Advertisement

Opioid prescriptions for acute pain after outpatient surgery at a large public university-affiliated hospital: Impact of state legislation in Florida

      Abstract

      Background

      In response to the growing opioid crisis, Florida recently implemented a law restricting the duration of opioid prescriptions for acute pain. Little is known about the impact of such legislation on opioid prescription practices at the time of discharge after surgery. The objective of this study was to determine whether Florida’s new legislation changed opioid prescription practices for analgesia after surgery.

      Methods

      Adults 18 years of age and older undergoing cholecystectomy, appendectomy, hernia repair, hysterectomy, mastectomy, or lymph node dissection were included in this retrospective cohort study at a large public university–affiliated hospital. We analyzed opioid prescriptions on discharge after these common outpatient surgical procedures between June 1, 2017, and December 31, 2018. Florida House Bill 21 was passed on March 2, 2018, and subsequent implementation of this law took place on July 1, 2018. The law restricts the duration of opioid prescriptions for acute pain to 3 days, which can be extended up to a maximum of 7 days with additional documentation. The outcomes studied included the following: the proportion of patients receiving opioid prescriptions on discharge, total opioid dose prescribed, daily opioid dose prescribed, and the proportion of patients receiving more than a 3-day supply of opioids. We colledted data on emergency department cumulative visits within 7 and 30 days after discharge. Drug doses were converted to morphine milligram equivalents and calculated for each selected procedure.

      Results

      A total of 1,467 surgical encounters were included. The cohort was predominantly female (963 [65.6%]) with a mean (SD) age of 49.6 (14.4) years. At 6 months after implementation of HB 21, the proportion of patients receiving opioid prescriptions decreased by 21% (95% CI 16.8% to 25.3%, P < .001), mean total opioid dose prescribed decreased by 64.2 morphine milligram equivalents (95% CI 54.7 to 73.7, P < .001) from a baseline mean (SD) of 172.5 (78.9) morphine milligram equivalents. The mean daily opioid dose prescribed increased by 3.5 morphine milligram equivalents (95% CI 1.8 to 5.1, P < .001) from a baseline mean (SD) of 30.5 (9.4) morphine milligram equivalents. The proportion of patients receiving opioid prescriptions for longer than a 3-day supply decreased by 68% (95% CI 63.4% to 72.7%, P < .001). We observed no change in the number of postoperative emergency department visits before and after implementation of the law.

