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Priest KC, Merlin JS, Lai J, Sorbero M, Taylor EA, Dick AW, Stein BD. A Longitudinal Multivariable Analysis: State Policies and Opioid Dispensing in Medicare Beneficiaries Undergoing Surgery. J Gen Intern Med 2024:10.1007/s11606-024-08888-3. [PMID: 39020230 DOI: 10.1007/s11606-024-08888-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 06/12/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND States have implemented policies to decrease clinically unnecessary opioid prescribing, but few studies have examined how state policies affect opioid dispensing rate trends for surgical patients. OBJECTIVE To examine trends in the perioperative opioid dispensing rates for fee-for-service Medicare beneficiaries and the effects of select state policies. DESIGN AND PARTICIPANTS A retrospective cohort study using 2006 to 2018 Medicare claims data for individuals undergoing surgical procedures for which opioid analgesic treatment is common. EXPOSURES State policies mandating prescription drug monitoring program (PDMP; PDMP policies) use, initial opioid prescription duration limit (duration limit policies), and mandated continuing medical education (CME; CME pain policies) on pain management. MAIN MEASURES Opioid dispensing rates, days' supply, and the daily morphine milligram equivalent dose (MMED). KEY RESULTS The percentage of Medicare beneficiaries dispensed opioids in the perioperative period increased from 2007 to 2018; MMED and days' supply decreased over the same period, with significant variation by age, sex, and race. None of the three state policies affected the likelihood of Medicare beneficiaries being dispensed perioperative opioids. However, CME pain policies and duration limit policies were associated with decreased days' supply and decreased MMED in the several years following implementation, respectively. CONCLUSION While we observed a slight increase in the rate of Medicare beneficiaries dispensed opioids perioperatively and a substantial decrease in MMED and days' supply for those receiving opioids, state policies examined had relatively modest effects on the main measures. Our findings suggest that these state policies may have a limited impact on opioid dispensing for a patient population that is commonly dispensed opioid analgesics to help control surgical pain, and as a result may have little direct effect on clinical outcomes for this population. Changes in opioid dispensing for this population may be the result of broader societal trends than such state policies.
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Affiliation(s)
- Kelsey C Priest
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Jessica S Merlin
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Julie Lai
- RAND Corporation, Santa Monica, CA, USA
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Shuey B, Zhang F, Rosen E, Goh B, Trad NK, Wharam JF, Wen H. Massachusetts' opioid limit law associated with a reduction in postoperative opioid duration among orthopedic patients. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad068. [PMID: 38756368 PMCID: PMC10986237 DOI: 10.1093/haschl/qxad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/24/2023] [Accepted: 11/30/2023] [Indexed: 05/18/2024]
Abstract
Postoperative orthopedic patients are a high-risk group for receiving long-duration, large-dosage opioid prescriptions. Rigorous evaluation of state opioid duration limit laws, enacted throughout the country in response to the opioid overdose epidemic, is lacking among this high-risk group. We took advantage of Massachusetts' early implementation of a 2016 7-day-limit law that occurred before other statewide or plan-wide policies took effect and used commercial insurance claims from 2014-2017 to study its association with postoperative opioid prescriptions greater than 7 days' duration among Massachusetts orthopedic patients relative to a New Hampshire control group. Our sample included 14 097 commercially insured, opioid-naive adults aged 18 years and older undergoing elective orthopedic procedures. We found that the Massachusetts 7-day limit was associated with an immediate 4.23 percentage point absolute reduction (95% CI, 8.12 to 0.33 percentage points) and a 33.27% relative reduction (95% CI, 55.36% to 11.19%) in the percentage of initial fills greater than 7 days in the Massachusetts relative to the control group. Seven-day-limit laws may be an important state-level tool to mitigate longer duration prescribing to high-risk postoperative populations.
