Prescription Drug Monitoring Program Database Research Articles

Association Between Prescription Drug Monitoring Program Use Mandate and Opioid Prescribing and Patient-Reported Outcomes After Surgery.

To evaluate changes in opioid prescribing and patient-reported outcomes after surgery following implementation of Michigan's prescription drug monitoring program (PDMP) use mandate in June 2018. Most states mandate clinicians to query prescription drug monitoring program (PDMP) databases before prescribing controlled substances. Whether these PDMP use mandates affect opioid prescribing and patient-reported outcomes after surgery is unclear, especially among patients with elevated "Narx" scores, a risk score for overdose death used in most PDMPs. We conducted an interrupted time series analysis of a statewide surgical registry linked to Michigan's PDMP database. Analyses included adults undergoing general surgical procedures during January 2017-October 2019. Outcomes included monthly mean days supplied in dispensed opioid prescriptions (those filled within 3 days of discharge) and monthly mean scores for 3 patient-reported outcomes (pain in the week after surgery, care satisfaction, regret undergoing surgery). Segmented regression models were used to assess for level and slope changes in outcomes in June 2018. Analyses were repeated among patients with Narx scores ≥200, a threshold that defines the top quartile. Analyses included 21,897 patients. The mandate was associated with a -0.5 (95% CI: -0.8, -0.2) level decrease in mean days supplied in dispensed opioid prescriptions, but not with worsened patient-reported outcomes. Findings were similar among patients with Narx scores ≥200. Following implementation of Michigan's PDMP use mandate, the duration of opioid prescriptions decreased, but patient-reported outcomes did not worsen. Findings suggest PDMP use mandates may not be associated with worsened experience among general surgical patients.

Opioid stewardship program implementation in rural and critical access hospitals in Arizona.

The objective of this study is to examine rural hospitals' status in implementing opioid stewardship program (OSP) elements and assess differences in implementation in emergency department (ED) and acute inpatient departments. Health administrator survey to identify the number and type of OSP elements that each hospital has implemented. Arizona critical access hospitals (CAHs). ED and acute inpatient department heads at 17 Arizona CAHs (total of 34 assessments). Implementation of 11 OSP elements, by department (ED vs inpatient) and prevention orientation (primary vs tertiary). The percentage of implemented elements ranged from 35 to 94 percent in EDs and 24 to 88 percent in acute care departments. Reviewing the prescription drug monitoring program database and offering alternatives to opioids were the most frequently implemented. Assessing opioid use disorder (OUD) and prescribing naloxone were among the least. The number of implemented elements tended to be uniform across departments. We found that CAHs implemented, on average, 67 percent of elements that prevent unnecessary opioid use and 54 percent of elements that treat OUD. Some OSP elements were in place in nearly every Arizona CAH, while others were present in only a quarter or a third of hospitals. To improve, more attention is needed to define and standardize OSPs. Equal priority should be given to preventing unnecessary opioid initiation and treating opioid misuse or OUD, as well as quality control strategies that provide an opportunity for continuous improvement.

The use of buprenorphine to-go packs in the emergency department

ObjectiveBuprenorphine is an effective treatment for opioid use disorder (OUD). Patients in the emergency department (ED) can be initiated or continued on buprenorphine as a bridge to follow-up in the outpatient setting, but gaps in care may arise. The objective was to evaluate the impact of buprenorphine to-go packs as a continuing treatment option for patients presenting to the ED with OUD across a health system. MethodsAdult patients discharged with a buprenorphine to-go pack from one of ten EDs within a major health system were included. The primary outcomes assessed within 30 days of ED discharge were: (1) return to a health system ED, and (2) fill history of buprenorphine in the state prescription drug monitoring program database. Data was analyzed using descriptive statistics in Microsoft Excel (Redmond, WA). ResultsA total of 124 patients received buprenorphine to-go packs. The sample was primarily male (79; 63.7%), white (89; 71.8%), on Medicaid (79; 63.7%), and had a mean age of 40.9 years. A total of 43 patients (34.7%) were initiated on buprenorphine for the first time, while 81 (65.3%) had received buprenorphine (prescription or to-go) previously. At 30 days post-visit, 76 (61.3%) had filled buprenorphine prescriptions, and 40 (32.3%) returned to an ED within the health system for opioid withdrawal (17; 42.5%), non-OUD-related reasons (22; 55%), or overdose (1; 2.5%). ConclusionThe implementation of a system-wide buprenorphine to-go supply at ED discharge is a feasible option to provide continuity of care to patients with OUD.

