Impact of a State Opioid Prescribing Limit and Electronic Medical Record Alert on Opioid Prescriptions: a Difference-in-Differences Analysis.
addiction
health policy
health services research
opioid
Journal
Journal of general internal medicine
ISSN: 1525-1497
Titre abrégé: J Gen Intern Med
Pays: United States
ID NLM: 8605834
Informations de publication
Date de publication:
03 2020
03 2020
Historique:
received:
27
12
2018
accepted:
25
07
2019
revised:
24
04
2019
pubmed:
12
10
2019
medline:
11
5
2021
entrez:
12
10
2019
Statut:
ppublish
Résumé
Prescribing limits are one policy strategy to reduce short-term opioid prescribing, but there is limited evidence of their impact. Evaluate implementation of a state prescribing limit law and health system electronic medical record (EMR) alert on characteristics of new opioid prescriptions, refill rates, and clinical encounters. Difference-in-differences study comparing new opioid prescriptions from ambulatory practices in New Jersey (NJ) to controls in Pennsylvania (PA) from 1 year prior to the implementation of a NJ state prescribing limit (May 2016-May 2017) to 10 months after (May 2017-March 2018). Adults with new opioid prescriptions in an academic health system with practices in PA and NJ. State 5-day opioid prescribing limit plus health system and health system EMR alert. Changes in morphine milligram equivalents (MME) and tablet quantity per prescription, refills, and encounters, adjusted for patient and prescriber characteristics. There were a total of 678 new prescriptions in NJ and 4638 in PA. Prior to the intervention, median MME/prescription was 225 mg in NJ and 150 mg in PA, and median quantity was 30 tablets in both. After implementation, median MME/prescription was 150 mg in both states, and median quantity was 20 in NJ and 30 in PA. In the adjusted model, there was a greater decrease in mean MME and tablet quantity in NJ relative to PA after implementation of the policy plus alert (- 82.99 MME/prescription, 95% CI - 148.15 to - 17.84 and - 10.41 tabs/prescription, 95% CI - 19.70 to - 1.13). There were no significant differences in rates of refills or encounters at 30 days based on exposure to the interventions. Implementation of a prescribing limit and EMR alert was associated with an approximately 22% greater decrease in opioid dose per new prescription in NJ compared with controls in PA. The combination of prescribing limits and alerts may be an effective strategy to influence prescriber behavior.
Sections du résumé
BACKGROUND
Prescribing limits are one policy strategy to reduce short-term opioid prescribing, but there is limited evidence of their impact.
OBJECTIVE
Evaluate implementation of a state prescribing limit law and health system electronic medical record (EMR) alert on characteristics of new opioid prescriptions, refill rates, and clinical encounters.
DESIGN
Difference-in-differences study comparing new opioid prescriptions from ambulatory practices in New Jersey (NJ) to controls in Pennsylvania (PA) from 1 year prior to the implementation of a NJ state prescribing limit (May 2016-May 2017) to 10 months after (May 2017-March 2018).
PARTICIPANTS
Adults with new opioid prescriptions in an academic health system with practices in PA and NJ.
INTERVENTIONS
State 5-day opioid prescribing limit plus health system and health system EMR alert.
MAIN MEASURES
Changes in morphine milligram equivalents (MME) and tablet quantity per prescription, refills, and encounters, adjusted for patient and prescriber characteristics.
KEY RESULTS
There were a total of 678 new prescriptions in NJ and 4638 in PA. Prior to the intervention, median MME/prescription was 225 mg in NJ and 150 mg in PA, and median quantity was 30 tablets in both. After implementation, median MME/prescription was 150 mg in both states, and median quantity was 20 in NJ and 30 in PA. In the adjusted model, there was a greater decrease in mean MME and tablet quantity in NJ relative to PA after implementation of the policy plus alert (- 82.99 MME/prescription, 95% CI - 148.15 to - 17.84 and - 10.41 tabs/prescription, 95% CI - 19.70 to - 1.13). There were no significant differences in rates of refills or encounters at 30 days based on exposure to the interventions.
CONCLUSIONS
Implementation of a prescribing limit and EMR alert was associated with an approximately 22% greater decrease in opioid dose per new prescription in NJ compared with controls in PA. The combination of prescribing limits and alerts may be an effective strategy to influence prescriber behavior.
