi Y, Cohen G, et al. (2012) Association of mental health disorders with prescription opioids and high risk opioid use in US veterans of Iraq and Afghanistan. JAMA 307: 940-947. https://doi.org/10.1001/jama.2012.234 |
| [34] |
Jennings MV, Lee H, Rocha DB, et al. (2022) Identifying high-risk comorbidities associated with opioid use patterns using electronic health record prescription data. Complex Psychiatry 8: 47-55. https://doi.org/10.1159/000525313
|
| [35] | Baller J, Barrett A, Gill P, et al. (2020) Identifying beneficiaries with a treated substance use disorder (SUD): Technical specifications. Baltimore, MD: Centers for Medicaid and Medicare Services. |
| [36] | Donohue J, Cochran G, Gellad W, et al. (2016) Procedure for creating three opioid overdose risk factors: Diagnosis-based opioid abuse, utilization-based opioid misuse, and morphine milligram equivalents. Pittsburgh, PA: The Medicaid Research Center, University of Pittsburgh. |
| [37] | (2021) Centers for Disease Control and Prevention [CDC]File of national drug codes for opioid analgesics, and linked oral morphine milligram equivalent conversion factors, 2020 version. Atlanta, GA: . Available from: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#T1_down. |
| [38] | Center for Medicare and Medicaid Services Chronic Conditions WarehouseOther chronic health, mental health, and potentially disabling chronic conditions algorithms: MBSF_OTCC_{YYYY} File revised 07/2023 (2023). Available from: file:///Users/jamesswartz/Downloads/other-condition-algorithms-7.pdf. |
| [39] | (2021) StataCorpStata 17.1 for Mac. College Station, TX: StataCorp. |
| [40] | (2022) R Development Core TeamR: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing. |
| [41] | Cohen J (1988) Statistical power analysis for the behavioral sciences. New York: Routledge. |
| [42] | Krassowski M krassowski/complex-upset (2020).Zenodo. |
| [43] | Von Hippel PT.How many imputations do you need? A two-stage calculation using a quadratic rule. Sociol Methods Res (2020) 49: 699-718. https://doi.org/10.1177/0049124117747303 |
| [44] | Manchikanti L, Singh VM, Staats PS, et al. (2022) Fourth wave of opioid (illicit drug) overdose deaths and diminishing access to prescription opioids and interventional techniques: Cause and effect. Pain Physician 25: 97-124. |
| [45] |
Goetz TG, Becker JB, Mazure CM (2021) Women, opioid use and addiction. FASEB J 35: e21303. https://doi.org/10.1096/fj.202002125R
|
| [46] |
Serdarevic M, Striley CW, Cottler LB (2017) Sex differences in prescription opioid use. Curr Opin Psychiatry 30: 238-246. https://doi.org/10.1097/YCO.0000000000000337
|
| [47] | (2020) U.S. Departmemt of Health and Human ServicesSmoking cessation. A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Available from: https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf. |
| [48] |
Morris CD, Garver-Apgar CE (2020) Nicotine and opioids: A call for co-treatment as the standard of care. J Behav Health Serv Res 47: 601-613. https://doi.org/10.1007/s11414-020-09712-6
|
| [49] |
Custodio L, Malone S, Bardo MT, et al. (2022) Nicotine and opioid co-dependence: Findings from bench research to clinical trials. Neurosci Biobehav Rev 134: 104507. https://doi.org/10.1016/j.neubiorev.2021.12.030
|
| [50] |
Lanham HJ, Papac J, Olmos DI, et al. (2022) Survey of barriers and facilitators to prescribing buprenorphine and clinician perceptions on the Drug Addiction Treatment Act of 2000 Waiver. JAMA Netw Open 5: e2212419. https://doi.org/10.1001/jamanetworkopen.2022.12419
|
| [51] |
McCollum CG, Eaton E, Creger T, et al. (2023) Physicians' experiences with buprenorphine: A qualitative study of motivations for becoming X waivered and barriers to and facilitators of prescribing the medication for opioid use disorder. Drug Alcohol Depend 244: 109777. https://doi.org/10.1016/j.drugalcdep.2023.109777
|
| [52] | (2022) National Institutes of Health (NIH)When addiction and mental illness collide. USA: National Institutes of Health. Available from: https://heal.nih.gov/news/stories/collaborative-care. |
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James A. Swartz, Dana Franceschini, Kamryn Scamperle. Mental health and substance use disorder comorbidities among Medicaid beneficiaries: Associations with opioid use disorder and prescription opioid misuse[J]. AIMS Public Health, 2023, 10(3): 658-677. doi: 10.3934/publichealth.2023046
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