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. 2019 Dec 2;2(12):e1918361.
doi: 10.1001/jamanetworkopen.2019.18361.

Association of State Opioid Duration Limits With Postoperative Opioid Prescribing

Sunil Agarwal  1   2 , John D Bryan  2   3 , Hsou Mei Hu  2   4 , Jay S Lee  2   4 , Kao-Ping Chua  5 , Rebecca L Haffajee  6 , Chad M Brummett  2   7 , Michael J Englesbe  2   4 , Jennifer F Waljee  2   4
Affiliations

Association of State Opioid Duration Limits With Postoperative Opioid Prescribing

Sunil Agarwal et al. JAMA Netw Open. .

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Lee reported receiving grants from Blue Cross Blue Shield of Michigan Foundation during the conduct of the study. Dr Haffajee reported receiving grants from National Center for Advancing Translational Sciences of the National Institutes of Health and the Centers for Disease Control and Prevention for the University of Michigan Injury Prevention Center during the conduct of the study. Dr Brummett reported receiving grants from the University of Michigan and Michigan Opioid Prescribing Engagement Network and the US Department of Health and Human Services, Institutional–Precision Health Initiative, Opioid Use Case, receiving grants from the National Institutes of Health National Institute on Drug Abuse Prevention of Iatrogenic Opioid Dependence After Surgery, and serving as a consultant for Heron Therapeutics during the conduct of the study; and receiving research funding from Neuros Medical Inc, serving as a consultant for Recro Pharma and Heron Therapeutics, and holding a patent for peripheral perineural dexmedetomidine licensed to the University of Michigan outside the submitted work. Dr Englesbe reported receiving grants from Blue Cross and Blue Shield of Michigan during the conduct of the study. Dr Waljee reported receiving grants from National Institutes of Health and grants from the Michigan Department of Health and Human Services during the conduct of the study and being an unpaid consultant for 3M Health Information Systems outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Mean Size of Initial Postoperative Prescription Before and After Opioid Legislation in Massachusetts and Connecticut
A, In Massachusetts, implementation of the limit was associated with an immediate level decrease in prescription size (−38 oral morphine equivalents [OMEs] [95% CI, −44 to −32 OMEs]) and slope decrease (−1.5 OMEs/mo [95% CI −2.1 to −0.9 OMEs/mo]). B, In Connecticut, implementation of the limit was not associated with a significant immediate level change in prescription size (−18 OMEs [95% CI, −49 to 14 OMEs]) or slope change (−1.3 OMEs/mo [95% CI, −4.6 to 2.0 OMEs/mo]).
Figure 2.
Figure 2.. Mean Days Supplied in the Initial Postoperative Prescription Before and After Opioid Legislation in Massachusetts and Connecticut
A, In Massachusetts, implementation of the limit was associated with an immediate level decrease in days supplied (−0.4 days [95% CI, −0.6 to −0.2 days]) but no significant slope change (0 d/mo [95% CI, −0.02 to 0.02 d/mo]). B, In Connecticut, implementation of the limit was not associated with a significant immediate level change in days supplied (−0.3 days [95% CI, −0.7 to 0.1 days]) or slope change (0 d/mo [95% CI, 0-0 d/mo]).
Figure 3.
Figure 3.. Proportion of Prescriptions Exceeding a 7-Day Supply Before and After Opioid Legislation in Massachusetts and Connecticut
A, In Massachusetts, implementation of the limit was associated with an immediate level decrease in the proportion of prescriptions exceeding a 7-day supply (−5.9 percentage points [95% CI, −7.9 to −3.9 percentage points]) but without a significant slope change (0.1 percentage points [95% CI, −0.1 to 0.3 percentage points]). B, In Connecticut, implementation of the limit was not associated with an immediate level change in the proportion of prescriptions exceeding a 7-day supply (−3.7 percentage points [95% CI, −8.2 to 0.8 percentage points]) or slope change (0.1 percentage points [95% CI, −0.7 to 0.5 percentage points]).
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References

    1. Larach DB, Waljee JF, Hu HM, et al. . Patterns of initial opioid prescribing to opioid-naive patients [published online July 24, 2018]. Ann Surg. doi:10.1097/SLA.0000000000002969 - DOI - PMC - PubMed
    1. Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL. Prescription opioid analgesics commonly unused after surgery: a systematic review. JAMA Surg. 2017;152(11):-. doi:10.1001/jamasurg.2017.0831 - DOI - PMC - PubMed
    1. Lee JS, Howard RA, Klueh MP, et al. . The impact of education and prescribing guidelines on opioid prescribing for breast and melanoma procedures. Ann Surg Oncol. 2019;26(1):17-24. doi:10.1245/s10434-018-6772-3 - DOI - PMC - PubMed
    1. Howard R, Fry B, Gunaseelan V, et al. . Association of opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg. 2019;154(1):e184234. doi:10.1001/jamasurg.2018.4234 - DOI - PMC - PubMed
    1. Centers for Disease Control and Prevention. CDC guideline for prescribing opioids for chronic pain. https://www.cdc.gov/drugoverdose/prescribing/guideline.html. Published April 17, 2019. Accessed June 1, 2019.

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