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Affiliation(s)
- Bryant Shuey
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
- Present address: Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
| | - Edward Rosen
- Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
| | - Brian Goh
- Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
- Present address: Department of Orthopedic Surgery, Emory University School of Medicine, Atlanta, GA 30329, United States
| | - Nicolas K Trad
- Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - James Franklin Wharam
- Department of Medicine, Duke University, Durham, NC 27710, United States
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC 27708, United States
| | - Hefei Wen
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
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Kelm JD, Aubry ST, Cain-Nielsen AH, Scott JW, Oliphant BW, Sangji NF, Waljee JF, Hemmila MR. Impact of state opioid laws on prescribing in trauma patients. Surgery 2023; 174:1255-1262. [PMID: 37709648 DOI: 10.1016/j.surg.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/30/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Excessive opioid prescribing has resulted in opioid diversion and misuse. In July 2018, Michigan's Public Act 251 established a state-wide policy limiting opioid prescriptions for acute pain to a 7-day supply. Traumatic injury increases the risk for new persistent opioid use, yet the impact of prescribing policy in trauma patients remains unknown. To determine the relationship between policy enactment and prescribing in trauma patients, we compared oral morphine equivalents prescribed at discharge before and after implementation of Public Act 251. METHODS In this cross-sectional study, adult patients who received any oral opioids at discharge from a Level 1 trauma center between January 1, 2016, and June 30, 2021, were identified. The exposure was patients admitted starting July 1, 2018. Inpatient oral morphine equivalents per day 48 hours before discharge and discharge prescription oral morphine equivalents per day were calculated. Student's t test and an interrupted time series analysis were performed to compare mean oral morphine equivalents per day pre- and post-policy. Multivariable risk adjustment accounted for patient/injury factors and inpatient oral morphine equivalent use. RESULTS A total of 3,748 patients were included in the study (pre-policy n = 1,685; post-policy n = 2,063). Implementation of the prescribing policy was associated with a significant decrease in mean discharge oral morphine equivalents per day (34.8 ± 49.5 vs 16.7 ± 32.3, P < .001). After risk adjustment, post-policy discharge prescriptions differed by -19.2 oral morphine equivalents per day (95% CI -21.7 to -16.8, P < .001). The proportion of patients obtaining a refill prescription 30 days post-discharge did not increase after implementation (0.38 ± 0.48 vs 0.37 ± 0.48, P = .7). CONCLUSION Discharge prescription amounts for opioids in trauma patients decreased by approximately one-half after the implementation of opioid prescribing policies, and there was no compensatory increase in subsequent refill prescriptions. Future work is needed to evaluate the effect of these policies on the adequacy of pain management and functional recovery after injury.
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Affiliation(s)
- Julia D Kelm
- Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Staci T Aubry
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Anne H Cain-Nielsen
- Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - John W Scott
- Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI. https://www.twitter.com/DrJohnScott
| | - Bryant W Oliphant
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI. https://www.twitter.com/BonezNQuality
| | - Naveen F Sangji
- Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI. https://www.twitter.com/waljeejenn
| | - Mark R Hemmila
- Department of Surgery, University of Michigan, Ann Arbor, MI; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.
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Tormohlen KN, White SA, Bandara S, Bicket MC, McCourt AD, Davis CS, McGinty EE. Effects of state opioid prescribing cap laws on providers' opioid prescribing patterns among patients with chronic non-cancer pain. Prev Med 2023; 172:107535. [PMID: 37150305 PMCID: PMC10256455 DOI: 10.1016/j.ypmed.2023.107535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/17/2023] [Accepted: 05/02/2023] [Indexed: 05/09/2023]
Abstract
Prior work suggests opioid prescribing cap laws are not associated with changes in opioid prescribing among patients with chronic pain. It is unknown how these effects differ by provider specialty, provider opioid prescribing volume, or patient insurer. This study assessed effects of state opioid prescribing cap laws on opioid prescribing among providers of patients with chronic non-cancer pain, by high volume prescribing, provider specialty, and patient insurer. We identified 224,290 providers of patients with low back pain, fibromyalgia, or headache from the IQVIA administrative database. Using a difference-in-differences approach, we examined impacts of opioid prescribing cap laws implemented between 2016 and 2018 on the annual proportion of a provider's patient panel who received any opioid prescription, as well as on dose and duration of opioid prescriptions. For providers overall, high volume prescribers, all specialties, and patient insurance categories, prescribing cap laws were associated with non-significant changes of <1.0, 1.5, and 3.5 percentage points in the proportion of chronic non-cancer patients receiving any opioid prescription, a prescription with 7 days' supply, or with >50 morphine milligram equivalents (MME)/day, per year, respectively. There were two exceptions with high dose prescribing: prescribing cap laws were associated with a 1.5 percentage point increase in the proportion of high-volume prescribers' patient panel receiving an opioid prescription with ≥50 MME/day, and a 3.0 percentage point decrease in the same measure among surgeons. Among nearly all measured subgroups of providers and patient insurers, opioid prescribing cap laws were not associated with changes in opioid prescribing.
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Affiliation(s)
- Kayla N Tormohlen
- Johns Hopkins Bloomberg School of Public Health, United States of America.