Persistent long-term opioid use after trauma: Incidence and risk factors.

The opioid epidemic in the United States continues to lead to a substantial number of preventable deaths and disability. The development of opioid dependence has been strongly linked to previous opioid exposure. Trauma patients are at particular risk since opioids are frequently required to control pain after injury. The purpose to this study was to examine the prevalence of opioid use before and after injury and to identify risk factors for persistent long-term opioid use after trauma. Records for all patients admitted to a Level 1 trauma center over a 1-year period were analyzed. Demographics, injury characteristics, and hospital course were recorded. A multistate Prescription Drug Monitoring Program database was queried to obtain records of all controlled substances prescribed from 6 months before the date of injury to 12 months after hospital discharge. Patients still receiving narcotics at 1 year were defined as persistent long-term users and were compared against those who were not. A total of 2,992 patients were analyzed. Of all patients, 20.4% had filled a narcotic prescription within the 6 months before injury, 53.5% received opioids at hospital discharge, and 12.5% had persistent long-term use after trauma with the majority demonstrating preinjury use. Univariate risk factors for long-term use included female sex, longer length of stay, higher Injury Severity Score, anxiety, depression, orthopedic surgeries, spine injuries, multiple surgical locations, discharge to acute inpatient rehab, and preinjury opioid use. On multivariate analysis, the only significant predictors of persistent long-term prescription opioid use were preinjury use and a much smaller effect associated with use at discharge. During a sustained opioid epidemic, concerns and caution are warranted in the use of prescription narcotics for trauma patients. However, persistent long-term opioid use among opioid-naive patients is rare and difficult to predict after trauma. Prognostic and Epidemiological; Level III.

Changes in Surgical Opioid Prescribing and Patient-Reported Outcomes After Implementation of an Insurer Opioid Prescribing Limit

Insurers are increasingly limiting the duration of opioid prescriptions for acute pain. Among patients undergoing surgery, it is unclear whether implementation of these limits is associated with changes in opioid prescribing and patient-reported outcomes, such as pain. To assess changes in surgical opioid prescribing and patient-reported outcomes after implementation of an opioid prescribing limit by a large commercial insurer in Michigan. This was a cross-sectional study with an interrupted time series analysis. Data analyses were conducted from October 1, 2022, to February 28, 2023. The primary data source was the Michigan Surgical Quality Collaborative, a statewide registry containing data on opioid prescribing and patient-reported outcomes from adults undergoing common general surgical procedures. This registry is linked to Michigan's prescription drug monitoring program database, allowing observation of opioid dispensing. The study included 6045 adults who were covered by the commercial insurer and underwent surgery from January 1, 2017, to October 31, 2019. Policy limiting opioid prescriptions to a 5-day supply in February 2018. Among all patients, segmented regression models were used to assess for level or slope changes during February 2018 in 3 patient-reported outcomes: pain in the week after surgery (assessed on a scale of 1-4: 1 = none, 2 = minimal, 3 = moderate, and 4 = severe), satisfaction with surgical experience (scale of 0-10, with 10 being the highest satisfaction), and amount of regret regarding undergoing surgery (scale of 1-5, with 1 being the highest level of regret). Among patients with a discharge opioid prescription and a dispensed opioid prescription (prescription filled within 3 days of discharge), additional outcomes included total morphine milligram equivalents in these prescriptions, a standardized measure of opioid volume. Among the 6045 patients included in the study, mean (SD) age was 48.7 (12.6) years and 3595 (59.5%) were female. Limit implementation was not associated with changes in patient-reported satisfaction or regret and was associated with only a slight level decrease in patient-reported pain score (-0.15 [95% CI, -0.26 to -0.03]). Among 4396 patients (72.7%) with a discharge and dispensed opioid prescription, limit implementation was associated with a -22.3 (95% CI, -32.8 to -11.9) and -26.1 (95% CI, -40.9 to -11.3) level decrease in monthly mean total morphine milligram equivalents of discharge and dispensed opioid prescriptions, respectively. These decreases corresponded approximately to 3 to 3.5 pills containing 5 mg of oxycodone. This cross-sectional analysis of data from adults undergoing general surgical procedures found that implementation of an insurer's limit was associated with modest reductions in opioid prescribing but not with worsened patient-reported outcomes. Whether these findings generalize to other procedures warrants further study.

