Trends in Hospital Stays Associated With Alcohol, Opioid, and Stimulant Use
Costs and quality of care vary by substance, state, and demographic group
Overview
In 2022, a national survey found that approximately 10% of U.S. adults with a substance use disorder (SUD) had been hospitalized in the previous year. Regardless of the immediate reason for their hospitalization, whether related or unrelated to alcohol or drugs, patients with SUDs critically need substance use treatment. Lack of treatment during hospitalization has been linked to patient discharges against medical advice and subsequent readmissions—metrics commonly used to assess healthcare quality—and people who use drugs face high rates of death following hospital stays.
The quality of hospital care provided to people with SUDs is a matter of vital importance, but many public health leaders and policymakers lack detailed information about how substance use drives hospital admissions across the country and in individual states, how much those admissions cost, how often patients are discharged against medical advice, how often they are readmitted, and which patient groups are most affected.
To better understand trends in hospitalizations associated with alcohol, opioids, and stimulants, The Pew Charitable Trusts analyzed recent data from the Healthcare Cost and Utilization Project’s online querying tool, HCUPnet. (See Methodology for more information about the dataset and how to use it. HCUP is a collection of healthcare databases and other tools sponsored by the Agency for Healthcare Research and Quality, a component of the U.S. Department of Health and Human Services.)
Pew’s analysis, which focused on data from 2016 through 2022, aimed to determine the number and cost of hospital stays associated with substance use, nationally and in individual states; to assess select markers of quality of care; and to examine differences among demographic groups. Pew analyzed hospital stays in which substance-related diagnoses were the main reason for admission, as well as substance-involved stays, in which substance use was either the primary or an additional factor in the admission.
Key findings include:
- Alcohol-involved hospitalizations far outpaced opioid- and stimulant-involved admissions, with an estimated 1,828,044 hospital stays involving alcohol in 2022. These admissions account for about 5.6% of all hospital stays—and were nearly on par with the estimated number of admissions involving COVID-19 during the same period.
- Compared with opioid- and stimulant-related hospital stays, alcohol-related hospitalizations accounted for the highest total hospital costs in each of the years studied and were the most expensive per stay.
- More patients were discharged against medical advice after alcohol-related stays than opioid- or stimulant-related hospitalizations, but a higher percentage of opioid-related stays—more than one in five in 2022—ended in discharge against medical advice.
- All-cause readmissions, a metric referring to readmission within 30 days for any reason, were higher for alcohol- and stimulant-related stays than for all hospital stays.
Part I: Alcohol-related hospital stays were more frequent than opioid- and stimulant-related stays nationally and in all states studied
The following interactives display the total number of hospital stays, as well as the rates of discharge, associated with alcohol, opioids, and stimulants. Use these interactives to examine and compare national and state-specific data. Data on principal diagnoses (reflecting the first-listed diagnosis in the patient’s medical record) is available on both the state and national levels. Data on all-listed diagnoses (reflecting all diagnoses in the patient’s medical record) is available only on the national level. State-level rates of discharge are from the Community-Level Statistics, and state-level numbers of discharge are from the State Inpatient Databases.
Alcohol-associated discharges outpaced opioid- and stimulant-associated discharges nationally
Nationwide, an estimated 1,828,044 discharges from inpatient care, or about 548.5 per 100,000 people, occurred in 2022 for alcohol-involved hospital stays. There were approximately 1 million more alcohol-involved discharges than opioid- or stimulant-involved discharges. Opioid-involved discharges steadily decreased after 2017—although opioid-involved overdose deaths increased during the same period—while discharges from stays involving stimulants were higher in 2022 than in 2016.
In 2022, the estimated number of discharges from stays involving stimulants was higher for the first time than the estimated number of discharges involving opioids, although the difference was within the margin of error, meaning it could be due to random chance.
Alcohol-related stays were most frequent in all states providing data, with opioid- and stimulant-related stays alternating as second
Among discharges with a substance-related cause as the first-listed diagnosis, alcohol-related stays had the highest rate of discharge per 100,000 people in 2022 across all states with data.
Stimulant-related stays have become more frequent in many states
The number of discharges from stimulant-related stays was the second highest in eight out of 38 states in 2016 and in 24 out of 40 states in 2022.
Part II: Substance-related hospital stays carry a high cost burden
The next interactives highlight differences in hospital costs among alcohol-, opioid-, and stimulant-related stays. Hospital costs refer to the costs a hospital incurs by providing service to a patient, not the amount the patient pays. (See Methodology for more information on how hospital costs are calculated.) These costs vary by the type of stay, with alcohol-related admissions resulting in higher aggregate and average costs nationally and in each state that provided data. This section provides data on discharges for the principal diagnosis.
