The branding of countries as pariah states, or “narco-states,” as it were, carries a stigma that resonates with the censuring functions performed by criminal labels in domestic contexts. These factors help explain why current efforts to restructure the regulatory frameworks governing cannabis markets are contained within the narrow space of policy experimentalism created by the textual ambiguity of the current treaties. Under these circumstances, many of the inherent weaknesses of the prohibitionist approach resurface in the new regulatory landscapes created by the decriminalization and depenalization of possession offenses. The involvement of criminal organizations in illicit drug markets remains significant given the illegality of supply-related activities. The growing formalizationof intermediate sanctions has a net-widening effect, which expands the use of control measures against low-risk drug offenders. Most fundamentally, the insistence on promoting drug liberalization reforms within the confines of the current system constrains the capacity of individual states and of the international community to imagine more effective and humane alternatives, such as those offered by harm-reduction and development-centered approaches. The United States faces a dynamic landscape regarding marijuana, opioids, and alcohol. Concerns about these substances center around opioid misuse, an ongoing high prevalence of alcohol-related harms, and the liberalization of marijuana use policies.
Not surprisingly, excessive use of alcohol, marijuana, weed dryer and prescription opioids increases risk of addiction and developing associated substance use disorders . In 2014, 17.0 million people 12 years of age or older were diagnosed with alcohol use disorder, 4.2 million had a marijuana use disorder, and 1.9 million had a disorder related to the non-medical use of prescription pain relievers. In recent years, heroin and other potent opioids such as fentanyl have made increasing contributions to rising opioid overdoses. In addition, persons with alcohol, marijuana, or opioid use disorder are more likely to have comorbid conditions, which worsen prognosis, contribute to poor health, and can lead to inappropriate health service use. Utilization of emergency department resources are 50% to 100% higher for patients with SUD compared with patients without SUD. In addition to acute medical emergencies, ED use may be indicative of poor health, unmet service need, or inappropriate use of health care. To date, studies have found most SUD-related ED visits are associated with alcohol, and frequently document ED-based treatments have focused on alcohol to the exclusion of other drugs. Yet, ED visits associated with the misuse of opioids and marijuana are common, and considerable SUD-related ED visits involve concurrent or other drug use. In addition, alcohol and opioid use disorders are among the most severe SUD diagnoses in terms of their negative impact on health, and evidence continues to emerge about the adverse health effects associated with marijuana use disorder. Thus, the study of ED trends among patients with alcohol, marijuana, and opioid use disorders is important.
High rates of SUD-related clinical emergencies and associated ED visits are a persistent barrier to improving health outcomes in this population. Thus, a study that seeks to identify how patients with alcohol, marijuana, and opioid use disorders use ED resources is important, to potentially inform more specific ED-based treatment efforts . This study examined ED trends across patients with alcohol, marijuana, and opioid use disorders, and controls, over time in a large integrated health care system in which all patients have insurance coverage to access health care. Using electronic health record data, we aimed to determine the odds of having an ED visit each year from 2010 to 2014 for patients with alcohol, marijuana, and opioid use disorders relative to controls without these conditions; evaluate differences in ED use between controls and those with alcohol, marijuana, and opioid use disorders over 5 years; and explore subsamples for which patients with SUD may have a greater impact on ED resources.We used secondary EHR data for this database-only study. These data were used to identify all health plan members who were aged 18 or older, who had a visit to a KPNC facility in 2010, and had a recorded ICD-9 diagnosis of alcohol, marijuana, or opioid abuse or dependence in 2010. The first mention for each ICD-9 diagnosis of alcohol, marijuana, or opioid use disorder recorded from January 1, 2010, to December 31, 2010, were included; patients in the sample could have multiple diagnoses . We also included all current or existing SUD diagnosis that were additionally documented for patients with alcohol, marijuana, or opioid use disorder during health plan visits in 2010 .
Within KPNC, SUD and other behavioral health diagnoses can be assigned to patients in any clinic setting, e.g., primary care or any specialty care clinic. Diagnoses can be assigned by physicians or any other qualified health care provider who is directly evaluating a patient. All diagnoses are captured through ICD-9 codes. Control patients were selected for all unique patients with alcohol, marijuana, and opioid use disorders and matched one-to-one on gender, age, and medical home facility. This accounted for differences in services, types of behavioral health conditions, or unobservable differences by geographic location. To control for varying lengths of membership, participants were required to be KPNC members for at least 80% of the study . The final analytical sample consisted of 35,148 patients: 12,411 with alcohol use disorder, 2752 with marijuana use disorder, 2411 with opioid use disorder, and 17,574 controls. Institutional review board approval was obtained from the Kaiser Foundation Research Institute. Alcohol, marijuana, and opioids frequently take center stage in public policy and debate as concerns remain focused around opioid misuse and overdose, ongoing drinking problems, and liberalization of marijuana use policies. Persons who excessively use these substances face the risk of developing an associated SUD,6 which can have considerable implications for patient health and health systems, in part by contributing to high use of ED services. Thus, we examined how patients with alcohol, marijuana, and opioid use disorders, and controls, used ED resources over time in a large health care system. Similar to studies conducted in the general population and other health systems, alcohol use disorder was diagnosed the most frequently, followed by marijuana use disorder, and opioid use disorder, and the rates of cooccurring medical, psychiatric, and SUD were substantial in each. Because these conditions worsen prognosis, lead to high morbidity, and can contribute to inappropriate service use, it is not surprising we found that patients with these disorders consistently had greater likelihood of ED use relative to controls. ED visits were the highest among patients with opioid use disorder, followed by those with marijuana and alcohol use disorders, which is contrary to prior work that has documented most SUD related ED visits are associated with alcohol use disorder. This difference could reflect the effects of changing marijuana use disorder patterns and an overall high morbidity among patients with opioid disorder, which may have large effects on health system resources. Most ED-based treatments focus on alcohol to the exclusion of other drugs, and since our data suggest that ED visits are also frequent among patients with marijuana and opioid use disorders, these patients may be at risk for having unmet or unidentified treatment needs.
