Our results identified heterogeneous baseline opioid-prescribing practices for acute pain by provider types, as expected given the differing conditions and degrees of pain being treated. Additionally, we identified a differential impact on opioid prescribing immediately following policy implementation, suggesting that the impact of opioid prescribing limit laws on prescribing behaviors likely depends on the specific provider type and their pre-established opioid-prescribing trends prior to policy implementation.
In our study, we found a decreasing pre-policy trend in opioid prescribing among surgeons, with no meaningful changes in mean days’ supply, number of units, or MMEs immediately after HB21 was implemented. These findings suggest surgeons’ opioid-prescribing trends were likely impacted by other forces outside of the HB21 law. Although lower than the pre-policy average of 5.4 days at 4.0 days, the surgeons’ mean days’ supply remained higher than 3 days, indicating a more frequent use of the exemption for acute pain prescribing. Another study in Florida analyzing whether the HB21 legislation changed opioid prescription practices after surgery did result in fewer patients receiving opioid prescriptions on discharge (21% reduction, p < 0.001) and fewer patients receiving prescriptions exceeding a 3-day supply (68% reduction, p < 0.001).16 However, 6 months after implementation of HB21, the authors also observed a mean daily dose increase of 3.5 morphine milligram equivalents from a baseline mean of 9.4 MME which could suggest an attempt to adjust dosage to reduce immediate follow-up visits.16 The discordance of evidence on which to base postoperative prescribing practices further highlights the need to create evidence-based opioid-prescribing recommendations that take into account the diverse surgery practice environments.17, 18 Thus, further analysis of stratification by surgery type or surgeon sub-specialty may be warranted given the vast heterogeneity of pain presentations associated with differing procedures.10
In our study population, the emergency care provider type was among the lowest in opioid prescribing for all three outcomes, and this appears to be in accordance with recent efforts by emergency departments to minimize opioid-related harms by taking advantage of non-opioid analgesics to manage acute pain.19,20,21 Anticipatory effects were observed for emergency care providers, who experienced marked increases across all three variables in the month immediately prior to policy implementation. Further research as to what caused this occurrence is warranted. Furthermore, there was still a 20 to 30% immediate reduction across all three opioid-prescribing metrics measured following HB21 for emergency care medicine providers, consistent with other studies evaluating state-level guidelines on recommended opioid-prescribing practices in the emergency department.22 However, there was a significant increase in mean MME from 61.0 to 95.5 in the 9 months following HB21 implementation. The increase in mean MME after the initial reduction may indicate a potential overcorrection in opioid prescribing (i.e., patients may not have been adequately treated immediately following HB21 implementation). The initial overcorrection of physicians’ prescribing trends as a result of opioid restriction guidelines has been previously reported as an unintended consequence of expecting clinicians to immediately mitigate the risks of high-dose opioids, with some providers universally stopping opioid prescriptions even when the benefits might outweigh the risks.21 Hence, the importance of individualizing application of policies and engaging in shared decision-making with patients when discussing pain therapy is warranted.23,24,25
Interpretations of specialty care providers’ trends is challenging due to the heterogeneity of provider subgroups, leading to constantly fluctuating data points before and immediately after HB21 implementation. Among dentists, there was an immediate reduction in mean days’ supply and a significant trend in the reductions of mean MME and mean number of units following HB21. This change, coupled with a recent statement by the American Dental Association on the use of opioids in the treatment of dental pain, which included a recommendation to consider NSAIDS as a first-line therapy option, represents a move towards potentially safer prescribing practices within the field of dentistry, especially as recent findings suggest the MME of opioid prescriptions by dentists was 29% higher than recommended for acute pain management, while 53% of dentists’ opioid prescriptions exceeded the recommended days’ supply.26,27,28,29
Our study has several limitations. First, it only captures the opioid prescription claims of a single private health plan serving a large university-affiliated hospital, which limits the generalizability of our findings to other healthcare settings. Second, pharmacy claims data are unable to capture the type and severity of pain for which each opioid prescription was written and thus future studies evaluating these differences could prove informative. Third, in 13% of opioid prescriptions, the provider was classified as “Student Health Care” suggesting their taxonomy has not been updated. These providers were not further assessed as they could belong to any provider type. Lastly, unlike the findings from Potnuru, we were unable to determine changes in the number of patients prescribed opioids by provider type since we were unable to assess visits in which an opioid was not prescribed.16
Our findings expand on the previous research analyzing the effects of opioid-prescribing limitation laws that assessed either provider types in aggregate or by individual provider types.6, 9, 10, 13, 16, 19, 30,31,32,33 To our knowledge, our study was the first to evaluate the impacts of an opioid-prescribing restriction policy across multiple provider types. Additionally, we utilized interrupted time series models, which allowed for the evaluation of pre- and post-policy trends which are not captured in simple pre-/post-analyses.