Short communicationHigh mortality rate of unintentional poisoning due to prescription opioids in adults enrolled in Medicaid compared to those not enrolled in Medicaid in Montana
Introduction
Unintentional death due to poisoning has been a growing concern in the United States, especially those poisonings due to prescription opioids (Paulozzi and Annest, 2007, Bohnert et al., 2010, Centers for Disease Control and Prevention, 2011). Since 2000, the unintentional poisoning rate in the United States has increased 2.5 times and correlates with the increased distribution of opioid pain medications (Paulozzi and Ryan, 2006, Paulozzi and Zi, 2008). In Montana, the crude mortality rate for unintentional poisoning has tripled since 2000 from 2.7 deaths/100,000 people to 8.8 deaths/100,000. Since 2003, nearly half (46%) of unintentional poisonings in Montana have been related to prescription opioids.
Several studies have reported that some sub-populations are at higher risk for death from unintentional opioid poisoning than others, including those enrolled in Medicaid (Centers for Disease Control and Prevention, 2011, Paulozzi and Zi, 2008). Among the risk characteristics associated with opioid overdose deaths are male gender, white or American Indian race, and adults aged 35–54 years. Opioid overdose deaths are not limited to any specific geography and rates vary widely by state depending on prescribing practices (CDC, 2011).
A number of studies have reported higher mortality rates associated with unintentional use of prescription opiates among persons enrolled in Medicaid compared to the general population (Centers for Disease Control and Prevention, 2009, Centers for Disease Control and Prevention, 2015). Washington State identified an eight-fold higher rate among adults enrolled in Medicaid than those not enrolled, while New York State reported a three-fold higher rate. A recent study using Medicaid claims from Tennessee found that having four or more prescribers, four or more pharmacies and more than 100 morphine milligram equivalences (MME) per year increased the risk of opioid-related overdose death (Baumblatt et al., 2014).
Several activities have occurred in Montana to address prescription opioid poisoning deaths. In 2003, Montana Medicaid initiated activities to monitor opioid prescribing more closely. These activities included: quantity limits, the early refill edit, and pharmacy case management for those being treated for pain management. In 2004, Team Care was implemented and restricted Medicaid members if the Montana Medicaid Program determined the member's utilization of service is excessive, inappropriate, or fraudulent with respect to medical need (ARM 37.86.5303). This program moved some members being treated with prescription opiates to one physician and one pharmacy. In 2005, a preferred drug list was implemented to restrict payment of non-preferred opioids. In October 2012 Montana implemented a voluntary statewide prescription drug registry (PDR). PDRs allow health care providers and pharmacists to protect their patients by determining if other controlled substance prescriptions from other prescribers have been filled. One goal of this program is to identify persons with drug seeking behaviors that may be in need of counseling as well as to decrease the amount of controlled substances available for illegal use.
In 2014, the Montana Department of Public Health and Human Services linked death records and Medicaid administrative claims to compare the morality rates associated with unintentional prescription opioid poisoning among adults who were enrolled and not enrolled in Medicaid at the time of their deaths as well as compare the change in mortality rates over two time periods. This report also describes the prescribing patterns, volume, and timeline for filling opioid prescriptions for Medicaid decedents.
Section snippets
Methods
Montana Medicaid is a fee-for-service model that provides health benefits to children and adults meeting certain eligibility criteria. Adults are eligible for basic Medicaid if they meet certain income requirements and are pregnant, blind or disabled, have dependent children under age 19, are former foster care children age 18–26 years, or are women diagnosed with breast or cervical cancer. Due to these eligibility requirements, there is about 1.8 times as many adult women as men enrolled in
Results
During 2003–2012, 358 Montana residents aged 18–64 years died from unintentional prescription opioid poisoning. One hundred decedents (28%) were determined to have been enrolled in Medicaid at the time of their death. Seventeen percent (n = 17) of the decedents enrolled in Medicaid were also dually enrolled in Medicare at the time of their death. The overall age adjusted mortality rate for unintentional prescription opiate use among adults aged 18–64 years was 6.1/100,000 (95% CI 5.5–6.8). The
Discussion
Our findings highlight the disproportionate burden of unintentional opioid prescription deaths among Montana adults enrolled compared to adults not enrolled in Medicaid. Adults enrolled in Medicaid had significantly higher rates of fatal unintentional prescription opioid poisoning than did non-Medicaid adults. Most of the Medicaid decedents also had multiple claims for prescription opioids over time and one third received a prescription within the month prior to their death. During the study
Role of funding source
This funding for this study was provided from the State of Montana and the authors are employees of the State of Montana.
Contributors
Jessie Fernandes and David Campana performed data analysis and drafting of the article. Steven Helgerson and Todd Harwell contributed to the design and drafting of the manuscript. All authors have given final approval for publishing.
Conflicts of interest
None.
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