(61) Comparison of Opioid and Alcohol Use Disorders in an Urban Health System

Background & Introduction: The crisis of opioid use disorders (OUDs) continues to wreak havoc in the United States, with overdose and opioid-related deaths continuing to rise, and continued challenges in accessing OUD treatment.1 The opioid pandemic has received considerable local and federal government attention and associated funding. However, another substance use disorder is also steadily worsening and impacting millions of Americans. Alcohol-related deaths increased to > 140,000 in 2022, and heavy alcohol use increases the risk of developing many serious health conditions, including trauma, liver failure, heart disease, and multiple types of cancer.2 The general societal acceptance for alcohol use masks its heavy burden on our communities. We compare the impacts of OUD and AUD at Denver Health – an urban, safety-net, integrated healthcare system in Denver, Colorado that has an emergency department, urgent care centers, 500-bed acute-care hospital, family health centers, school-based health centers, public health clinics, specialty medical clinics, and outpatient behavioral health services. Comparing the impact of OUD and AUD helps to design better services and in advocate for population-level interventions.

Methods: We extracted data from Denver Health’s single electronic health record (EHR, Epic) to characterize the impact of opioid and alcohol misuse on the health system. We compared multiple measures of healthcare utilization among persons misusing opioids or alcohol, including 1) temporal trends in OUD- and AUD-related encounters between 2018-2023; 2) overall number and percent of patients with OUD and AUD diagnoses in 2023; 3) number and percent of emergency department visits related to OUD or opioid overdose and AUD or alcohol poisoning in 2023; and 4) number and percent of hospital admissions related to OUD or opioid overdose and AUD or alcohol poisoning in 2023. We captured patient and encounter-level data by querying encounter and billing ICD-10-CM diagnosis codes for opioid-related (OUD [F11] and opioid overdose [T40]) and alcohol-related (AUD [F10] and alcohol poisoning [T51]) for emergency department visits, hospital admissions, and outpatient visits (excluding immunization only visits) that occurred between 2018 and 2023 (excluding remission codes). We included AUD and OUD problem list ICD-10-CM diagnosis codes that were ‘active’ between 2018 and 2023 and patients were counted if they had an encounter in the period. For the temporal analysis, we counted unique patients with OUD or AUD across quarters and years. For 2023 we compared unique counts of patients and the percent of unique patients seen overall by type of substance.

Results: Whether assessed as active diagnoses, emergency department visits, or hospitalizations, alcohol-related visits were consistently more common than opioid-related visits in the Denver Health system. Between 2018-2023 there were almost twice as many patients with AUD than OUD at Denver Health. There were increases in the overall number of patients with OUD and AUD, though the percent of patients with either SUD stayed fairly stable (other than a transient increase in the percentage of patients seen with OUD and AUD during the first year of the COVID-19 pandemic). Looking in more detail at 2023, 3.5% of all patients had a diagnosed AUD (n=10,805 patients), compared with 1.7% of patients with a diagnosed OUD (n=5,074 patients). The ratio of AUD to OUD diagnoses was 2.1. Similar differences were seen for emergency department and hospitalization visits related to opioids and alcohol. In 2023, alcohol-related emergency department visits (n=15,865) outnumbered opioid-related emergency department visits (n=4,873) by more than three to one. Alcohol-related visits made up 9% of all emergency department visits in 2023, whereas opioid-related visits made up 3% of all emergency department visits. There were also more than twice as many alcohol-related hospitalizations compared to opioid-related hospitalizations at Denver Health in 2023. More than 12% of hospitalizations were related to alcohol (n=3,523), compared to more than 6% of hospitalizations related to opioids (n=1,768).

Conclusion & Discussion: We found a 2-4-fold greater impact of alcohol than opioids in an urban integrated healthcare system. The consistency of this finding over the 6 years of this analysis and across different measures to assess impact (diagnoses, emergency department visits, and hospitalization) are strong evidence of the greater impact of alcohol even at the height of the fentanyl epidemic. Clearly, there is a need for both individual-level interventions for AUD (e.g., enhanced screening, increased access to treatment) and population-level interventions (e.g., increased alcohol excise taxes, more public information about alcohol and health). This analysis has several limitations. It is limited to a single publicly-funded healthcare system, and we do not know if its results are generalizable. This analysis relies on diagnoses within the EHR; there was no standard screening for substance use disorders. The results may be affected by organizational changes between 2018-2023. There has also been a tremendous focus on OUD at Denver Health over the past 6 years, including implementing 24-hour availability of initiating medication-assisted treatment in the emergency department and expansions of methadone and buprenorphine in clinics. These changes may have increased propensity to diagnose OUD. Finally, it is likely that both OUD and AUD are under-diagnosed.

References: 1. Stein, B. D., Kilmer, B., Taylor, J., & Vaian, M. E. (2023). America’s Opioid Ecosystem: How Leveraging System Interactions Can Help Curb Addiction, Overdose, and Other Harms (RR-A604-1). RAND Corporation.
2. National Institute on Alcohol Abuse and Alcoholism (NIAAA). 2023. Alcohol Use in the United States: Age Groups and Demographic Characteristics. Retrieved from [https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-united-states-age-groups-and-demographic-characteristics]
3. Neisler, J., Shree, S., Reitzel, L. R., Chen, T. A., Kendzor, D. E., Obasi, E. M., Wrighting, Q., & Businelle, M. S. (2019). Characterizing Alcohol Use Behaviors among Homeless Men and Women. American journal of health behavior, 43(1), 37–49. https://doi.org/10.5993/AJHB.43.1.4