Effects of State Opioid Prescribing Laws on Use of Opioid and Other Pain Treatments Among Commercially Insured U.S. Adults

Abstract

Background: There is concern that state laws to curb opioid prescribing may adversely affect patients with chronic noncancer pain, but the laws' effects are unclear because of challenges in disentangling multiple laws implemented around the same time.

Objective: To study the association between state opioid prescribing cap laws, pill mill laws, and mandatory prescription drug monitoring program query or enrollment laws and trends in opioid and guideline-concordant nonopioid pain treatment among commercially insured adults, including a subgroup with chronic noncancer pain conditions.

Design: Thirteen treatment states that implemented a single law of interest in a 4-year period and unique groups of control states for each treatment state were identified. Augmented synthetic control analyses were used to estimate the association between each state law and outcomes.

Setting: United States, 2008 to 2019.

Patients: 7 694 514 commercially insured adults aged 18 years or older, including 1 976 355 diagnosed with arthritis, low back pain, headache, fibromyalgia, and/or neuropathic pain.

Measurements: Proportion of patients receiving any opioid prescription or guideline-concordant nonopioid pain treatment per month, and mean days' supply and morphine milligram equivalents (MME) of prescribed opioids per day, per patient, per month.

Results: Laws were associated with small-in-magnitude and non-statistically significant changes in outcomes, although CIs around some estimates were wide. For adults overall and those with chronic noncancer pain, the 13 state laws were each associated with a change of less than 1 percentage point in the proportion of patients receiving any opioid prescription and a change of less than 2 percentage points in the proportion receiving any guideline-concordant nonopioid treatment, per month. The laws were associated with a change of less than 1 in days' supply of opioid prescriptions and a change of less than 4 in average monthly MME per day per patient prescribed opioids.

Limitations: Results may not be generalizable to non-commercially insured populations and were imprecise for some estimates. Use of claims data precluded assessment of the clinical appropriateness of pain treatments.

Conclusion: This study did not identify changes in opioid prescribing or nonopioid pain treatment attributable to state laws.

Primary funding source: National Institute on Drug Abuse.

Figure 1.

Changes in the proportion of patients receiving any opioid prescription, per month, attributable to the law in its first 2 years of implementation. Augmented synthetic control analyses were used to estimate changes in outcomes between the prelaw and postlaw periods in the treatment state and its control group. The results in this figure show the percentage point difference in the proportion of patients with any opioid prescription, per month, in the 2 years before versus after the law implementation date in the treatment state versus its control group. Analyses were adjusted for mean patient age; mean patient Elixhauser Comorbidity Index; the proportion of patients who were male; the proportion with a mental illness diagnosis; the proportion with a substance use disorder diagnosis; and the proportions of the state population that were Black, were Hispanic, were living below the federal poverty line, were employed, and had no postsecondary degree, per state, per year. The chronic noncancer pain sample included patients diagnosed with arthritis, low back pain, headache, fibromyalgia, or neuropathic pain in the prelaw period. Across all 13 treatment states and their control groups, the overall sample included 7 694 514 unique adults aged ≥18 years and 1 976 355 unique adults aged ≥18 years with chronic noncancer pain conditions. State-specific analytic sample sizes are shown in Table 1. PDMP = prescription drug monitoring program.

Figure 2.

Changes in the proportion of patients with chronic noncancer pain receiving any clinical guideline-concordant nonopioid pain medication or procedure, per month, attributable to the law in its first 2 years of implementation. Augmented synthetic control analyses were used to estimate changes in outcomes between the prelaw and postlaw periods in the treatment state and its control group. The results in this figure show the percentage point difference in the proportion of patients with any clinical guideline–concordant nonopioid pain medication or procedure, per month, in the 2 years before versus after the law implementation date in the treatment state versus its control group. Analyses were adjusted for mean patient age; mean patient Elixhauser Comorbidity Index; the proportion of patients who were male; the proportion with a mental illness diagnosis; the proportion with a substance use disorder diagnosis; and the proportions of the state population that were Black, were Hispanic, were living below the federal poverty line, were employed, and had no postsecondary degree, per state, per year. The chronic noncancer pain sample included patients diagnosed with arthritis, low back pain, headache, fibromyalgia, or neuropathic pain in the prelaw period. Across all 13 treatment states and their control groups, the overall sample included 7 694 514 unique adults aged ≥18 years and 1 976 355 unique adults aged ≥18 years with chronic noncancer pain conditions. State-specific analytic sample sizes are shown in Table 1. PDMP = prescription drug monitoring program.