Impact of a State Opioid Prescribing Limit and Electronic Medical Record Alert on Opioid Prescriptions: a Difference-in-Differences Analysis
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.
KEY WORDShealth policy health services research opioid addiction
Contributors: The authors would like to thank the executive directors of the University of Pennsylvania Health System Opioid Task Force, David Horowitz and John Sestito, and the leadership of the Information Technology Subcommittee, Christine Vanzandbergen and John T. Howell, for their operational and logistical contributions to this project.
Dr. Lowenstein is funded by the Department of Veterans Affairs through the National Clinician Scholars Program. Additional funding was provided by the Division of General Internal Medicine at the University of Pennsylvania School of Medicine pilot grant (Dr. Lowenstein), NIH K23HD090272001 (Dr. Delgado), and NIH R01DA042299-02 (Dr. Neuman).
Compliance with Ethical Standards
The study was approved by the University of Pennsylvania Institutional Review Board.
Conflict of Interest
Dr. Delgado reports receiving an honorarium for participating in an Expert Roundtable on Innovations in Acute Pain Management convened by United Health Group in 2017. He has no current financial conflicts of interest. Dr. Ashburn reported receiving personal fees from the Department of Justice, the Attorney General for the State of Maryland, the Department of State for the Commonwealth of Pennsylvania, the Montgomery County District Attorney, and the Carolinas Pain Society. All remaining authors declare that they do not have a conflict of interest.
- 3.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.Google Scholar
- 9.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.Google Scholar
- 10.Prescription Drug Abuse Policy System (PDAPS) 2018; http://pdaps.org. Accessed July 8, 2019.
- 11.CVS Health Responds to Nation’s Opioid Crisis [press release]. September 21, 2017.Google Scholar
- 12.Zezima K. With drug overdoses soaring, states limit the length of painkiller prescriptions. The Washington Post. August 7, 2017.Google Scholar
- 13.Independence limits new opioid prescriptions to five days [press release]. June 27 2017.Google Scholar
- 14.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.
- 16.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.Google Scholar
- 17.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.Google Scholar
- 19.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.
- 24.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.
- 29.Centers for Disease Control and Prevention. Prescription Opioid Data. 2018; https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html. Accessed July 8, 2019.
- 33.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.
- 34.Opioid Prescribing Engagement Network. Opioid Prescribing Recommendations for Surgery. 2019; https://opioidprescribing.info/. Accessed July 9, 2019.
- 35.Howard R, Fry B, Gunaseelan V, et al. Association of Opioid Prescribing With Opioid Consumption After Surgery in Michigan. JAMA surgery. 2018:e184234.Google Scholar