Ten-year trends in opioid prescribing and vaso-occlusive crises in sickle cell disease: a population-based national cohort study (2011-2022)

Abstract

Background: Patterns of opioid prescribing and vaso-occlusive crises (VOCs) are poorly characterized among individuals with sickle cell disease (SCD) across diverse insurance types and age groups. We aimed to evaluate opioid prescribing and VOC trends in publicly and commercially insured individuals with SCD over a 10-year time period in the United States (US).

Methods: We conducted a retrospective cohort study of US administrative claims (2011-2022), analyzing 45,726 commercial and Medicaid beneficiaries with SCD. Primary outcomes were monthly rates of outpatient opioid prescriptions and VOC-related acute care encounters. We used joinpoint regression models to estimate trends without pre-specifying breakpoints, stratified by insurance type (Medicaid vs commercial) and age group (1-12, 13-17, 18-27, 28-45, 46-64 years). Primary outcomes were monthly rates of outpatient opioid prescriptions and VOC-related acute care encounters. We used joinpoint regression models to estimate trends without pre-specifying breakpoints, stratified by insurance type (Medicaid vs commercial) and age group.

Findings: Among 45,726 individuals with SCD (mean age [SD] = 25.1 [16.2]; 39.7% female; 52.9% Medicaid, 47.1% commercial insurance), Medicaid beneficiaries had higher rates than commercial beneficiaries for monthly opioid prescribing (18.3 vs 14.0 per 100) and VOC encounters (16.6 vs 8.2 per 100). Monthly opioid prescribing per 100 people increased with age: 1-12 y = 5.1; 13-17 y = 11.3; 18-27 y = 22.5; 28-45 y = 24.6; 46-64 y = 20.6 per 100. Both Medicaid and commercial beneficiaries experienced declining opioid prescribing beginning in 2011 (commercial monthly percentage change [MPC] = -0.3% [95% CI: -0.3%, -0.2%]; Medicaid MPC = -0.5% [-0.6%, 0.5%]). Down-trending opioid prescribing was not consistently accompanied by up-trending VOCs until the COVID-19 pandemic's onset. Particularly among children and adolescents, VOC-related encounters increased significantly after 2020 across both commercial (MPC = 1.8% [1.5%, 2.2%]) and Medicaid (MPC = 0.6% [0.1%, 1.6%]) beneficiaries.

Interpretation: Opioid prescribing and VOC admissions vary by insurance and age. Opioid prescribing declined from 2011 but was not consistently accompanied by increased VOCs until after COVID-19.

Funding: Analyses of Merative MarketScan Commercial and Multi-State Medicaid Database were funded by grants NIH K12 DA041449 (PI: KYX; data analysts: JLB, DS). Effort for some personnel was supported by P50 MH122351 (KYX, PI: Eric Lenze MD, Michael Avidan MBBCh), K08 K08 DA061258 (KYX), the American Psychiatric Association (APA) Psychiatric Research Fellowship (with funding by NIDA and the APA, KYX), NIH K12NS130673 (LSM), NIH L60HL170453 (LSM), and the St. Louis University Research Institute Fellowship (RAG, JS, JFS, RH); these grants did not fund Merative MarketScan Commercial and Multi-State Medicaid Database data pull.

Keywords: Administrative claims; Age disparities; COVID-19; Insurance; Opioid prescribing; Sickle cell disease; Vaso-occlusive crises.