The prescription drug monitoring program in a multifactorial approach to the opioid crisis: PDMP data, Pennsylvania, 2016–2020

BackgroundPrescription opioids remain an important contributor to the United States opioid crisis and to the development of opioid use disorder for opioid-naïve individuals. Recent legislative actions, such as the implementation of state prescription drug monitoring programs (PDMPs), aim to reduce opioid morbidity and mortality through enhanced tracking and reporting of prescription data. The primary objective of our study was to describe the opioid prescribing trends in the state of Pennsylvania (PA) as recorded by the PA PDMP following legislative changes in reporting guidelines, and discuss the PDMP’s role in a multifactorial approach to opioid harm reduction.MethodsState-level opioid prescription data summaries recorded by the PA PDMP for each calendar quarter from August 2016 through March 2020 were collected from the PA Department of Health. Data for oxycodone, hydrocodone, and morphine were analyzed by quarter for total prescription numbers and refills. Prescription lengths, pill quantities, and average morphine milliequivalents (MMEs) were analyzed by quarter for all 14 opioid prescription variants recorded by the PA PDMP. Linear regression was conducted for each group of variables to identify significant differences in prescribing trends.ResultsFor total prescriptions dispensed, the number of oxycodone, hydrocodone, and morphine prescriptions decreased by 34.4, 44.6, and 22.3% respectively (p < 0.0001). Refills fluctuated less consistently with general peaks in Q3 of 2017 and Q3 of 2018 (p = 0.2878). The rate of prescribing for all opioid prescription lengths decreased, ranging in frequency from 22 to 30 days (47.5% of prescriptions) to 31+ days of opioids (0.8% of prescriptions) (p < 0.0001). Similarly, decreased prescribing was observed for all prescription amounts, ranging in frequency from 22 to 60 pills (36.6% of prescriptions) to 60–90 pills (14.2% of prescriptions) (p < 0.0001). Overall, the average MME per opioid prescription decreased by 18.9%.ConclusionsPer the PA PDMP database, opioid prescribing has decreased significantly in PA from 2016 to 2020. The PDMP database is an important tool for tracking opioid prescribing trends in PA, and PDMPs structured similarly in other states may enhance our ability to understand and influence the trajectory of the U.S. opioid crisis. Further research is needed to determine optimal PDMP policies and practices nationwide.

Concordance of opioid exposure in all-payer claims databases with prescription drug monitoring program database using Arkansas as a case example.

