Association Between State Opioid Prescribing Cap Laws and Receipt of Opioid Prescriptions Among Children and Adolescents

Abstract

Importance: High-dose and long-duration opioid prescriptions remain relatively common among children and adolescents, but there is insufficient research on the association of state laws limiting the dose and/or duration of opioid prescriptions (referred to as opioid prescribing cap laws) with opioid prescribing for this group.

Objective: To examine the association between state opioid prescribing cap laws and the receipt of opioid prescriptions among children and adolescents.

Design setting and participants: This repeated cross-sectional study used a difference-in-differences approach accounting for staggered policy adoption to assess the association of state opioid prescribing cap laws in the US from January 1, 2013, to December 31, 2019, with receipt of opioid prescriptions among children and adolescents. Analyses were conducted between March 22 and December 15, 2021. Data were obtained from the OptumLabs Data Warehouse, a national commercial insurance claims database. The analysis included 482 118 commercially insured children and adolescents aged 0 to 17 years with full calendar-year continuous insurance enrollment between 2013 and 2019. Individuals were included for every year in which they were continuously enrolled; they did not need to be enrolled for the entire 7-year study period. Those with any cancer diagnosis were excluded from analysis.

Exposure: Implementation of a state opioid prescribing cap law between January 1, 2017, and July 1, 2019. This date range allowed analysis of the same number years for both pre-cap and post-cap data.

Main outcomes and measures: Outcomes of interest included receipt of any opioid prescription and, among those with at least 1 opioid prescription, the mean number of opioid prescriptions, mean morphine milligram equivalents (MMEs) per day, and mean days' supply.

Results: Among 482 118 children and adolescents (754 368 person-years of data aggregated to the state-year level), 245 178 (50.9%) were male, with a mean (SD) age of 9.8 (4.8) years at the first year included in the sample (data on race and ethnicity were not collected as part of this data set, which was obtained from insurance billing claims). Overall, 10 659 children and adolescents (2.2%) received at least 1 opioid prescription during the study period. Among those with at least 1 prescription, the mean (SD) number of filled opioid prescriptions was 1.2 (0.8) per person per year. No statistically significant association was found between state opioid prescribing cap laws and any outcome. After opioid prescribing cap laws were implemented, a -0.001 (95% CI, -0.005 to 0.002) percentage point decrease in the proportion of youths receiving any opioid prescription was observed. In addition, percentage point decreases of -0.01 (95% CI, -0.10 to 0.09) in high-dose opioid prescriptions (>50 MMEs per day) and -0.02 (95% CI, -0.12 to 0.08) in long-duration opioid prescriptions (>7 days' supply) were found after cap laws were implemented.

Conclusions and relevance: In this cross-sectional study, no association was observed between state opioid prescribing cap laws and the receipt of opioid prescriptions among children and adolescents. Alternative strategies, such as opioid prescribing guidelines tailored to youths, are needed.

Figure 1.. Mean Percentage of Children and Adolescents With Any Filled Opioid Prescription by Treatment Cohort, 2013-2019

Descriptive statistics were derived using insurance claims data from the OptumLabs Data Warehouse for the 12 states that implemented an opioid prescribing cap law in 2017, the 12 states that implemented an opioid prescribing cap law in 2018, the 9 states that implemented an opioid prescribing cap law in 2019, and the 16 states with no opioid prescribing cap law (control cohort).

Figure 2.. Change in Annual Probability of Receiving an Opioid Prescription and Change in Annual Volume, Dose, and Duration of Opioid Prescriptions per Person per Year

Changes associated with state opioid prescribing cap laws during the first year after implementation among those receiving ≥1 opioid prescription. Effect size estimates were derived using the staggered adoption design of Callaway and Sant’Anna. Insurance claims data were obtained from the OptumLabs Data Warehouse for the 33 states that implemented an opioid prescribing cap law between 2017 and 2019 and the 16 control states with no opioid prescribing cap law. Vertical bars represent 95% CIs. MME indicates morphine milligram equivalent.

Figure 3.. Change in Annual Probability of Receiving Any Opioid Prescription Among Children and Adolescents

Changes associated with state opioid prescribing cap laws during the first year after implementation. Effect size estimates were derived using the staggered adoption design of Callaway and Sant’Anna. Insurance claims data were obtained from the OptumLabs Data Warehouse for the 33 states that implemented an opioid prescribing cap law between 2017 and 2019 and the 16 control states with no opioid prescribing cap law. Vertical bars represent 95% CIs.