Fig. 1

Joinpoint (JP) models illustrating age-standardized rates of monthly outpatient opioid prescribing and VOC-related acute care encounters, 2011–2022 stratified by insurance. Joinpoint regression models identified significant trend changes marked by breakpoints for monthly age-standardized outpatient opioid prescribing and VOC-related acute care encounters by insurance type from 2011 to 2022. (a) Monthly age-standardized opioid prescribing per 100 individuals among commercial enrollees. Trend periods are as follows: January 2011–April 2012, MPC = −0.92% (95% CI: −2.91, −0.45)∗; April 2012–January 2021, MPC = −0.36% (−0.39, −0.30)∗; January 2021–December 2022, MPC = 0.56% (0.18, 1.25)∗. (b) Monthly age-standardized opioid prescribing per 100 individuals among Medicaid enrollees. Trend periods are as follows: January 2011–April 2012, MPC = −1.66% (95% CI: −2.93, −1.08)∗; April 2012–October 2016, MPC = −0.48% (−0.57, −0.29)∗; October 2016–June 2022, MPC = −1.00% (−1.13, −0.91)∗; June 2022–December 2022, MPC = 7.17% (3.11, 15.40)∗. (c) Monthly age-standardized VOC-related acute care encounters per 100 individuals among commercial enrollees. Trend periods are as follows: January 2011–March 2015, MPC = −0.46% (95% CI: −0.64, −0.33)∗; March 2015–January 2020, MPC = 0.21% (0.10, 0.41)∗; January 2020–April 2020, MPC = −7.96% (−9.88, −1.15)∗; April 2020–December 2022, MPC = 1.76% (1.48, 2.15)∗. (d) Monthly age-standardized VOC-related acute care encounters per 100 individuals among Medicaid enrollees. Trend periods are as follows: January 2011–September 2015, MPC = −0.16% (95% CI: −0.38, −0.04)∗; September 2015–March 2016, MPC = 1.88% (0.02, 5.03)∗; March 2016–December 2020, MPC = −0.45% (−0.69, −0.35)∗; December 2020–December 2022, MPC = 0.60% (0.11, 1.58)∗. MPC = monthly percentage change (95% CI); VOC = vaso-occlusive crisis. ∗Indicates MPC values significantly different from zero at α = 0.05 level.

Fig. 2

Joinpoint (JP) models illustrating age- and insurance-stratified rates of monthly outpatient opioid prescribing, 2011–2022. Joinpoint regression models identified trend changes in monthly age-stratified outpatient opioid prescribing by age group and insurance type from 2011 to 2022. Different colored lines represent distinct age groups (1–12, 13–17, 18–27, 28–45, 46–64 years). (a) Monthly age-stratified opioid prescribing per 100 individuals among commercial enrollees across age groups. Trend periods are as follows. For children, 1–12 years of age (orange line): January 2011–May 2017, MPC = 0.43% (95% CI: 0.29, 0.62)∗; May 2017–December 2022, MPC = −0.68% (−1.01, −0.46)∗. For adolescents, 13–17 years of age (blue line): January 2011–December 2022, MPC = −0.17% (−0.25, −0.11)∗. For adults, 18–27 years of age (purple line): January 2011–April 2012, MPC = −1.81% (−3.32, −1.09)∗; April 2012–February 2021, MPC = −0.28% (−0.34, −0.23)∗; February 2021–December 2022, MPC = 1.37% (0.77, 2.36)∗. For adults, 28–45 years of age (red line): January 2011–April 2020, MPC = −0.46% (−0.50, −0.42)∗; April 2020–December 2022, MPC = 0.29% (0.01, 0.77)∗. For adults, 46–64 years of age (green line): January 2011–December 2019, MPC = −0.46% (−0.55, −0.42)∗; December 2019–December 2022, MPC = −0.04% (−0.32, 1.11). (b) Monthly age-stratified opioid prescribing per 100 individuals among Medicaid enrollees across age groups. Trend periods are as follows. For children, 1–12 years of age (orange line): January 2011–September 2016, MPC = 0.45% (95% CI: 0.34, 0.61)∗; September 2016–September 2019, MPC = −0.55% (−1.15, −0.01)∗; September 2019–July 2022, MPC = −2.08% (−10.46, −1.51)∗; July 2022–December 2022, MPC = 11.65% (−0.38, 37.55). For adolescents, 13–17 years of age (blue line): January 2011–August 2022, MPC = −0.25% (−0.33, −0.20)∗; August 2022–December 2022, MPC = 8.99% (−0.17, 29.02). For adults, 18–27 years of age (purple line): January 2011–September 2017, MPC = −0.58% (−0.64, −0.51)∗; September 2017–April 2020, MPC = −1.47% (−6.19, −1.15)∗; April 2020–December 2022, MPC = −0.18% (−0.66, 0.80). For adults, 28–45 years of age (red line): January 2011–March 2013, MPC = −1.93% (−2.31, −1.69)∗; March 2013–July 2013, MPC = 2.91% (−0.36, 5.69); July 2013–April 2022, MPC = −1.01% (−1.07, −0.97)∗; April 2022–December 2022, MPC = 5.18% (2.52, 10.23)∗. For adults, 46–64 years of age (green line): January 2011–April 2012, MPC = −3.23% (−4.15, −2.54)∗; April 2012–October 2013, MPC = 0.97% (0.43, 2.12)∗; October 2013–July 2022, MPC = −0.93% (−0.99, −0.89)∗; July 2022–December 2022, MPC = 12.74% (6.98, 22.27)∗. MPC = monthly percentage change (95% CI); ∗Indicates MPC values significantly different from zero at α = 0.05 level.