To assess the concordance between and benefit of adding prescription drug monitoring program (PDMP) data to all-payer claims database (APCD) data for identifying and classifying opioid exposure among insured individuals. Arkansas APCD and PDMP. Enrollees in APCD were classified as (1) true positives: if they received opioids in both databases, (2) false positives: if they only received opioids in APCD, (3) true negatives: if they had no opioid exposure in both databases, (4) false negatives: if they only received opioids in the PDMP database. Specificity, sensitivity, negative, and positive predictive values were calculated using PDMP as the "gold standard" database source. Subjects were also categorized as those who received any opioid, chronic opioid, high-dose opioid, or high-risk opioid therapies. Arkansas residents continuously enrolled with pharmacy coverage in 2016 were included. APCD and PDMP were linked using an encrypted enrollee identifier, gender, and year of birth. The degree of concordance in opioid exposure between the two databases among 1,411,565 enrollees was high (sensitivity=92.67%, specificity=96.13%, positive predictive value=91.60%, negative predictive value=96.65%). Enrollees classified as having any opioid (APCD: 31.64% vs. PDMP: 31.26% vs. APCD+PDMP: 33.93%), chronic opioid (APCD: 7.81% vs. PDMP: 7.54% vs. APCD+PDMP: 8.24%), high-dose opioid (APCD: 10.60% vs. PDMP: 9.62% vs. APCD+PDMP: 11.33%), or high-risk opioid (APCD: 5.28% vs. PDMP: 5.33% vs. APCD+PDMP: 6.20%) therapies, were similar using only APCD versus PDMP versus the combined APCD and PDMP data sources. Claims data sources, such as APCDs, are fairly accurate in identifying opioid exposure and the level of opioid exposure among persons with continuous pharmacy coverage.

Controlled Substance Prescription History among Individuals Who Died of an Accidental Opioid-Involved Drug Overdose in Rhode Island

Background: Accidental opioid-involved overdose deaths are increasing nationally in the wake of the COVID-19 pandemic, but it is unclear if this reflects a change in populations most at risk. Objective: To determine whether the demographic characteristics and controlled substance prescription history of accidental opioid-involved drug overdose decedents in 2020 differed from prior years. Methods: We identified accidental opioid-involved overdose decedents using Rhode Island (RI) State Medical Examiner’s Office data. Decedents were linked to the RI Prescription Drug Monitoring Program database. We compared demographic characteristics and prescription history by year of death. Results: From 2018 to 2020, 763 RI residents died from accidental opioid-involved overdose in RI. From 2018 to 2019, deaths decreased by 7%, but then increased by 31% from 2019 to 2020. Demographic characteristics were similar by year of death (all p > 0.05). The percentage of decedents with a prior opioid prescription and a prior benzodiazepine prescription declined from 2018 to 2020 (p < 0.01 and p = 0.03). Conclusions: We found that opioid-involved overdose deaths in RI are increasing overall, but without significant changes in demographics. While prior exposure to some controlled substances did decline over time, it is not clear if these changes reflect more responsible prescribing practices, or a more concerning pattern such as patient abandonment or decreased healthcare access. More studies are needed to better describe the current trend of increasing opioid-involved deaths while also pursuing current evidence-based interventions.

Identifying Persistent Opioid Use After Surgery: The Reliability of Pharmacy Dispensation Databases.

The present study assessed concordance in perioperative opioid fulfillment data between Michigan's prescription drug monitoring program (PDMP) and a national pharmacy prescription database. PDMPs and pharmacy dispensation databases are widely utilized, yet no research has compared their opioid fulfilment data postoperatively. This retrospective study included participants (N=19,823) from 2 registry studies at Michigan Medicine between July 1, 2016, and February 7, 2019. We assessed the concordance of opioid prescription fulfilment between the Michigan PDMP and a national pharmacy prescription database (Surescripts). The primary outcome was concordance of opioid fill data in the 91 to 180 days after surgical discharge, a time period frequently used to define persistent opioid use. Secondary outcomes included concordance of opioid dose and number of prescriptions fulfilled. Multinomial logistic regression analysis examined concordance across key subgroups. In total, 3076 participants had ≥1 opioid fulfillments 91 to 180 days after discharge, with 1489 (49%) documented in PDMP only, 243 (8%) in Surescripts only, and 1332 (43%) in both databases. Among participants with fulfillments in both databases, there were differences in the number (n=239; 18%) and dose (n=227; 17%). The PDMP database was more likely to capture fulfillment among younger and publicly insured participants, while Surescripts was more likely to capture fulfillment from counties bordering neighboring states. The prevalence of persistent opioid use was 10.7% using PDMP data, 5.5% using Surescripts data only, and 11.7% using both data resources. The state PDMP appears reliable for detecting opioid fulfillment after surgery, detecting 2 times more patients with persistent opioid use compared with Surescripts.