Alcohol-related stays resulted in the highest hospital costs
For all three substances, estimated average hospital costs increased between 2016 and 2022, despite the average length of stay remaining roughly the same. The estimated average length of principally diagnosed alcohol-, opioid-, and stimulant-related hospital stays was 4.7, 4.8, and 5.5 days, respectively, in 2022.
State-level costs for substance-related hospital stays largely mirrored national trends
Hospital costs vary by state. A previous analysis of HCUP data found that the average cost of care per inpatient stay in 2016 was highest in the Pacific Census division, which comprises Alaska, California, Hawaii, Oregon, and Washington.
To examine state-level hospital costs for substance-related stays, Pew analyzed average and aggregate costs in all states with available data in the HCUPnet databases. Stimulant-related stays in Alaska in 2022 were the most expensive on average, costing $23,021 per stay.
Part III: Substance-related stays resulted in more discharges against medical advice than all stays
Discharges against medical advice, also known as self-discharges, are associated with higher readmission and mortality rates and are common among people who use drugs or alcohol. People who use drugs report that poor quality of care—including undertreated pain and withdrawal symptoms—stigma, and restrictive hospital policies contribute to self-discharges.
The following interactives examine the number and percentage of discharges against medical advice for hospital stays related to alcohol, opioids, and stimulants, nationally and at the state level. This section relies on data relating to the principal diagnosis at discharge.
Opioid-related stays resulted in the highest rate of discharge against medical advice
Alcohol-, opioid-, and stimulant-related stays all resulted in significantly higher estimated rates of discharge against medical advice compared with all inpatient stays. Opioid-related stays had the highest rate of discharge against medical advice, with more than one in five patients estimated to have self-discharged in 2022, compared with fewer than 2% of patients overall.
Some states had remarkably high rates of discharge against medical advice
Opioid-related stays had the highest percentage of discharges against medical advice in most states across the majority of the years examined. West Virginia had the highest percentage of opioid-related stays resulting in discharge against medical advice in 2022, with more than 1 in 3 (34.58%) patients self-discharging. That figure represents a considerable increase from 2016, when 11.6% of opioid-related stays ended in discharge against medical advice.
Part IV: Medicaid was the largest expected payer of substance-involved hospital costs
The following visualization displays the expected payer of substance-involved hospital stays. For each category of substance—alcohol, opioid, and stimulant—Medicaid, followed by Medicare, was expected to pay for the greatest number of hospitalizations. This section provides data on discharges for all-listed diagnoses.
Of all expected payers, Medicaid had the most discharges for all substance-involved hospital stays
Part V: Some sociodemographic groups received more inpatient care than others
The next interactive displays the rate of discharge, nationally, for alcohol-, opioid-, and stimulant-involved diagnoses broken down by sociodemographic group. The data is useful in understanding differences in inpatient care across subgroups and may help policymakers develop targeted policy solutions. This section provides data on discharges for all-listed diagnoses.
Inpatient stays varied among sociodemographic groups
Pew found that:
- Among all age groups examined, the highest estimated rate of discharge occurred among patients ages 45-64 with an alcohol-involved diagnosis.
- Comparing inpatient care for male and female patients, the difference in the rates of discharge after opioid-involved stays was not statistically significant for the two groups. Male patients had higher estimated rates of discharge for alcohol- and stimulant-involved stays, however.
Part VI: Substance-related hospital stays had high readmission rates
Hospital readmission metrics are commonly used to assess healthcare quality, with high rates of readmission associated with poor quality of care. Many patients hospitalized for conditions related to substance use are not connected with treatment following their discharge, a gap in care that may contribute to the high rates of readmission among people who use drugs and alcohol.
The next interactive displays the estimated national rate and cost of readmissions for all initial hospital stays and for alcohol-, opioid-, and stimulant-related hospitalizations. Hospitals record a readmission when a patient re-enters the hospital for any reason within 30 days of the initial stay, also known as an index stay, and regardless of the type of initial discharge (routine, for example, or against medical advice). This section relies on data relating to the principal diagnosis at discharge and reflects the rate of readmission per 100 index stays.
Some demographic groups were more likely to be readmitted
Pew found that readmissions were more common for alcohol-related index stays than for opioid- or stimulant-related index stays, as well as for hospitalizations overall. The cost of readmission for alcohol- and opioid-related index stays was higher than the cost of readmissions for stimulant-related stays.