Fig. 3

Joinpoint (JP) models illustrating age- and insurance-stratified rates of VOC-related acute care encounters, 2011–2022. Joinpoint regression models identified trend changes in monthly age-stratified VOC-related acute care encounters by age group and insurance type from 2011 to 2022. Different colored lines represent distinct age groups (1–12, 13–17, 18–27, 28–45, 46–64 years). (a) Monthly age-stratified VOC-related acute care encounters per 100 individuals among commercial enrollees across age groups. Trend periods are as follows. For children, 1–12 years of age (orange line): January 2011–January 2020, MPC = 0.02% (95% CI: −0.08, 0.11); January 2020–April 2020, MPC = −24.58% (−29.23, −5.48)∗; April 2020–December 2022, MPC = 3.62% (2.72, 4.92)∗. For adolescents, 13–17 years of age (blue line): January 2011–July 2021, MPC = −0.10% (−0.26, −0.02)∗; July 2021–December 2022, MPC = 2.30% (0.24, 13.84)∗. For adults, 18–27 years of age (purple line): January 2011–February 2014, MPC = −0.72% (−1.49, 0.74); February 2014–January 2020, MPC = −0.05% (−3.47, 4.17); January 2020–April 2020, MPC = −5.84% (−8.46, 3.97); April 2020–December 2022, MPC = 1.78% (0.40, 2.67)∗. For adults, 28–45 years of age (red line): January 2011–March 2011, MPC = 23.06% (−0.48, 39.16); March 2011–January 2014, MPC = −0.89% (−1.65, 0.15); January 2014–December 2021, MPC = 0.22% (0.10, 0.31)∗; December 2021–December 2022, MPC = 2.77% (1.15, 7.39)∗. For adults, 46–64 years of age (green line): January 2011–December 2013, MPC = 0.31% (−0.10, 1.02); December 2013–May 2015, MPC = −1.94% (−10.88, −0.79)∗; May 2015–December 2022, MPC = 0.64% (0.53, 0.76)∗. (b) Monthly age-stratified VOC-related acute care encounters per 100 individuals among Medicaid enrollees across age groups. Trend periods are as follows. For children, 1–12 years of age (orange line): January 2011–January 2020, MPC = 0.19% (95% CI: 0.11, 0.27)∗; January 2020–April 2020, MPC = −15.48% (−18.94, −2.71)∗; April 2020–December 2022, MPC = 2.19% (1.56, 3.13)∗. For adolescents, 13–17 years of age (blue line): January 2011–February 2020, MPC = 0.47% (0.40, 0.56)∗; February 2020–May 2020, MPC = −22.87% (−28.45, −10.43)∗; May 2020–August 2020, MPC = 25.38% (8.58, 35.97)∗; August 2020–December 2022, MPC = 0.95% (0.30, 1.45)∗. For adults, 18–27 years of age (purple line): January 2011–May 2011, MPC = 7.41% (0.48, 21.44)∗; May 2011–November 2017, MPC = −0.08% (−0.18, 0.004); November 2017–February 2018, MPC = −4.91% (−6.25, −0.45)∗; February 2018–December 2022, MPC = −0.17% (−0.30, 0.07). For adults, 28–45 years of age (red line): January 2011–April 2015, MPC = −0.39% (−0.56, −0.27)∗; April 2015–August 2016, MPC = 0.82% (0.23, 5.36)∗; August 2016–May 2019, MPC = −0.74% (−1.64, −0.53)∗; May 2019–December 2022, MPC = 0.04% (−0.12, 0.28). For adults, 46–64 years of age (green line): January 2011–December 2015, MPC = −0.61% (−0.90, −0.41)∗; December 2015–May 2016, MPC = 5.25% (0.72, 11.57)∗; May 2016–December 2022, MPC = −0.14% (−0.30, −0.04)∗. VOC = vaso-occlusive crisis; MPC = monthly percentage change (95% CI). ∗Indicates MPC values significantly different from zero at α = 0.05 level.