Identifiants
pubmed: 31602561
doi: 10.1007/s11606-019-05302-1
pii: 10.1007/s11606-019-05302-1
pmc: PMC7080923
doi:
Substances chimiques
Analgesics, Opioid
0
Types de publication
Journal Article
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, Non-P.H.S.
Langues
eng
Sous-ensembles de citation
IM
Pagination
662-671Subventions
Organisme : NIDA NIH HHS
ID : R01 DA042299
Pays : United States
Commentaires et corrections
Type : CommentIn
Références
Barnett ML, Olenski AR, Jena AB. Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use. The New England journal of medicine. 2017;376(7):663–673.
doi: 10.1056/NEJMsa1610524
Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States, 2006-2015. MMWR Morbidity and mortality weekly report. 2017;66(10):265–269.
doi: 10.15585/mmwr.mm6610a1
Shah A, Hayes CJ, Martin BC. Factors Influencing Long-Term Opioid Use Among Opioid Naive Patients: An Examination of Initial Prescription Characteristics and Pain Etiologies. The journal of pain : official journal of the American Pain Society. 2017.
Deyo RA, Hallvik SE, Hildebran C, et al. Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naive Patients: A Statewide Retrospective Cohort Study. Journal of general internal medicine. 2017;32(1):21–27.
doi: 10.1007/s11606-016-3810-3
Bicket MC, Long JJ, Pronovost PJ, Alexander GC, Wu CL. Prescription Opioid Analgesics Commonly Unused After Surgery: A Systematic Review. JAMA surgery. 2017;152(11):1066–1071.
doi: 10.1001/jamasurg.2017.0831
Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use United States, 2008-2011. JAMA internal medicine. 2014;174(5):802–803.
doi: 10.1001/jamainternmed.2013.12809
Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health. Annals of internal medicine. 2017;167(5):293–301.
doi: 10.7326/M17-0865
Cicero TJ, Ellis MS, Kasper ZA. Increased use of heroin as an initiating opioid of abuse. Addictive behaviors. 2017;74:63–66.
doi: 10.1016/j.addbeh.2017.05.030
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recommendations and reports : Morbidity and mortality weekly report Recommendations and reports. 2016;65(1):1–49.
Prescription Drug Abuse Policy System (PDAPS) 2018; http://pdaps.org . Accessed July 8, 2019.
CVS Health Responds to Nation’s Opioid Crisis [press release]. September 21, 2017.
Zezima K. With drug overdoses soaring, states limit the length of painkiller prescriptions. The Washington Post. August 7, 2017.
Independence limits new opioid prescriptions to five days [press release]. June 27 2017.
National Conference of State Legislatures. Prescribing Policies: States Confront Opioid Overdose Epidemic. 2018; http://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx .
Chua KP, Brummett CM, Waljee JF. Opioid Prescribing Limits for Acute Pain: Potential Problems With Design and Implementation. Jama. 2019;321(7):643–644.
doi: 10.1001/jama.2019.0010
Bohnert ASB, Guy GP, Jr., Losby JL. Opioid Prescribing in the United States Before and After the Centers for Disease Control and Prevention’s 2016 Opioid Guideline. Annals of internal medicine. 2018;169(6):367–375.
Mundkur ML, Gordon AJ, Kertesz SG. Will strict limits on opioid prescription duration prevent addiction? advocating for evidence-based policymaking. Substance abuse. 2017:1–2.
Lowenstein M, Grande D, Delgado MK. Opioid Prescribing Limits for Acute Pain - Striking the Right Balance. The New England journal of medicine. 2018;379(6):504–506.
doi: 10.1056/NEJMp1803661
New Jersey Academy of Family Physicians. NEW PRESCRIBING LAW FOR TREATMENT OF ACUTE AND CHRONIC PAIN. 2017; https://www.njafp.org/content/new-prescribing-law-treatment-acute-and-chronic-pain . Accessed July 8, 2019.
