Changes in Initial Opioid Prescribing Practices After the 2016 Release of the CDC Guideline for Prescribing Opioids for Chronic Pain

Abstract

Importance: The Centers for Disease Control and Prevention (CDC) released the "Guideline For Prescribing Opioids For Chronic Pain" (hereafter, CDC guideline) in 2016, but its association with prescribing practices for patients who are opioid naive is unknown.

Objective: To estimate changes in initial prescribing rates, duration, and dosage practices to patients who are opioid naive after the release of the CDC guideline.

Design, setting, and participants: This cohort study used 6 sequential cohorts to estimate preguideline trends in prescribing among patients who were opioid naive, project that trend forward, and compare it with postguideline prescribing practices. Participants included commercially insured adults without current cancer or hospice care diagnoses and with no past-year opioid claims in the US from 2011 to 2017. All adjusted models were controlled for patient demographics and state-fixed effects. Data were analyzed from January 2020 to May 2021.

Exposures: The release of the CDC guideline.

Main outcomes and measures: Indicators of any opioid prescription fills during a 9-month period, the number of days' supply of the initial prescription, and the binary indicator of whether the initial prescription was for 50 or more morphine milligram equivalents (MMEs) per day.

Results: There were 12 870 612 eligible unique patients across cohorts (mean [SD] age in 2016, 51.2 [18.7] years; 6 553 458 [50.9%] women); and the mean (SD) age of the cohorts increased annually, from 48.7 (17.9) years in the April 2011 to December 2012 cohort to 51.9 (19.2) years in the April 2016 to December 2017 cohort. The postguideline prescribing prevalence was 532 962 of 5 834 088 individuals (9.1%), which exceeded that projected from the preguideline trend, estimated at 9.0% (95% CI, 9.0%-9.1%). Among patients receiving prescriptions during follow-up, adjusted mean days' supply was 4.7% (95% CI, 4.3%-5.1%) lower in the first year after release of the guideline and 9.8% (95% CI, 9.3%-10.3%) lower in the second year after release, compared with the expected rate from the preguideline trend. The adjusted odds of receiving a high-dose (ie, ≥50 MME/d) initial prescription were lower in the first year (odds ratio, 0.97; 95% CI, 0.96-0.98) and in the second year (odds ratio, 0.94; 95% CI, 0.93-0.96) after the release of the CDC guideline compared with the odds expected from the preguideline trend.

Conclusions and relevance: This cohort study found that patients who were opioid naive continued to initiate opioid therapy after the release of opioid prescribing guidelines by the CDC, but trends in prescribing duration reversed and decreased, after increasing in each of 4 preguideline cohorts examined. High-dose prescribing rates were already decreasing, but those trends accelerated after the CDC guideline release. These results suggest that nonmandatory, evidence-based guidelines from trusted sources were associated with prescribing practices. Guideline-concordant care has potential to improve pain management and reduce opioid-related harms.

Figure 1.. Patients Who Were Opioid Naive and Who Subsequently Received an Opioid Prescription vs Linear Projections Based on Preguideline Trend

The vertical blue line indicates the 2016 release of the Centers for Disease Control and Prevention’s “Guideline for Prescribing Opioids for Chronic Pain”; orange line, projected opioid prescriptions based on linear projections from preguideline trend; shading, 95% CI; dark blue line, observed opioid prescriptions.

Figure 2.. Mean Initial Prescription Duration Among Patients Who Were Opioid Naive Receiving Any Opioid Prescription vs Projections From Preguideline Trend

The vertical blue line indicates the 2016 release of the Centers for Disease Control and Prevention’s “Guideline for Prescribing Opioids for Chronic Pain”; orange line, projected opioid prescription duration based on linear projections from preguideline trend; shading, 95% CI; dark blue line, observed opioid prescription duration.

Figure 3.. Distribution of Initial Doses of New Opioid Prescriptions in Morphine Milligram Equivalents per Day in Each Year Among Patients Who Were Opioid Naive and Who Subsequently Received Opioids, United States, 2011-2017

Preguideline indicates the 2016 release of the Centers for Disease Control and Prevention’s “Guideline for Prescribing Opioids for Chronic Pain”; postguideline indicates after the release.