Introduction

The opioid epidemic has reached alarming levels in many parts of the United States, affecting the lives of thousands of individuals and families. Between 2000 and 2014, the rate of overdose deaths involving opioids in the United States increased 200 percent.¹ Between 2013 and 2014 alone, the rate of opioid overdose deaths increased 14 percent, from 7.9 to 9.0 per 100,000 population.² Hospitalizations related to opioid misuse and dependence also have increased dramatically, with the rate of adult hospital inpatient stays per 100,000 population nearly doubling between 2000 and 2012.³ The substantial increase over the past decade in the misuse of opioids, which include prescription opioids and illicit opioids such as heroin, has been declared an “opioid epidemic” by the U.S. Department of Health and Human Services (HHS).⁴

In March 2015, HHS launched its Opioid Initiative to help reverse the increasing trend in opioid misuse, use disorder, and overdoses, and to support State efforts to address the opioid crisis.⁵ In response to HHS initiatives, in December 2016 the Agency for Healthcare Research and Quality released statistics on opioid-related hospital use by State in the interactive, online tool for the Healthcare Cost and Utilization Project (HCUP), HCUP Fast Stats.⁶

This HCUP Statistical Brief presents data from HCUP Fast Stats on the national rate of opioid-related hospital inpatient stays and emergency department (ED) visits from 2005 to 2014. Rates for more than 40 individual States and the District of Columbia are provided for 2014 along with changes in rates for the 6-year period from 2009 to 2014. Identification of opioid-related stays and visits is based on all-listed diagnoses and includes events associated with prescription opioids or illicit opioids such as heroin. Differences greater than 10 percent between estimates are noted in the text.

Findings

National rate of opioid-related inpatient stays and ED visits, 2005–2014

Figure 1 presents the national rate per 100,000 population of opioid-related inpatient stays and ED visits from 2005 through 2014.

Figure 1

National rate of opioid-related inpatient stays and emergency department visits, 2005–2014. Abbreviation: ED, emergency department Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare (more...)

• Overall, the population rate of opioid-related inpatient stays was higher than the rate of opioid-related ED visits.
  Between 2005 and 2014, the population rate of opioid-related inpatient stays ranged from approximately 25 to 90 percent higher than the population rate of opioid-related ED visits.
• The rate of increase for opioid-related ED visits was greater than that for opioid-related inpatient stays.
  Between 2005 and 2014, the rate of opioid-related inpatient stays increased 64.1 percent, from 136.8 per 100,000 population in 2005 to 224.6 per 100,000 population in 2014. This represented a 5.7 percent average annual growth rate. During this same time period, the rate of opioid-related ED visits increased 99.4 percent, from 89.1 per 100,000 population in 2005 to 177.7 per 100,000 population in 2014. This represented an 8.0 percent average annual growth rate.

State rates of opioid-related inpatient stays, 2014

Figure 2 presents the rate per 100,000 population of opioid-related inpatient stays among 44 States and the District of Columbia that provided data in 2014. States are ordered according to their rate of opioid-related stays.

Figure 2

Rate of opioid-related inpatient stays by State, 2014. Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), HCUP Fast Stats, Opioid-Related Hospital (more...)

• The rate of opioid-related inpatient stays varied by a factor of 5.6 across 44 States and the District of Columbia in 2014.
  In 2014, the highest rate of opioid-related inpatient stays was in Maryland (403.8 stays per 100,000 population), which was 5.6 times higher than the lowest rate in Iowa (72.7). Following Maryland, the next highest rates of opioid-related inpatient stays were in Massachusetts (393.7), the District of Columbia (388.8), Rhode Island (377.4), and New York (360.5).
  The next lowest rates of opioid-related inpatient stays above Iowa were in Nebraska (78.6), Wyoming (96.7), Texas (98.6), and Kansas (104.3).