APCDs can Provide Important Insights for Surveilling the Opioid Epidemic, With Caveats.

State-level all-payer claims databases (APCDs) are a possible new public health surveillance tool, but their reliability is unclear. We compared Colorado's APCD with other state-level databases for use in monitoring the opioid epidemic (Colorado Hospital Association and Colorado's Prescription Drug Monitoring Program database for 2010-2017), using descriptive analyses comparing quarterly counts/rates of opioid-involved inpatient and emergency department visits and counts/rates of 30-day opioid fills between databases. Utilization is lower in the Colorado APCD than the other databases for all outcomes but trends are parallel and consistent between databases. State APCDs hold promise for researchers, but they may be better suited to individual-level analyses or comparisons of providers than for surveillance of public health trends related to addiction.

Nonsurgical Providers Provide the Majority of Postoperative Opioid Prescriptions After Hand Surgery.

IntroductionThe increased use of Prescription Drug Monitoring Program (PDMP) websites has helped physicians to limit overlapping controlled substance prescriptions and help prevent opioid abuse. Many studies have investigated risk factors for prolonged opioid use after orthopedic surgery, but few studies have investigated who is prescribing opioids to postoperative patients. The purpose of this study is to investigate the types of medical providers prescribing opioids to hand surgery patients postoperatively.MethodsInstitutional Review Board approval was obtained prior to initiation of this study. An institutional database search was performed to identify all patients ≥18 years old that underwent a single hand surgery at our institution during a specified time period. Patients with more than one surgical procedure during this time were excluded to prevent potential crossover with opioid prescriptions for different surgical procedures. A search of the state PDMP website was performed to identify opioid prescriptions filled by hand surgery patients from six months preoperatively to 12 months postoperatively. Opioid prescribers were classified into several groups: 1) the patient’s operating surgeon, 2) other orthopedic surgery providers, 3) general medicine providers (internal medicine, primary care, family medicine, and adult health providers), and 4) all other medical providers.ResultsThree hundred twenty-seven patients could be identified in the PDMP database who received an opioid prescription on the day of surgery. Of these, 108 (33.0%) filled a total of 341 additional opioid prescriptions postoperatively. Non-orthopedic providers prescribed 81.5% of all opioid prescriptions within 12 months postoperatively, with the patient’s operating surgeon prescribing only 10% of all prescriptions. General medicine providers were the highest prescriber group at 28.7% of total postoperative opioid prescriptions. From six to 12 months postoperatively, the patient’s operating surgeon prescribed only 4.9% of total opioid prescriptions filled. The patient’s operating surgeon prescribed significantly smaller average opioid prescriptions in total morphine milligram equivalents compared to all other provider groups.ConclusionsSurgeons should be aware that their surgical patients may be receiving opioid prescriptions from a wide variety of medical providers postoperatively, and that these other providers may be prescribing larger prescriptions. The findings of this study emphasize the importance of collaboration across medical specialties to mitigate the risks of prolonged opioid use after hand surgery.

Opioid Prescribing After Implementation of Single Click Access to a State Prescription Drug Monitoring Program Database in a Health System's Electronic Health Record.