Consequently, building on ED based treatments for patients with alcohol use disorder, it will be important for future studies to extend these treatments to patients with opioid and marijuana use disorders, to reduce medical emergencies and improve patient health in this population. Patients with opioid use disorder constituted a modest proportion of the sample, and these patients consistently had high odds of ED use. Similar to this, previous studies report that patients with opioid use disorder are over represented in ED settings. This could be due to the individual or combined effects of complex medical conditions, injury, or overdose, weed dryers which have large impact on the burden of disease and are some of the more persistent barriers to improving overall health outcomes among patients with opioid use disorder. Consequently, ED settings offer important opportunities to identify patients with opioid use disorder and initiate treatment. Recent evidence suggests that ED-initiated buprenorphine increases subsequent engagement in addiction treatment and reduces illicit opioid use. Devoting more health resources to initiating evidence-based ED-based treatments for patients with opioid use disorder in health systems, including ED-initiated buprenorphine and referral to SUD treatment, may be a step toward improving health outcomes and reducing high SUDrelated ED visits among patients with opioid use disorder. Over time, all patients had fewer ED visits, and a greater decrease in ED use was observed for patients with SUDs compared with controls, although those with SUDs continued to have more ED visits. These ED utilization patters are consistent with general population studies, which show decreasing ED visits involving alcohol and opioid use disorders. At the same time, our ED utilization patterns regarding marijuana use disorder are inconsistent with national data, which suggest increasing ED visits involving marijuana-related problems. This national increase could be due to the combined effects of increasing marijuana potency, liberalizing views of the drug, and increasing trends toward its legalization. Notably, however, we found a decrease in ED use over time across patients with marijuana use disorder as well as those with alcohol and opioid use disorders, which may suggest that some patients’ health status improves more quickly. Another possibility is that the observed decrease in ED use may be specific to those who receive care within integrate health systems in which specialty services are provided internally. For example, prior studies conducted within KPNC found that patients with SUD who had ongoing primary care and addiction treatment were less likely to have subsequent ED visits. It will be important for future studies in other systems to investigate the potential impact of specialty and primary care on reducing subsequent acute services across those with alcohol, marijuana, and opioid use disorders. Our results confirm the work of prior studies showing that patients with alcohol and opioid use disorders, and to a lesser degree patients with marijuana use disorder, have frequent and increasing ED visits over time associated with poor health or complex medical conditions. Since our medical comorbidity measure combined acute and chronic conditions, it will be important for future work to identify which individual medical conditions contribute most strongly to ED admission. Other characteristics that were not measured may also influence ED use rates in patients with SUD, and understanding these factors may further help improve service planning efforts and ED-based treatments for this population. In addition, comorbid conditions were common among patients with SUD, and these individuals may have ED visits that require a range of medical treatments, psychiatric symptom stabilization, or detoxification from alcohol or drugs. Limitations should be noted. Our use of provider-assigned diagnoses restricted the sample to patients with at least 1 of the 3 most common SUD diagnoses in 2010 . As with other studies that have used claims-based data, our study captures patients with SUD through ICD-9 codes noted in health plan visits during the study period. This methodology is vulnerable to diagnostic underestimation. Therefore, the SUD prevalence data in our study may underestimate the general ED patient population prevalence. Although not available for this study, future database studies could examine if the inclusion of pharmacy-based prescription data to ICD-9 diagnosis improves prevalence estimates. Another potential limitation with the methods we used to select our SUD sample is that we required a single mention of an ICD-9 code for SUD during the study period to link the patient with that diagnosis. Although the single mention methodology is well established, it could result in an overestimation of the true diagnostic rates if diagnoses only mentioned one time in the EHR are more likely to be inaccurate. Patients were insured members of an integrated health system, and thus our results may not be generalizable to uninsured populations or other types of health systems. Our findings of SUD-related ED trends are somewhat inconsistent with prior work, which suggests a need for replication. All patients were required to have a health system visit in 2010 to enter the study, but they were not required to have a health system visit to remain in the study. These criteria may explain the steep decline in ED visits between 2010 and 2011 and subsequent leveling of ED use. We cannot identify the reason for why patients had an ED visit , which will be an important focus of future work.