Mandatory Prescription Limits and Opioid Utilization Following Orthopaedic Surgery

Abstract

Background: Since 2016, over half of the states in the United States have passed mandatory limits on opioid prescriptions, with limited evidence of effectiveness. In this study, we evaluated postoperative opioid prescriptions following orthopaedic surgery before and after the implementation of one of the earliest such laws. Methods: Following the implementation of state legislation limiting opioid prescriptions for opioid-naïve patients, 2 patient cohorts (pre-law and post-law) were compared. Both opioid-tolerant and opioid-naïve patients undergoing 6 common orthopaedic procedures (total knee arthroplasty, rotator cuff repair, anterior cruciate ligament reconstruction, open reduction and internal fixation for a distal radial fracture, open reduction and internal fixation for an ankle fracture, and lumbar discectomy) met inclusion criteria. Patients undergoing >1 primary procedure in the same operative session were excluded. All benzodiazepine and opioid prescriptions from 30 days before to 90 days after the surgical procedure were recorded. Logistic regression was performed to determine risk factors for prolonged postoperative opioid use. Results: In this study, 836 pre-law patients were compared with 940 post-law patients. The 2 groups were similar with regard to demographic variables, baseline opioid tolerance, and recent benzodiazepine use (all p > 0.05). Post-law, for all patients, there were decreases in the initial prescription pill quantity (49.65 pills pre-law and 22.08 pills post-law; p < 0.001) and the total morphine milligram equivalents (MMEs) (417.67 MMEs pre-law and 173.86 MMEs post-law; p < 0.001), regardless of patient preoperative opioid exposure (all p < 0.001). Additionally, there were decreases in the mean cumulative 30-day MMEs (790.01 MMEs pre-law and 524.61 MMEs post-law; p < 0.001) and the 30 to 90-day MMEs (243.51 MMEs pre-law and 208.54 MMEs post-law; p = 0.008). Despite being specifically exempted from the legislation, opioid-tolerant patients likewise experienced a significant decrease in cumulative 30-day MMEs (1,304.08 MMEs pre-law and 1,015.19 MMEs post-law; p = 0.0016). Opioid-tolerant patients required more postoperative opioids at all time points and had an increased likelihood of prolonged opioid use compared with those who were opioid-naïve preoperatively (odds ratio, 8.73 [95% confidence interval, 6.21 to 12.29]). Conclusions: A clinically important and significant reduction in opioid utilization after orthopaedic surgery was observed following the implementation of statewide mandatory opioid prescription limits. Clinical Relevance: After implementation of mandatory opioid prescription regulations, a clinically important and significant decline in the volume of opioids dispensed in the short term and intermediate term following orthopaedic surgery was observed. Furthermore, important clinical predictors of prolonged postoperative opioid use, including preoperative opioid use and preoperative benzodiazepine use, were identified. These findings have important implications for public health, as well as the potential to influence policymakers and to change practice among orthopaedic surgeons.

The Association of Prescriber Awareness of Opioid Consumption Trends with Postoperative Opioid Prescription Volume in Hip Arthroscopy: Prescriber Awareness of Opioid Consumption

“…A recent report by Reid et al. 20 demonstrated that the volume of opioids prescribed by orthopaedic surgeons decreased by approximately one-half after the implementation of statewide legislation restricting early postoperative opioid prescriptions in Rhode Island. Our state enacted legislation limiting postoperative opioid prescribing on January 1, 2018.…”

Editorial Commentary: Uncle Sam Wants YOU! (to Stop the Opioid Crisis)

“…Matzkin and colleagues 5 have corroborated this, with >80% of patients reporting satisfactory pain control after simple knee arthroscopy with NSAIDS alone. The use of preprocedure opiates also seems to play a large role in the usage of postoperative narcotics, [5][6][7][8] which underscores the importance of a comprehensive, educational, multimodal, and perhaps multidisciplinary approach to opioid-tolerant patients.…”

Strategies aimed at preventing chronic opioid use in trauma and acute care surgery: a scoping review protocol

“…29 Recently, mandatory prescription limits have been associated with a reduction of opioid use after elective surgeries. [30][31][32][33] However, our knowledge of the potential strategies is limited, and none are currently broadly applied as standard of care interventions. The objective of our scoping review is to understand the strategies aiming at preventing chronic opioid use specific to adult trauma and acute care surgery patients.…”