Association of State Opioid Duration Limits With Postoperative Opioid Prescribing

• Type of Material: Article
• Authors: Sunil Agarwal, Emory University; John D Bryan, Michigan Opioid Prescribing Engagement Network; Hsou Mei Hu, Michigan Opioid Prescribing Engagement Network; Jay S Lee, Michigan Opioid Prescribing Engagement Network; Kao-Ping Chua, University of Michigan; Rebecca L Haffajee, University of Michigan; Chad M Brummett, Michigan Opioid Prescribing Engagement Network; Michael J Englesbe, Michigan Opioid Prescribing Engagement Network; Jennifer F Waljee, Michigan Opioid Prescribing Engagement Network
• Language: English
• Date: 2019-12-01
• Publisher: AMER MEDICAL ASSOC
• Publication Version: Final Published Version
• Copyright Statement: 2019 Agarwal S et al. JAMA Network Open.
• License: Creative Commons Attribution 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1001/jamanetworkopen.2019.18361
• Title of Journal or Parent Work: JAMA NETWORK OPEN
• Volume: 2
• Issue: 12
• Start Page: e1918361
• End Page: e1918361
• Grant/Funding Information: Dr Waljee receives funding from the National Institute on Drug Abuse (grant RO1 DA042859), National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant P50 AR070600), the Michigan Department of Health and Human Services (grant E20180672-00 Michigan DHHS - MA-2018 Master Agreement Program), the Substance Abuse and Mental Health Administration (grant SAMHSA: E20180568-00 MA-2018 Master Agreement Program), and the Centers for Disease Control and Prevention (grant E20182818-00 MA-2018 Master Agreement Program). Dr Chua is supported by a career development award from the National Institute on Drug Abuse (grant 1K08DA048110-01). Additional funding was provided by the University of Michigan School Dean's Office—Michigan Genomics Initiative and Precision Health Initiative, by the American College of Surgeons and the American Foundation for Surgery of the Hand (Dr Waljee), and by the Michigan Department of Health and Human Services (Drs Brummett, Waljee, and Englesbe).
• Keywords: Life Sciences & Biomedicine; General & Internal Medicine; PRESCRIPTIONS; Medicine, General & Internal; PAIN; Science & Technology
• Research Categories: Health Sciences, Health Care Management; Health Sciences, Public Health

Abstract

Importance: Since the Centers for Disease Control and Prevention published opioid prescribing guidelines in March 2016, 31 states have implemented legislation to restrict the duration of opioid prescriptions for acute pain. However, the association of these policies with the amount of opioid prescribed following surgery remains unknown. Objective: To examine the association of opioid prescribing duration limits with postoperative opioid prescribing in Massachusetts and Connecticut, the first 2 states to implement limits after March 2016. Design, Setting, and Participants: This interrupted time series analysis and cross-sectional study examined immediate level and slope changes in monthly outcomes after prescribing limit implementation in Massachusetts and Connecticut. These states implemented 7-day limits on initial opioid prescriptions on March 14, 2016, and July 1, 2016, respectively. Using the 2014 to 2017 IBM MarketScan Research Database, 16 281 opioid-naive adults in these states who filled a prescription within 3 days of surgery between July 1, 2014, and November 30, 2017, were identified. Data were analyzed from December 2018 to June 2019. Main Outcomes and Measures: The primary outcome was the prescription size in oral morphine equivalents (OMEs) for the initial postoperative opioid prescription (one 5/325 mg hydrocodone-acetaminophen pill = 5 OMEs). Secondary outcomes included days supplied in the initial prescription and the proportion of initial prescriptions exceeding a 7-day supply. Results: In total, 16 281 opioid-naive patients (9708 [59.6%] female; median [interquartile range] age range, 45-54 [35-44 to 55-64] years) undergoing surgical procedures were included. In Massachusetts, there were 5340 and 5435 patients in the preimplementation and postimplementation periods, respectively. In Connecticut, there were 2869 and 2637 patients in the preimplementation and postimplementation periods, respectively. Limit implementation in Massachusetts was associated with an immediate mean level decrease in prescription size (-38 OMEs [95% CI, -44 to -32 OMEs]) and with a mean decrease in slope (-1.5 OMEs/mo [95% CI, -2.1 to -0.9 OMEs/mo]). Implementation was also associated with an immediate mean level decrease in days supplied (-0.4 days [95% CI, -0.6 to -0.2 days]) and the proportion of prescriptions exceeding a 7-day supply (-5.9 percentage points [95% CI, -7.9 to -3.9 percentage points]). In contrast, limit implementation in Connecticut was not associated with level or slope changes in any outcome. Conclusions and Relevance: Opioid prescribing duration limits had a variable association with postoperative opioid prescribing in Massachusetts and Connecticut. The mean opioid prescription size filled, days supplied, and prescribing exceeding a 7-day supply decreased after limit implementation in Massachusetts only. Given the potential differences in policy dissemination and uptake, efforts to reduce opioid prescribing should also include surgeon education and evidence-based prescribing recommendations.