Figure 3 illustrates the percent change in the population rate of opioid-related inpatient stays from 2009 to 2014 among 43 States with data available in both years. States are ordered according to the percent change in their rate of opioid-related stays over the 6-year time period.

Figure 3

Cumulative percent change in the rate of opioid-related inpatient stays by State, 2009–2014. Note: Percent change could not be calculated for North Dakota or the District of Columbia because data were not available in 2009. Source: Agency for (more...)

• Most States had an increase in the rate of opioid-related inpatient stays between 2009 and 2014, with Georgia having the largest increase at 99.8 percent.
  The vast majority of States (36 of 43 States) had an increase of at least 10 percent in the population-based rate of opioid-related inpatient stays between 2009 and 2014. The largest increases occurred in Georgia (99.8 percent increase), North Carolina (70.9 percent increase), Oregon (60.2 percent increase), Washington (60.1 percent increase), and South Dakota (59.6 percent increase).
  Six States had a relatively stable rate of opioid-related inpatient stays, with a 6-year change in rate (increase or decrease) of less than 10 percent: Nebraska, New York, Maine, Louisiana, Illinois, and Maryland. In 2014, New York, Illinois, and Maryland were among the top 10 States in rate of opioid-related inpatient stays, as shown in Figure 2.
  Only one State, Kansas, showed a substantial decrease in the rate of opioid-related hospital inpatient stays (18.0 percent decrease). In 2014, Kansas was among the States with the lowest rate of opioid-related inpatient stays (104.3 stays per 100,000 population, as shown in Figure 2).

State rates of opioid-related ED visits, 2014

Figure 4 presents the rate per 100,000 population of opioid-related ED visits among 30 States that provided data in 2014. States are ordered according to their rate of opioid-related ED visits.

Figure 4

Rate of opioid-related emergency department visits by State, 2014. Abbreviation: ED, emergency department Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (more...)

• The rate of opioid-related ED visits varied 10-fold across 30 States in 2014.
  In 2014, the highest rate of opioid-related ED visits was in Massachusetts (450.2 visits per 100,000 population), which was approximately 10 times higher than the lowest rate in Iowa (45.1). Following Massachusetts, the next highest rates of opioid-related ED visits were in Maryland (300.7), Rhode Island (298.3), Ohio (287.9), and Connecticut (254.6).
  The next lowest rates above Iowa were in Nebraska (52.8), South Dakota (63.1), Arkansas (71.6), and Kansas (81.8).
  States with the highest opioid-related rate for inpatient stays also tended to have the highest opioid-related rate for ED visits: there was a strong, positive correlation (0.85) between States’ opioid-related population rates for inpatient stays and ED visits.

Figure 5 illustrates the percent change in the population rate of opioid-related ED visits from 2009 to 2014 among 27 States with data available in both years. States are ordered according to the percent change in their rate of opioid-related ED visits over the 6-year time period.

Figure 5

Cumulative percent change in the rate of opioid-related emergency department visits by State, 2009–2014. Abbreviation: ED, emergency department Notes: Percent change could not be calculated for three States (Arkansas, Nevada, North Dakota) because (more...)

• Almost all States had an increase in the rate of opioid-related ED visits between 2009 and 2014, with Ohio having the largest increase at 106.4 percent.
  Almost all States (26 of 27 States) had an increase of at least 10 percent in the population rate of opioid-related ED visits between 2009 and 2014. The highest rate increases occurred in Ohio (106.4 percent increase), South Dakota (94.7 percent increase), and Georgia (85.2 percent increase).
  Only one State, Iowa, showed a substantial decrease in the rate of opioid-related ED visits (15.6 percent decrease). Iowa also had the lowest rate of opioid-related ED visits (45.1 visits per 100,000 population, as shown in Figure 4).

