Author: Chase Doyle
A new controlled substance law in Florida has helped to decrease opioid prescriptions after outpatient surgery, according to a retrospective analysis at a large academic center.
The study of more than 1, 000 outpatient surgical encounters at Jackson Memorial Hospital showed that fewer patients received opioid prescriptions, and less milligram morphine equivalents (MMEs) of opioids were prescribed following implementation of the Florida state law (House Bill 21). However, the authors also noted an increase in MMEs prescribed per day—a possible unintended consequence of restricting the duration, but not the amount or dosage, of opioid prescriptions.
“It was somewhat predictable that people would prescribe a higher daily dose to get around the law, but on the plus side, lower total doses of opioids were prescribed,” said Paul Potnuru, MD, an anesthesiologist at Jackson Memorial Hospital of the University of Miami Leonard M. Miller School of Medicine. “Overall, these results demonstrate the effectiveness of such legislation in modifying and decreasing high-risk opioid prescribing practices.”
As Dr. Potnuru explained, in response to the national opioid crisis, Florida implemented the law on July 1, 2018, to reduce the supply of circulating opioids. The law limits opioid prescriptions for acute pain to a three-day supply, which can be extended up to seven days if medically necessary, and does not apply to traumatic injuries with an Injury Severity Score of 9 or more for chronic pain.
For this retrospective study, Dr. Potnuru and his colleagues sought to characterize the immediate effect of Florida’s new law on opioid prescription patterns for acute pain after outpatient surgery at a large public teaching hospital.
The researchers reviewed opioid prescriptions for outpatient surgeries at Jackson Memorial Hospital from July 2017 to September 2018. Adult outpatients who underwent cholecystectomy, appendectomy, hernia repair, hysterectomy, colectomy, mastectomy and lymph node dissection were included in the analysis.
For each surgical encounter, the researchers obtained the following anonymized data: age, sex, surgical procedure, surgery duration and discharge opioid prescriptions. Investigators then calculated the total MMEs prescribed and MME per day for each encounter. Finally, the data were divided into two cohorts: before (July 2017 to June 2018) and after (July-September 2018) implementation of the law.
Lower Total Doses of Opioids
As Dr. Potnuru reported, a total of 1,167 outpatient surgical encounters were included in the analysis, and cohorts were similar with respect to age, sex, and surgery duration before (n=904) and after (n=263) implementation of the law. Following implementation of the law, said Dr. Potnuru, fewer patients received opioid prescriptions on discharge after surgery (93% before vs. 65% after; P<0.001). Among patients receiving opioid prescriptions on discharge, mean MMEs prescribed also decreased by 43.5 (P<0.001). In addition, fewer patients received opioid prescriptions for longer than a three-day supply (74% vs. 15%; P<0.001).
Although the law was successful in reducing several high-risk opioid prescribing practices, according to the researchers, they observed an unintended consequence of not restricting the amount or dosage of opioids prescribed. Among patients receiving opioid prescriptions, the mean MMEs prescribed per day increased by 6.4 (P<0.001). According to Dr. Potnuru, this increase in doses per day most likely arose from a misunderstanding of the law.
“A survey of our surgery department when the law first went into effect showed that people were unaware that they could prescribe more than three days if they completed the paperwork, so they prescribed higher doses per day to ensure that their patients had enough pills,” he said. “Once they realized that they could prescribe up to seven days, most people have come back down to reasonable doses.”
As Dr. Potnuru explained, the underlying issue has been a lack of guidance on how much providers should be prescribing for a given surgery, which also accounts for a large variability in prescription size among providers. Recently, however, the University of Michigan published prescription guidelines based on patient-reported usage of opioids after surgery.
“After making the Michigan guidelines available to our providers, we noticed that the prescriptions became more uniform and the range became tighter,” Dr. Potnuru observed.
Finally, despite the decrease in total opioids prescribed, researchers found no difference in ER visits. Both before and after implementation of the law, approximately 6% of patients returned to the ER for pain after surgery. “That’s one good indicator that the opioids we were prescribing before were probably excessive,” Dr. Potnuru said.
The researchers plan to further investigate the law’s broader effect on opioid prescriptions and secondary consequences, including inadequate postsurgical analgesia and overdose deaths, to identify evidence-based solutions to the opioid crisis.