To determine the effect of one-click integration of a state's prescription drug monitoring program (PDMP) on the number of PDMP searches and opioid prescriptions, stratified by specialty. Our large health system worked with the state department of public health to integrate the PDMP with the electronic health record (EHR), which enabled providers to query the data with a single click inside the EHR environment. We evaluated Schedule II or III opioid prescriptions reported to the Massachusetts PDMP 6 months before (November 15, 2017-May 15, 2018) and 6 months after (May 16, 2018, to November 16, 2018) integration. Search counts, prescriptions, patients, morphine milligram equivalents, as well as prescriber specialty were compared. There were 3,185 unique prescribers with a record of a Schedule II and/or III opioid prescription in both study periods that met inclusion criteria. After integration, the number of PDMP searches increased from 208,684 in the pre-integration phase to 298,478 searches in the post-integration phase (+43.0%). The number of opioid prescriptions dispensed decreased by 4.8%, the number of patients receiving a prescription decreased by 5.1%, and the mean morphine milligram equivalents (MMEs) per prescriber decreased by 5.4%. There were some notable specialty-specific differences in these measures. Integration of the PDMP into the EHR markedly increased the number of searches but was associated with modest decreases in opioids prescribed and patients receiving a prescription. Single click EHR integration of the PDMP, if implemented broadly, may be a way for states to significantly increase PDMP utilization.

Managing Nonmedical Opioid Use Among Patients With Cancer Pain During the COVID-19 Pandemic Using the CHAT Model and Telehealth

Managing Nonmedical Opioid Use Among Patients With Cancer Pain During the COVID-19 Pandemic Using the CHAT Model and Telehealth

The importance of data source in prescription drug monitoring program research.

To develop a legal research protocol for identifying various measures of prescription drug monitoring program (PDMP) start dates, apply the protocol to create a useable PDMP database, and test whether the different legal databases that are meant to contain the same information produce divergent results when used in an illustrative empirical exercise. Original research from state statutes, regulations, policy statements, and interviews; alternative PDMP data from the National Alliance for Model State Drug Laws and Prescription Drug Abuse Policy System; claims from a 40 percent random sample of Medicare beneficiaries, 2006-2014. Collaborative research effort among a group of lawyers to develop protocol. Legal research to produce an original database of dates state PDMP laws: (a) were enacted, (b) became operational, and (c) required query before prescribing controlled substances. Descriptive analyses characterize differences in dates of enactment, operation, and must query requirements. Regression analyses estimating, for each beneficiary annually any opioid prescription received in a calendar year, among other measures. Estimates conducted on under age 65 and full Medicare population. PDMP legal databases were linked to annual Medicare claims. An original database differs from commonly used, publicly available data. Outcomes tested depend on the measure of PDMP date used and differ by data source. Must-query laws show the largest effects among all the laws tested. Data choices likely have had large consequences for study results and may explain contradictory outcomes in prior research. Researchers must understand and report protocol for dates used in PDMP research to ensure that results are internally consistent and verifiable.

Changes in Opioid Prescribing Patterns: A Survey of the Florida Society of Plastic Surgeons.

With thousands of people in the United States dying of opioid overdose each month, the opioid epidemic has become a serious public health concern. Legislators have attempted to address this problem at various levels of the government. Evaluation of outcomes of these measures is a necessary part of resolving the epidemic. Our survey was designed to evaluate the impact of measures enacted in Florida State in 2018 upon prescribing practices of plastic surgeons. The survey was prepared electronically using the online Qualtrics platform. Survey questions were multiple choice and inquired regarding changes in prescribing practices after enactment of mandatory query of the prescription drug monitoring program database and prescribing limits in Florida. The survey was distributed by e-mail 1 year after these laws took effect. Two survey reminder e-mails were sent at 2-week intervals after the initial message. Results were collected for an additional 3 weeks after the final correspondence. Thirty-two survey responses were received after distribution to the 156 members of the Florida Society of Plastic Surgeons, for a response rate of 20.5%. Twenty-two respondents reported changing their prescribing practices. The most common change reported was decreased number of tablets prescribed. Most respondents reported they believe that mandatory prescription drug monitoring program query and prescribing limits will be effective. This included 17 (53.1%) and 18 (56.3%) respondents, respectively. Results from our survey indicate that Florida plastic surgeons have adjusted their prescribing practices in response to recently enacted legislation. Most plastic surgeons reported decreased number of tablets of opioids prescribed. Many also reported incorporating nonopioid analgesics. Further study will be necessary to determine the impact of these changes on rates of opioid overdose.