Data Source

The estimates in this Statistical Brief are based upon data from the Healthcare Cost and Utilization Project (HCUP) 2005–2014 National (Nationwide) Inpatient Sample (NIS), 2005–2014 Nationwide Emergency Department Sample (NEDS), 2009–2014 State Inpatient Databases (SID), and 2009–2014 State Emergency Department Databases (SEDD). The statistics were generated from HCUP Fast Stats, a free, online tool that provides users with easy access to the latest HCUP-based statistics for health information topics, including opioid-related hospital use.⁷

Inpatient statistics from HCUP Fast Stats were available for the following 44 individual States and the District of Columbia in 2009 and 2014: Arizona, Arkansas, California, Colorado, Connecticut, District of Columbia (2014 only), Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota (2014 only), Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.

Emergency department (ED) statistics from HCUP Fast Stats were available for the following 30 individual States in 2009 and 2014: Arizona, Arkansas (2014 only), California, Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Maryland, Massachusetts, Minnesota, Missouri, Nebraska, Nevada (2014 only), New Jersey, New York, North Carolina, North Dakota (2014 only), Ohio, Rhode Island, South Carolina, South Dakota, Tennessee, Utah, Vermont, and Wisconsin.

Definitions

For More Information

For other information on mental health and substance abuse, including opioids, refer to the HCUP Statistical Briefs located at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb_mhsa.jsp.

For additional HCUP statistics, visit:

• HCUP Fast Stats at http://www.hcup-us.ahrq.gov/faststats/landing.jsp for easy access to the latest HCUP-based statistics for health information topics
• HCUPnet, HCUP’s interactive query system, at http://hcupnet.ahrq.gov/

For more information about HCUP, visit http://www.hcup-us.ahrq.gov/.

For a detailed description of HCUP and more information on the design of the National (Nationwide) Inpatient Sample, Nationwide Emergency Department Sample (NEDS), State Inpatient Databases (SID), or State Emergency Department Databases (SEDD), please refer to the following database documentation:

Agency for Healthcare Research and Quality. Overview of the National (Nationwide) Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality. Updated November 2015. http://www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed February 17, 2016.

Agency for Healthcare Research and Quality. Overview of the Nationwide Emergency Department Sample (NEDS). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality. Updated January 2016. http://www.hcup-us.ahrq.gov/nedsoverview.jsp. Accessed February 17, 2016.

Agency for Healthcare Research and Quality. Overview of the State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality. Updated January 2016. http://www.hcup-us.ahrq.gov/sidoverview.jsp. Accessed February 17, 2016.

Agency for Healthcare Research and Quality. Overview of the State Emergency Department Databases (SEDD). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality. Updated January 2016. http://www.hcup-us.ahrq.gov/seddoverview.jsp. Accessed February 17, 2016.

About Statistical Briefs

HCUP Statistical Briefs are descriptive summary reports presenting statistics on hospital inpatient, ambulatory surgery, and emergency department use and costs, quality of care, access to care, medical conditions, procedures, patient populations, and other topics. The reports use HCUP administrative health care data.

About the NIS

The HCUP National (Nationwide) Inpatient Sample (NIS) is a nationwide database of hospital inpatient stays. The NIS is nationally representative of all community hospitals (i.e., short-term, non-Federal, nonrehabilitation hospitals). The NIS includes all payers. It is drawn from a sampling frame that contains hospitals comprising more than 95 percent of all discharges in the United States. The vast size of the NIS allows the study of topics at the national and regional levels for specific subgroups of patients. In addition, NIS data are standardized across years to facilitate ease of use. Over time, the sampling frame for the NIS has changed; thus, the number of States contributing to the NIS varies from year to year. The NIS is intended for national estimates only; no State-level estimates can be produced.

The 2012 NIS was redesigned to optimize national estimates. The redesign incorporates two critical changes:

• Revisions to the sample design—starting with 2012, the NIS is now a sample of discharge records from all HCUP-participating hospitals, rather than a sample of hospitals from which all discharges were retained (as is the case for NIS years before 2012).
• Revisions to how hospitals are defined—the NIS now uses the definition of hospitals and discharges supplied by the statewide data organizations that contribute to HCUP, rather than the definitions used by the American Hospital Association (AHA) Annual Survey of Hospitals.

