Research Spotlights: March 2021

Certain state policies unintentionally increase overdose mortality for those with opioid use disorders

To address the growing opioid epidemic, policymakers have focused largely on controlling the prescription and use of opioid analgesics through the implementation of supply-side drug policies and harm-reduction policy measures. However, these policies have not yet been evaluated for their impact on indicators of prescription opioid abuse. In a study funded by the NIDA, scientists evaluated whether U.S. state drug policies were associated with variation in opioid misuse, opioid use disorder, and drug overdose mortality. Although this study found that existing state policies were associated with reduced misuse of prescription opioids, many of these policies were also associated with an increase in mortality from other illicit drugs like synthetic opioids.

Researchers focused on the evaluation of six U.S. state-level drug policies to determine if there was a reduction in indicators of prescription opioid abuse, the prevalence of opioid use disorder and overdose, the prescription of medication-assisted treatment (MAT), and drug overdose deaths. Mortality data from 50 states (obtained from the National Vital Statistics Systems) and claims data (obtained from 23 million commercially insured patients) between 2007 and 2018 were evaluated before and after implementation of state-level policies. These state-level policies included changes in access to prescription drug monitoring program (PDMP) state databases, mandatory PDMPs which require prescribers to access the PDMP database and review patient records prior to prescribing opioids under certain circumstances, pain clinic laws, prescription limit laws, naloxone access laws, and Good Samaritan laws.

Mandatory PDMPs were associated with decreases in: (1) number of overdose deaths due to natural opioids and methadone, (2) proportion of patients taking opioids, (3) number of patients with overlapping opioid claims, (4) number of patients with greater to or equal to 90 mg daily morphine doses, and 5) number of patients who engaged in drug seeking. The proportion of patients receiving MAT increased after the enactment of mandatory PDMPs, pain clinic laws, and prescription limit laws. Implementation of prescription limit laws were associated with a decrease in synthetic opioid deaths. However, other policies such as PDMPs (not mandatory) and naloxone access laws were associated with increases in overdose deaths due to other illicit drugs like synthetic opioids, cocaine, and heroin.

Although existing state policies were shown to reduce misuse of prescription opioids, this study shows that they may also have the unintended consequence of motivating those with opioid use disorders to access the illicit drug market, potentially increasing overdose mortality. These findings highlight the complexities of addressing the opioid epidemic in the U.S. Additional policy goals may need to be utilized that not only address the availability of legal opioids, but also improve social conditions in order to decrease the demand for opioids and other drugs of abuse.

Lee B, Zho W, Yang K, Ahn Y, Perry BL 2021. Systematic Evaluation of State Policy Interventions Targeting the US Opioid Epidemic, 2007-2018. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2020.36687

Out-of-pocket costs may increase for patients when insurers end grace period for COVID-19 hospital costs

In the U.S., insurance companies and government programs have absorbed the usual hospital costs patients would owe when treated for severe cases of COVID-19. Unfortunately, many of these waivers are temporary, and the associated future costs to patients are not known. Researchers supported by a grant from the NIDA assessed predictors of out-of-pocket costs for flu hospitalizations to estimate the potential costs for COVID-19 hospitalization and found that a permanent cost share waiver for hospitalizations may be a solution.

Since COVID-19 has disproportionally impacted the elderly, the current study assessed the magnitude of potential cost sharing for COVID-19 hospitalizations among patients enrolled in Medicare Advantage and the factors associated with higher levels of cost sharing. Data from the 2018 Optum De-Identified Clinformatics DataMart on patients hospitalized for influenza were used to estimate the financial burden of COVID-19 hospitalizations. The database housed 5.5 million Medicare Advantage patients during 2018. The sample included 14,278 hospitalizations of patients ages 65 and older that began in 2018 and included a primary or secondary diagnosis of influenza. Out-of-pocket spending was a sum of deductibles, coinsurance, and copays. Independent variables were patient demographic variables, the quarter when hospitalization began, plan type, intensive care use, and length of stay.

They found that the median hospital stay was four days with an average out-of-pocket spending of $987. Only 3 percent of the participants spent more than $2,500 and 0.3 percent exceeded $4,000. Factors associated with higher out-of-pocket expenses were intensive care use and enrollment in preferred provider organization plan. Some variation in out-of-pocket spending was found by patient age, sex, and census region.