Keller PA, Harlam B, Loewenstein G, Volpp KG. Enhanced active choice: A new method to motivate behavior change. Journal of Consumer Psychology. 2011;21(4):376–383.
doi: 10.1016/j.jcps.2011.06.003
Braden JB, Sullivan MD, Ray GT, et al. Trends in long-term opioid therapy for noncancer pain among persons with a history of depression. General hospital psychiatry. 2009;31(6):564–570.
doi: 10.1016/j.genhosppsych.2009.07.003
Halbert BT, Davis RB, Wee CC. Disproportionate longer-term opioid use among U.S. adults with mood disorders. Pain. 2016;157(11):2452–2457.
doi: 10.1097/j.pain.0000000000000650
Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA internal medicine. 2016;176(9):1286–1293.
doi: 10.1001/jamainternmed.2016.3298
Centers for medicare and Medicaid Services. Opioid Oral Morphine Milligram Equivalent (MME) Conversion Factors. 2017; https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Opioid-Morphine-EQ-Conversion-Factors-Aug-2017.pdf . Accessed July 8, 2019.
Rutkow L, Chang HY, Daubresse M, Webster DW, Stuart EA, Alexander GC. Effect of Florida’s Prescription Drug Monitoring Program and Pill Mill Laws on Opioid Prescribing and Use. JAMA internal medicine. 2015;175(10):1642–1649.
doi: 10.1001/jamainternmed.2015.3931
Chang HY, Lyapustina T, Rutkow L, et al. Impact of prescription drug monitoring programs and pill mill laws on high-risk opioid prescribers: A comparative interrupted time series analysis. Drug and alcohol dependence. 2016;165:1–8.
doi: 10.1016/j.drugalcdep.2016.04.033
Meisenberg BR, Grover J, Campbell C, Korpon D. Assessment of Opioid Prescribing Practices Before and After Implementation of a Health System Intervention to Reduce Opioid Overprescribing. JAMA network open. 2018;1(5):e182908.
doi: 10.1001/jamanetworkopen.2018.2908
Tan WH, Yu J, Feaman S, et al. Opioid Medication Use in the Surgical Patient: An Assessment of Prescribing Patterns and Use. J Am Coll Surg. 2018;227(2):203–211.
doi: 10.1016/j.jamcollsurg.2018.04.032
Centers for Disease Control and Prevention. Prescription Opioid Data. 2018; https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html . Accessed July 8, 2019.
Dimick JB, Ryan AM. Methods for evaluating changes in health care policy: the difference-in-differences approach. Jama. 2014;312(22):2401–2402.
doi: 10.1001/jama.2014.16153
Meara E, Horwitz JR, Powell W, et al. State Legal Restrictions and Prescription-Opioid Use among Disabled Adults. The New England journal of medicine. 2016;375(1):44–53.
doi: 10.1056/NEJMsa1514387
Pitt AL, Humphreys K, Brandeau ML. Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic. American journal of public health. 2018;108(10):1394–1400.
doi: 10.2105/AJPH.2018.304590
American College of Emergency Physicians. E-QUAL Network Opioid Initiative. 2018; https://www.acep.org/administration/quality/equal/e-qual-opioid-initiative/ . Accessed July 8, 2019.
Opioid Prescribing Engagement Network. Opioid Prescribing Recommendations for Surgery. 2019; https://opioidprescribing.info/ . Accessed July 9, 2019.
Howard R, Fry B, Gunaseelan V, et al. Association of Opioid Prescribing With Opioid Consumption After Surgery in Michigan. JAMA surgery. 2018:e184234.
Patel MS, Kurtzman GW, Kannan S, et al. Effect of an Automated Patient Dashboard Using Active Choice and Peer Comparison Performance Feedback to Physicians on Statin Prescribing: The PRESCRIBE Cluster Randomized Clinical Trial. JAMA network open. 2018;1(3):e180818.
doi: 10.1001/jamanetworkopen.2018.0818
Patel MS, Volpp KG, Small DS, et al. Using Active Choice Within the Electronic Health Record to Increase Influenza Vaccination Rates. Journal of general internal medicine. 2017;32(7):790–795.
doi: 10.1007/s11606-017-4046-6
Delgado MK, Shofer FS, Patel MS, et al. Association between Electronic Medical Record Implementation of Default Opioid Prescription Quantities and Prescribing Behavior in Two Emergency Departments. Journal of general internal medicine. 2018;33(4):409–411.
doi: 10.1007/s11606-017-4286-5
Chiu AS, Jean RA, Hoag JR, Freedman-Weiss M, Healy JM, Pei KY. Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing. JAMA surgery. 2018;153(11):1012–1019.
doi: 10.1001/jamasurg.2018.2083