| | - Sarah A White
- Johns Hopkins Bloomberg School of Public Health, United States of America
| | - Sachini Bandara
- Johns Hopkins Bloomberg School of Public Health, United States of America
| | - Mark C Bicket
- University of Michigan School of Public Health, United States of America
| | | | - Corey S Davis
- Network for Public Health Law, United States of America
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McGinty EE, Tormohlen KN, Seewald NJ, Bicket MC, McCourt AD, Rutkow L, White SA, Stuart EA. Effects of U.S. State Medical Cannabis Laws on Treatment of Chronic Noncancer Pain. Ann Intern Med 2023; 176:904-912. [PMID: 37399549 DOI: 10.7326/m23-0053] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND State medical cannabis laws may lead patients with chronic noncancer pain to substitute cannabis in place of prescription opioid or clinical guideline-concordant nonopioid prescription pain medications or procedures. OBJECTIVE To assess effects of state medical cannabis laws on receipt of prescription opioids, nonopioid prescription pain medications, and procedures for chronic noncancer pain. DESIGN Using data from 12 states that implemented medical cannabis laws and 17 comparison states, augmented synthetic control analyses estimated laws' effects on receipt of chronic noncancer pain treatment, relative to predicted treatment receipt in the absence of the law. SETTING United States, 2010 to 2022. PARTICIPANTS 583 820 commercially insured adults with chronic noncancer pain. MEASUREMENTS Proportion of patients receiving any opioid prescription, nonopioid prescription pain medication, or procedure for chronic noncancer pain; volume of each treatment type; and mean days' supply and mean morphine milligram equivalents per day of prescribed opioids, per patient in a given month. RESULTS In a given month during the first 3 years of law implementation, medical cannabis laws led to an average difference of 0.05 percentage points (95% CI, -0.12 to 0.21 percentage points), 0.05 percentage points (CI, -0.13 to 0.23 percentage points), and -0.17 percentage points (CI, -0.42 to 0.08 percentage points) in the proportion of patients receiving any opioid prescription, any nonopioid prescription pain medication, or any chronic pain procedure, respectively, relative to what we predict would have happened in that month had the law not been implemented. LIMITATIONS This study used a strong nonexperimental design but relies on untestable assumptions involving parallel counterfactual trends. Statistical power is limited by the finite number of states. Results may not generalize to noncommercially insured populations. CONCLUSION This study did not identify important effects of medical cannabis laws on receipt of opioid or nonopioid pain treatment among patients with chronic noncancer pain. PRIMARY FUNDING SOURCE National Institute on Drug Abuse.
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Affiliation(s)
- Emma E McGinty
- Division of Health Policy and Economics, Weill Cornell Medicine, New York, New York (E.E.M.)
| | - Kayla N Tormohlen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.N.T., N.J.S., A.D.M., L.R., S.A.W.)
| | - Nicholas J Seewald
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.N.T., N.J.S., A.D.M., L.R., S.A.W.)
| | - Mark C Bicket
- Departments of Anesthesiology and Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan (M.C.B.)
| | - Alexander D McCourt
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.N.T., N.J.S., A.D.M., L.R., S.A.W.)
| | - Lainie Rutkow
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.N.T., N.J.S., A.D.M., L.R., S.A.W.)
| | - Sarah A White
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.N.T., N.J.S., A.D.M., L.R., S.A.W.)
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (E.A.S.)
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Bicket MC, Brummett CM, Mariano ER. Tapentadol and the opioid epidemic: a simple solution or short-lived sensation? Anaesthesia 2023; 78:416-419. [PMID: 36449368 DOI: 10.1111/anae.15932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 12/02/2022]
Affiliation(s)
- M C Bicket
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - C M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - E R Mariano
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Peri-operative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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Schmid I, Stuart EA, McCourt AD, Tormohlen KN, Stone EM, Davis CS, Bicket MC, McGinty EE. Effects of state opioid prescribing cap laws on opioid prescribing after surgery. Health Serv Res 2022; 57:1154-1164. [PMID: 35801988 PMCID: PMC9441291 DOI: 10.1111/1475-6773.14023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To evaluate the effects of state opioid prescribing cap laws on opioid prescribing after surgery. DATA SOURCES OptumLabs Data Warehouse administrative claims data covering all 50 states from July 2012 through June 2019. STUDY DESIGN We included individuals from 20 states that had implemented prescribing cap laws without exemptions for postsurgical pain by June 2019 and individuals from 16 control states plus the District of Columbia. We used a difference-in-differences approach accounting for differential timing in law implementation across states to estimate the effects of state prescribing cap laws on postsurgical prescribing of opioids. Outcome measures included filling an opioid prescription within 30 days after surgery; filling opioid prescriptions of specific doses or durations; and the number, days' supply, daily dose, and pill quantity of opioid prescriptions. To assess the validity of the parallel counterfactual trends assumption, we examined differences in outcome trends between law-implementing and control states in the years preceding law implementation using an equivalence testing framework. DATA COLLECTION/EXTRACTION METHODS We included the first surgery in the study period for opioid-naïve individuals undergoing one of eight common surgical procedures. PRINCIPAL FINDINGS State prescribing cap laws were associated with 0.109 lower days' supply of postsurgical opioids on the log scale (95% Confidence Interval [CI]: -0.139, -0.080) but were not associated with the number (Average treatment effect on the treated [ATT]: -0.011; 95% CI: -0.043, 0.021) or daily dose of postsurgical opioid prescriptions (ATT: -0.013; 95% CI: -0.030, 0.005). The negative association observed between prescribing cap laws and the probability of filling a postsurgical opioid prescription (ATT: -0.041; 95% CI: -0.054, -0.028) was likely spurious, given differences between law-implementing and control states in the pre-law period. CONCLUSIONS Prescribing cap laws appear to have minimal effects on postsurgical opioid prescribing.
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Affiliation(s)
- Ian Schmid
- Department of Mental HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Elizabeth A. Stuart
- Department of Mental HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of BiostatisticsJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Alexander D. McCourt
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Kayla N. Tormohlen
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Elizabeth M. Stone
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | | | - Mark C. Bicket
- Department of AnesthesiologyUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
- Department of Health Policy and ManagementUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
| | - Emma E. McGinty
- Department of Mental HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
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