306. Opioid-limiting legislation effectively decreases 30-day opioid utilization following anterior cervical decompression and fusion

Abstract

BACKGROUND CONTEXT Since 2016, over half of US states have passed mandatory opioid-limiting laws. The impacts of such mandates on postoperative opioid prescribing and secondary outcomes following anterior cervical discectomy and fusion (ACDF) have not been previously described. PURPOSE The purpose of this study is to evaluate the impact of newly implemented statewide opioid-limiting regulations in Rhode Island on postoperative opioid prescriptions, emergency department (ED) visits, unplanned readmissions and reoperations following elective ACDF. STUDY DESIGN/SETTING Retrospective review of prospectively-collected data PATIENT SAMPLE A total of 211 patients undergoing primary elective 1-3 level ACDF during specified pre-law (12/01/15 - 06/30/16) and post-law (06/01/17 - 12/31/17) study periods were considered eligible for study inclusion. Patients undergoing ACDF for trauma or other emergencies, requiring corpectomy, undergoing simultaneous procedures, or undergoing ACDF as part of a staged procedure were excluded. OUTCOME MEASURES Primary outcome measures included the number of prescriptions and total morphine milligram equivalents (MMEs) filled at 30-day postoperative intervals for 4 months following ACDF. Secondary outcome measures included prescription refill requests as well as 30-day and 90-day ED visits, readmissions and reoperations. METHODS Demographic, medical, surgical, clinical and pharmacological data were collected from all eligible patients. Those not filling any opioid prescriptions within the 30-day preoperative period were considered opioid-naïve. Patients filling at least one opioid prescription in the 30-day preoperative period were considered opioid-tolerant. Cumulative oral morphine milligram equivalents (MMEs) filled were compared at 30-day postoperative intervals following ACDF, before and after stratification by preoperative opioid-tolerance and pre/post-law status. The mean number of prescription refills required within 30-days of surgery was also compared between groups. Thirty- and 90-day ED visit, readmission and reoperation rates were calculated. Independent predictors of increased 30-day and chronic (>90 day) opioid utilization were evaluated using backwards stepwise linear and logistic regression modeling respectively. RESULTS Demographic, medical and surgical factors were similar between pre-law and post-law patients (all p>0.05). Post-law, ACDF patients received fewer opioids in their first postoperative prescription (26.65 pills post-law vs 62.08 pills pre-law, p<.001; 202.23 MMEs post-law vs 549.18 MMEs pre-law, p<.001) and in their first 30 postoperative days (444.14 cumulative 30-day MMEs post-law vs 877.87 cumulative 30-day MMEs pre-law, p<.001). There was no difference in the mean number of prescriptions filled in the 30-day postoperative period (1.70 prescriptions post-law vs 1.63 prescriptions pre-law, p=0.417). Post-law reductions in cumulative 30-day MMEs were seen among both opioid-naïve (363.54 MMEs post-law vs 632.20 MMEs pre-law, p<.001) and opioid-tolerant (730.08 MMEs post-law vs 1,122.90 MMEs pre-law, p=0.022) patient populations. Increased 30-day opioid utilization was associated with surgery in the pre-law period (coeff. -394.72 MMEs, p<.001) preoperative opioid-tolerance (coeff. +311.32 MMEs, p<.001), preoperative benzodiazepine exposure (coeff. +355.45 MMEs, p=0.003), and number of levels fused (coeff. + 113.54 MME/level, p=0.038). Chronic (>90 day) opioid requirements were associated with preoperative opioid-tolerance (OR 4.42, p<.001) but not with pre/post-law status (p>0.05). Pre- and post-law patients were similar in terms of 30- and 90-day ED visit, unplanned readmission, and reoperation rates (all p>0.05). CONCLUSIONS Implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization following ACDF, regardless of preoperative opioid tolerance and without a rebound increase in prescription refills, ED visits, unplanned hospital readmissions, or reoperations. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Since 2016, over half of US states have passed mandatory opioid-limiting laws. The impacts of such mandates on postoperative opioid prescribing and secondary outcomes following anterior cervical discectomy and fusion (ACDF) have not been previously described. The purpose of this study is to evaluate the impact of newly implemented statewide opioid-limiting regulations in Rhode Island on postoperative opioid prescriptions, emergency department (ED) visits, unplanned readmissions and reoperations following elective ACDF. Retrospective review of prospectively-collected data A total of 211 patients undergoing primary elective 1-3 level ACDF during specified pre-law (12/01/15 - 06/30/16) and post-law (06/01/17 - 12/31/17) study periods were considered eligible for study inclusion. Patients undergoing ACDF for trauma or other emergencies, requiring corpectomy, undergoing simultaneous procedures, or undergoing ACDF as part of a staged procedure were excluded. Primary outcome measures included the number of prescriptions and total morphine milligram equivalents (MMEs) filled at 30-day postoperative intervals for 4 months following ACDF. Secondary outcome measures included prescription refill requests as well as 30-day and 90-day ED visits, readmissions and reoperations. Demographic, medical, surgical, clinical and pharmacological data were collected from all eligible patients. Those not filling any opioid prescriptions within the 30-day preoperative period were considered opioid-naïve. Patients filling at least one opioid prescription in the 30-day preoperative period were considered opioid-tolerant. Cumulative oral morphine milligram equivalents (MMEs) filled were compared at 30-day postoperative intervals following ACDF, before and after stratification by preoperative opioid-tolerance and pre/post-law status. The mean number of prescription refills required within 30-days of surgery was also compared between groups. Thirty- and 90-day ED visit, readmission and reoperation rates were calculated. Independent predictors of increased 30-day and chronic (>90 day) opioid utilization were evaluated using backwards stepwise linear and logistic regression modeling respectively. Demographic, medical and surgical factors were similar between pre-law and post-law patients (all p>0.05). Post-law, ACDF patients received fewer opioids in their first postoperative prescription (26.65 pills post-law vs 62.08 pills pre-law, p<.001; 202.23 MMEs post-law vs 549.18 MMEs pre-law, p<.001) and in their first 30 postoperative days (444.14 cumulative 30-day MMEs post-law vs 877.87 cumulative 30-day MMEs pre-law, p<.001). There was no difference in the mean number of prescriptions filled in the 30-day postoperative period (1.70 prescriptions post-law vs 1.63 prescriptions pre-law, p=0.417). Post-law reductions in cumulative 30-day MMEs were seen among both opioid-naïve (363.54 MMEs post-law vs 632.20 MMEs pre-law, p<.001) and opioid-tolerant (730.08 MMEs post-law vs 1,122.90 MMEs pre-law, p=0.022) patient populations. Increased 30-day opioid utilization was associated with surgery in the pre-law period (coeff. -394.72 MMEs, p<.001) preoperative opioid-tolerance (coeff. +311.32 MMEs, p<.001), preoperative benzodiazepine exposure (coeff. +355.45 MMEs, p=0.003), and number of levels fused (coeff. + 113.54 MME/level, p=0.038). Chronic (>90 day) opioid requirements were associated with preoperative opioid-tolerance (OR 4.42, p<.001) but not with pre/post-law status (p>0.05). Pre- and post-law patients were similar in terms of 30- and 90-day ED visit, unplanned readmission, and reoperation rates (all p>0.05). Implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization following ACDF, regardless of preoperative opioid tolerance and without a rebound increase in prescription refills, ED visits, unplanned hospital readmissions, or reoperations.