Opioid-Limiting Regulation: Effect on Patients Undergoing Knee and Shoulder Arthroscopy

To determine the effect prescription-limiting legislation passed in Rhode Island has had on opioids prescribed following arthroscopic knee and shoulder surgery at various time points, up to 90 days postoperatively. All patients undergoing the 3 most common arthroscopic procedures at our institution (anterior cruciate ligament reconstruction, partial meniscectomy, and rotator cuff repair) were included. Patients were selected from 2 6-month study periods (prepassage and postimplementation of the law). The state's Prescription Drug Monitoring Program database was queried for controlled substances filled in the perioperative period (from 30 days preoperatively to 90 days postoperatively). Multiple logistic regressions were used to identify predictors of chronic (>30 days) opioid use. The morphine milligram equivalents (MMEs) prescribed in the initial postoperative script decreased from 319.04 (∼43 5-mg oxycodone tablets) in the prepassage to 152.45 MMEs (∼20 5-mg oxycodone tablets) in the postimplementation group (P < .001). The total MMEs filled in the first 30 days decreased from 520.93 to 299.94 MMEs (∼70 to ∼40 5-mg oxycodone tablets) (P < .001). MMEs filled between 30 and 90 days fell by 22.5% for all patients in this study; however, this change was not statistically significant (P= .263). Preoperative opioid use (odds ratio, 10.85; P < .001) and preoperative benzodiazepine use (odds ratio, 2.13; P= .005) predicted chronic opioid use postoperatively. State opioid-limiting legislation reduced cumulative MMEs following arthroscopic knee and shoulder surgery in the first 30 days. Further research assessing the impact of this legislation on postoperative pain control, patient satisfaction, and functional outcomes following surgery is warranted. Level III, case-control study.

227 Emergency Physician Opioid Prescriptions That Resulted in Chronic Use

There is mounting evidence that the characteristics of a first opioid prescription filled by a patient can portend long-term use. Emergency physicians (EPs) are responsible for only about 5% of all opioid prescriptions but may be the first prescribers for patients with acute pain. The aim of this study was to determine the proportion of ED prescriptions that led to long-term use and the characteristics of those prescriptions. This was a study of the Ohio Prescription Drug Monitoring Program database, which contains a record of all opioid prescriptions filled in the state of Ohio, regardless of payer. Data from 2010-2017 were analyzed. We studied pill forms of the prescribed opioids in the state. We included individuals who had at least one opioid prescription in 2013 but no prescription from 2010-2012, and then followed them through 2017. We first evaluated all first prescriptions and then the subset of those first prescriptions written by emergency physicians. Specialty was available for 59.3% of providers, and we attributed the specialty of “emergency medicine” to a provider if every prescription written by that prescriber in the database during the study period listed EM as their specialty. The primary outcomes were active opioid prescriptions during the follow-up period for 12 and 36 consecutive months with no gap of >30 days. There were 1,205,942 first-time opioid prescriptions written in Ohio in 2013 (representing about 10.4% of the state’s population in that year). Overall, 4,860 (0.40%) initial prescriptions led to chronic use at 1 year and 2,318 (0.19%) led to chronic use at 3 years. Of all first-time prescriptions, 128,347 (10.6%) were confirmed as written by emergency physicians. These prescriptions resulted in 153 (0.12%) chronic users at 1 year and 88 (0.07%) chronic users at 3 years. Features associated with chronic use at 1 year were higher pill count (mean 23.7 (95% CI 20.8-26.5) vs. 17.3 (95% CI 17.3-17.4) pills), higher days’ supply (mean 6.7 (95% CI 5.1-8.2) vs. 3.4 (95% CI 3.4-3.5) days), and higher morphine milligram equivalents per prescription (mean 171.3 (95% CI 127.2-215.4) vs. mean 99.4 (95% CI 98.8-99.9) milligram equivalents). The most common agents first prescribed to the group without long-term use were: hydrocodone (57.4%), oxycodone (20.9%) and tramadol (15.6%). The most common agents first prescribed to those who developed chronic use at 1 year were hydrocodone (43.8%), oxycodone (32.0%), and tramadol (19.6%). Opioid prescriptions written by emergency physicians rarely lead to long-term chronic use at 1 and 3 years. When they do, the prescriptions are more likely to be written for higher pill counts, longer days’ supply and higher morphine milligram equivalents per prescription, and a greater proportion are for oxycodone. When writing for opioids, emergency physicians should use the lowest amount possible to avoid leading to long-term use.

