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Original Investigation
June 24, 2020

Predictive Modeling of Opioid Overdose Using Linked Statewide Medical and Criminal Justice Data

Author Affiliations
  • 1Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 2Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 3Center for Population Health IT, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 4Department of Population Health, New York University School of Medicine, New York
  • 5Chesapeake Regional Information System for Our Patients, Columbia, Maryland
  • 6Behavioral Health Administration, Maryland Department of Health, Baltimore
JAMA Psychiatry. Published online June 24, 2020. doi:10.1001/jamapsychiatry.2020.1689
Key Points

Question  What factors most strongly predict opioid overdose in a linked statewide administrative data set?

Findings  In this predictive modeling study of 4 statewide Maryland databases with data from 2.2 million individuals, fatal opioid overdose in the next 12 months could be predicted with an area under the curve as high as 0.89. The factors most strongly associated with the baseline year (by odds ratio) included male sex, use of addiction treatment, at least 1 nonfatal overdose, and release from prison.

Meaning  Public health efforts to prioritize lifesaving interventions should consider the relative risk of overdose across different population groups.


Importance  Responding to the opioid crisis requires tools to identify individuals at risk of overdose. Given the expansion of illicit opioid deaths, it is essential to consider risk factors across multiple service systems.

Objective  To develop a predictive risk model to identify opioid overdose using linked clinical and criminal justice data.

Design, Setting, and Participants  A cross-sectional sample was created using 2015 data from 4 Maryland databases: all-payer hospital discharges, the prescription drug monitoring program (PDMP), public-sector specialty behavioral treatment, and criminal justice records for property or drug-associated offenses. Maryland adults aged 18 to 80 years with records in any of 4 databases were included, excluding individuals who died in 2015 or had a non-Maryland zip code. Logistic regression models were estimated separately for risk of fatal and nonfatal opioid overdose in 2016. Model performance was assessed using bootstrapping. Data analysis took place from February 2018 to November 2019.

Exposures  Controlled substance prescription fills and hospital, specialty behavioral health, or criminal justice encounters.

Main Outcomes and Measures  Fatal opioid overdose defined by the state medical examiner and 1 or more nonfatal overdoses treated in Maryland hospitals during 2016.

Results  There were 2 294 707 total individuals in the sample, of whom 42.3% were male (n = 970 019) and 53.0% were younger than 50 years (647 083 [28.2%] aged 18-34 years and 568 160 [24.8%] aged 35-49 years). In 2016, 1204 individuals (0.05%) in the sample experienced fatal opioid overdose and 8430 (0.37%) experienced nonfatal opioid overdose. In adjusted analysis, the factors mostly strongly associated with fatal overdose were male sex (odds ratio [OR], 2.40 [95% CI, 2.08-2.76]), diagnosis of opioid use disorder in a hospital (OR, 2.93 [95% CI, 2.17-3.80]), release from prison in 2015 (OR, 4.23 [95% CI, 2.10-7.11]), and receiving opioid addiction treatment with medication (OR, 2.81 [95% CI, 2.20-3.86]). Similar associations were found for nonfatal overdose. The area under the curve for fatal overdose was 0.82 for a model with hospital variables, 0.86 for a model with both PDMP and hospital variables, and 0.89 for a model that further added behavioral health and criminal justice variables. For nonfatal overdose, the area under the curve using all variables was 0.85.

Conclusions and Relevance  In this analysis, fatal and nonfatal opioid overdose could be accurately predicted with linked administrative databases. Hospital encounter data had higher predictive utility than PDMP data. Model performance was meaningfully improved by adding PDMP records. Predictive models using linked databases can be used to target large-scale public health programs.

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