Medicare Advantage patients have lower out-of-pocket expenses; however, previous research has indicated that 40 percent of Americans lacked enough savings to pay for a $400 emergency. In addition, the COVID-19 pandemic has put even more economic pressure on the lowest-income Americans. An examination of out-of-pocket expenses for people with private non-Medicare insurance who were hospitalized for respiratory infections pre-COVID-19 suggests out-of-pocket costs could be even higher. A limitation of this study is that examining flu or other respiratory infection hospitalizations may not accurately estimate out-of-pocket costs of COVID-19 pandemic. As the COVID-19 pandemic persists, this study provides support for making COVID-19 hospitalization coverage permanent or longer-term so that patients will not be fearful of high out-of-pocket expenses and delay seeking care for COVID-19, ultimately leading to worse outcomes.

Chua, K. P., & Conti, R. M. 2021. Out-of-Pocket Spending for Influenza Hospitalizations in Medicare Advantage. American Journal of Preventive Medicine

Mental illness may not be a factor in most mass shootings

What is the relationship between severe psychosis and mass shootings (defined by three or more victims, excluding the shooter)? The authors of this study were funded by the NIMH and other funding organizations to examine the relationship between mental health disorders and mass shootings. Depending on the study and definition of mental illness used, there is high variability in the percentage of mass shootings associated with mental illness. If the link between severe psychosis and mass shootings is overstated, then possibly both stigma of mental illness and policies to mitigate the risk of mass shootings need to be redirected to more effective indicators.

To examine the question linking mass shootings to severe psychosis, the researchers collected data of mass murders that had a personal cause, as opposed to within the context of war, terrorism, gang activity, or organized crime, from 1900 to 2019. 14,785 murders (1315 mass murders) were examined, in which 65 percent involved firearms. Data, including demographics, drug/alcohol misuse, history/symptoms of psychiatric or neurologic illness, firearm use and type of firearm, were compiled in the Columbia Mass Murder Database. Mass murderers were separated into two groups—those who used firearms versus those who did not. Their primary dependent variable was the proportion of individuals with a reported history of psychotic episodes in each group. Regression models were used to examine rate of mass murder by type and the impact of the above variables on the odds of using a firearm to commit mass murder.

Interestingly, researchers found that since 1970, mass shootings have occurred at more than twice the rate of other non-firearm mass murders. Descriptively, they found that 92 percent of the mass murderers were male, 63 percent of the cases were in the U.S., and 52 percent of the cases were committed by Caucasians with the average age of 32.3 years old. Of the mass murders in their database, lifetime psychotic symptoms were noted among 11 percent of the perpetrators (compared to 0.3–1 percent of the general population), including 18 percent of mass murderers who did not use firearms and 8 percent of those who did. Thirty percent of mass murderers had histories or symptoms of a psychiatric or severe neurologic disorder, and 20 percent had histories of restraining orders, arrests, or incarcerations. U.S.-based mass shooters were more likely to have histories of recreational drug use, misuse of alcohol, legal histories, and non-psychotic or neurologic symptoms.

In summary, the researchers found that mass murderers who used firearms were significantly less likely to have a lifetime history of psychotic symptoms than mass murderers who used other methods. These findings indicate that emphasis on serious mental illness as a risk factor for mass shootings is overstated, which may lead to public fear and stigmatization of mental illness. The authors noted limitations to this study, including the prospective study design and collection of psychiatric diagnoses from media reports and court/police records. Despite these limitations, the authors conclude that a more efficient and effective set of policies aimed at preventing mass shootings should target firearm access, recreational drug use and alcohol misuse, legal history, and non-psychotic psychopathology.

Brucato G, Appelbaum PS, Hesson H, Shea EA, Dishy G, Lee K, Pia T, Syed F, Villalobos A, Wall MM, Lieberman JA, Girgis RR. 2021. Psychotic symptoms in mass shootings v. mass murders not involving firearms: findings from the Columbia mass murder database. Psychol Med. 17:1-9. doi: 10.1017/S0033291721000076.