Estimating the impact of prescribing limits on prolonged opioid use following surgery

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  • September 28, 2022
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  • Young, Jessica
    • Affiliation: Gillings School of Global Public Health, Department of Epidemiology
  • Dasgupta, Nabarun
    • Affiliation: Injury Prevention Research Center
  • Chidgey, Brooke
    • Affiliation: School of Medicine, Department of Anesthesiology
  • Stürmer, Til
    • Affiliation: Gillings School of Global Public Health, Department of Epidemiology
  • Pate, Virginia
    • Affiliation: Gillings School of Global Public Health, Department of Epidemiology
  • Hudgens, Michael
    • Affiliation: Gillings School of Global Public Health, Department of Biostatistics
  • Funk, Michele
    • Affiliation: Gillings School of Global Public Health, Department of Epidemiology
Abstract
  • Background: In response to concerns about opioid addiction, some states now limit the days supplied (DS) for initial postoperative prescriptions. However, few studies have examined the impact of these policy changes on prolonged opioid use in the population. Objectives: To a) examine the gradient of risk of prolonged postsurgical opioid use based on the initial prescription duration, and b) estimate the potential impact of varying prescribing limits on risk of prolonged postsurgical opioid use. Methods: We used a 20% random sample of Medicare claims (2007-2016) to identify opioid naive patients undergoing invasive surgery. Prolonged use was defined as at least 1 Rx in each of 3 consecutive 30-day windows immediately following surgery. We calculated 90-day risk of prolonged use comparing patients at a given DS level to patients receiving longer initial prescriptions. Adjusted risk differences (aRD) were obtained via standardized mortality ratio weights (adjusted for demographics, surgical characteristics, baseline medication use and comorbidities), comparing patients with a Rx greater than a given prescribing limit versus those at the limit. Estimated number of averted cases was also quantified. Results: We identified 749,269 patients who received a perioperative opioid (median DS=5, mean age=73yr, 44% male). The overall risk of prolonged use was 14.0 (95%CI: 13.7, 14.3) per 1000 exposed patients, increasing with days supplied (14.7 for >2 days to 34.4 for >15 days). Among patients with >2 DS (n=615,490; 92%), we estimated 3.3 (1.0, 5.6)/1000 additional cases of prolonged opioid use compared to those receiving 2 DS. Among patients receiving >7 days (n=143,408; 22%), a common limit in state laws, the aRD was nearly null (-0.1/1000). At 15+ days (n=21,382; 3%), we estimated 3.5 (-0.6, 7.6)/1,000 additional cases compared to those receiving exactly 15 days. The estimated number of potentially averted cases of prolonged opioid use ranged from 10,144 (2 days) to 373 (15 days). Conclusions: We illustrate a method to examine potential impacts of prescribing limits. While risk of prolonged postsurgical opioid use increased as patients received larger initial DS, the number of prolonged use cases theoretically preventable by prescribing limits differed by orders of magnitude depending on the number of patients above the proposed limit. While most laws focus on DS limits, results for quantity and dosage dispensed show similar trends and will also be presented, along with procedure specific (knee arthroplasty, hernia repair, cholecystectomy) results.
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  • ICPE 2020
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