The new sampling strategy is expected to result in more precise estimates than those that resulted from the previous NIS design by reducing sampling error: for many estimates, confidence intervals under the new design are about half the length of confidence intervals under the previous design. The change in sample design for 2012 makes it necessary to recalculate prior years’ NIS data to enable analyses of trends that use the same definitions of discharges and hospitals.

About the NEDS

The HCUP Nationwide Emergency Department Database (NEDS) is a unique and powerful database that yields national estimates of emergency department (ED) visits. The NEDS was constructed using records from both the HCUP State Emergency Department Databases (SEDD) and the State Inpatient Databases (SID). The SEDD capture information on ED visits that do not result in an admission (i.e., treat-and-release visits and transfers to another hospital); the SID contain information on patients initially seen in the emergency department and then admitted to the same hospital. The NEDS was created to enable analyses of ED utilization patterns and support public health professionals, administrators, policymakers, and clinicians in their decisionmaking regarding this critical source of care. The NEDS is produced annually beginning in 2006. Over time, the sampling frame for the NEDS has changed; thus, the number of States contributing to the NEDS varies from year to year. The NEDS is intended for national estimates only; no State-level estimates can be produced.

About the SID

The HCUP State Inpatient Databases (SID) are hospital inpatient databases from data organizations participating in HCUP. The SID contain the universe of the inpatient discharge abstracts in the participating HCUP States, translated into a uniform format to facilitate multistate comparisons and analyses. Together, the SID encompass more than 95 percent of all U.S. community hospital discharges. The SID can be used to investigate questions unique to one State, to compare data from two or more States, to conduct market-area variation analyses, and to identify State-specific trends in inpatient care utilization, access, charges, and outcomes.

About the SEDD

The HCUP State Emergency Department Databases (SEDD) include information from hospital-owned emergency departments (EDs) from data organizations participating in HCUP, translated into a uniform format to facilitate multistate comparisons and analyses. The SEDD capture information on ED visits that do not result in an admission to the same hospital (i.e., patients who are treated in the ED and then discharged, transferred to another hospital, left against medical advice, or died). The SEDD contain a core set of clinical and nonclinical information on all patients, including individuals covered by Medicare, Medicaid, or private insurance, as well as those who are uninsured. The SEDD can be used to investigate questions unique to one State, to compare data from two or more States, to conduct market-area variation analyses, and to identify State-specific trends in injury surveillance, emerging infections, and other conditions treated in the ED.

About HCUP Fast Stats

HCUP Fast Stats is an interactive, online tool that provides easy access to HCUP-based statistics for select State and national health information topics. HCUP Fast Stats uses side-by-side comparisons of visual statistical displays, trend figures, or simple tables to convey complex information at a glance. Topics currently available in HCUP Fast Stats include the Effect of Health Insurance Expansion on Hospital Use by State; National Hospital Utilization and Costs; and Opioid-Related Hospital Use, National and State. HCUP Fast Stats presents statistics using data from HCUP’s National (Nationwide) Inpatient Sample (NIS), the Nationwide Emergency Department Sample (NEDS), the State Inpatient Databases (SID), and the State Emergency Department Databases (SEDD).

Suggested Citation

Weiss AJ (Truven Health Analytic), Elixhauser A (AHRQ), Barrett ML (M.L. Barrett, Inc.), Steiner CA (AHRQ), Bailey MK (Truven Health Analytics), O’Malley L (Truven Health Analytics). Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009–2014. HCUP Statistical Brief #219. December 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www​.hcup-us.ahrq​.gov/reports/statbriefs​/sb219-Opioid-Hospital-Stays-ED-Visits-by-State.pdf.

Acknowledgments

The authors would like to acknowledge the contributions of Brian Eppert of Coding Leap, LLC, and Minya Sheng of Truven Health Analytics.