      Conclusion

      Opioid prescriptions for patients undergoing common outpatient surgical procedures at a large public university–affiliated hospital in Florida were substantially reduced within 6 months after implementation of state legislation limiting the duration of opioid prescriptions. This reduction was not associated with an increase in the number of postoperative emergency department visits. The legislation should significantly decrease the amount of unused opioid pills potentially available for diversion and abuse. Secondary effects from the enactment of this law remain to be evaluated.
      To read this article in full you will need to make a payment
      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Buvanendran A.
        • Fiala J.
        • Patel K.A.
        • Golden A.D.
        • Moric M.
        • Kroin J.S.
        The incidence and severity of postoperative pain following inpatient surgery.
        Pain Med. 2015; 16: 2277-2283
        • Gan T.J.
        • Habib A.S.
        • Miller T.E.
        • White W.
        • Apfelbaum J.L.
        Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey.
        Curr Med Res Opin. 2014; 30: 149-160
        • Thiels C.A.
        • Anderson S.S.
        • Ubl D.S.
        • et al.
        Wide variation and overprescription of opioids after elective surgery.
        Ann Surg. 2017; 266: 564-573
        • Hill M.V.
        • McMahon M.L.
        • Stucke R.S.
        • Barth R.J.
        Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures.
        Ann Surg. 2017; 265: 709-714
        • Bates C.
        • Laciak R.
        • Southwick A.
        • Bishoff J.
        Overprescription of postoperative narcotics: A look at postoperative pain medication delivery, consumption and disposal in urological practice.
        J Urol. 2011; 185: 551-555
        • Bicket M.C.
        • Long J.J.
        • Pronovost P.J.
        • Alexander G.C.
        • Wu C.L.
        Prescription opioid analgesics commonly unused after surgery: A systematic review.
        JAMA Surg. 2017; 152: 1066-1071
        • Lankenau S.E.
        • Teti M.
        • Silva K.
        • Jackson Bloom J.
        • Harocopos A.
        • Treese M.
        Initiation into prescription opioid misuse amongst young injection drug users.
        Int J Drug Policy. 2012; 23: 37-44
        • Sun E.C.
        • Darnall B.D.
        • Baker L.C.
        • Mackey S.
        Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period.
        JAMA Intern Med. 2016; 176: 1286-1293
        • Brummett C.M.
        • Waljee J.F.
        • Goesling J.
        • et al.
        New persistent opioid use after minor and major surgical procedures in us adults.
        JAMA Surg. 2017; 152: e170504
        • Makary M.A.
        • Overton H.N.
        • Wang P.
        Overprescribing is major contributor to opioid crisis.
        BMJ. 2017; 359: j4792
        • Makary M.A.
        • Mehta A.
        • Xu T.
        Improving wisely using physician metrics.
        Am J Med Qual. 2018; 33: 103-105
        • Hill M.V.
        • Stucke R.S.
        • McMahon M.L.
        • Beeman J.L.
        • Barth R.J.
        An educational intervention decreases opioid prescribing after general surgical operations.
        Ann Surg. 2018; 267: 468-472
        • Doctor J.N.
        • Nguyen A.
        • Lev R.
        • et al.
        Opioid prescribing decreases after learning of a patient’s fatal overdose.
        Science. 2018; 361: 588-590
        • McGinty E.E.
        • Stuart E.A.
        • Caleb Alexander G.
        • Barry C.L.
        • Bicket M.C.
        • Rutkow L.
        Protocol: Mixed-methods study to evaluate implementation, enforcement, and outcomes of US state laws intended to curb high-risk opioid prescribing.
        Implement Sci. 2018; 13: 37
        • Scott R.
        • Philip C.
        Statewide Drug Policy Advisory Council 2016 annual report, website.
      1. CS/CS/HB 21: Controlled substances, 2018, web site.
        https://www.flsenate.gov/Session/Bill/2018/21
        Date accessed: October 3, 2018
      2. E-FORCSE, Florida Prescription Drug Monitoring Program website.
        • Copes W.S.
        • Champion H.R.
        • Sacco W.J.
        • Lawnick M.M.
        • Keast S.L.
        • Bain L.W.
        The Injury Severity Score revisited.
        J Trauma. 1988; 28: 69-77
        • Davis C.S.
        • Lieberman A.J.
        • Hernandez-Delgado H.
        • Suba C.
        Laws limiting the prescribing or dispensing of opioids for acute pain in the United States: A national systematic legal review.
        Drug Alcohol Depend. 2019; 194: 166-172
        • Scully R.E.
        • Schoenfeld A.J.
        • Jiang W.
        • et al.
        Defining optimal length of opioid pain medication prescription after common surgical procedures.
        JAMA Surg. 2018; 153: 37-43
        • Centers for Medicare & Medicaid Services
        Opioid oral morphine milligram equivalent (MME) conversion factors, 2018, website.
        • Brat G.A.
        • Agniel D.
        • Beam A.
        • et al.
        Postsurgical prescriptions for opioid naïve patients and association with overdose and misuse: Retrospective cohort study.
        BMJ. 2018; 360: j5790
        • Shah A.
        • Hayes C.J.
        • Martin B.C.
        Factors influencing long-term opioid use among opioid naive patients: An examination of initial prescription characteristics and pain etiologies.
        J Pain. 2017; 18: 1374-1383
        • Michigan Opioid Prescribing Engagement Network
        Opioid prescribing recommendations for surgery, website.
        https://opioidprescribing.info
        Date accessed: April 11, 2019
        • Dowell D.
        • Haegerich T.M.
        • Chou R.
        CDC guideline for prescribing opioids for chronic pain–United States, 2016.
        JAMA. 2016; 315: 1624-1645