Effects of Rescheduling Hydrocodone on Opioid Prescribing in Ohio.

We quantified opioid prescribing after the 2014 rescheduling of hydrocodone from schedule III to II in the United States using a state-wide prescription database and studied trends three years before and after the policy change, focusing on certain specialties. We used Ohio's state prescription drug monitoring program database, which includes all filled schedule II and III prescriptions regardless of payer or pharmacy, to conduct an interrupted time series analysis of the nine most prescribed opioids: hydrocodone, oxycodone, tramadol, codeine, and others. We analyzed hydrocodone prescribing trends for the physician specialties of internal medicine, anesthesiology, and emergency medicine. We evaluated trends 37 months before and after the rescheduling change. Rescheduling was associated with a hydrocodone level change of -26,358 (95% confidence interval [CI] = -36,700 to -16,016) prescriptions (-5.8%) and an additional decrease in prescriptions of -1,568 (95% CI = -2,296 to -839) per month (-0.8%). Codeine prescribing temporarily increased, at a level change of 6,304 (95% CI = 3,003 to 9,606) prescriptions (18.5%), indicating a substitution effect. Hydrocodone prescriptions by specialty were associated with a level change of -805 (95% CI = -1,280 to -330) prescriptions (-8.5%) for anesthesiologists and a level change of -14,619 (95% CI = -23,710 to -5,528) prescriptions (-10.2%) for internists. There was no effect on prescriptions by emergency physicians. The 2014 federal rescheduling of hydrocodone was associated with declines in hydrocodone prescriptions in Ohio beyond what had already been occurring, and hydrocodone may have been briefly substituted with codeine. These results indicate that rescheduling did have a lasting effect but affected prescribing specialties variably.

Has a Prescription-limiting Law in Rhode Island Helped to Reduce Opioid Use After Total Joint Arthroplasty?

In the United States, since 2016, at least 28 of 50 state legislatures have passed laws regarding mandatory prescribing limits for opioid medications. One of the earliest state laws (which was passed in Rhode Island in 2016) restricted the maximum morphine milligram equivalents provided in the first postoperative prescription for patients defined as opioid-naïve to 30 morphine milligram equivalents per day, 150 total morphine milligram equivalents, or 20 total doses. While such regulations are increasingly common in the United States, their effects on opioid use after total joint arthroplasty are unclear. (1) Are legislative limitations to opioid prescriptions in Rhode Island associated with decreased opioid use in the immediate (first outpatient prescription postoperatively), 30-day, and 90-day periods after THA and TKA? (2) Is this law associated with similar changes in postoperative opioid use among patients who are opioid-naïve and those who are opioid-tolerant preoperatively? Patients undergoing primary THA or TKA between January 1, 2016 and June 28, 2016 (before the law was passed on June 28, 2016) were retrospectively compared with patients undergoing surgery between June 1, 2017 and December 31, 2017 (after the law's implementation on April 17, 2017). The lapse between the pre-law and post-law periods was designed to avoid confounding from potential voluntary practice changes by physicians after the law was passed but before its mandatory implementation. Demographic and surgical details were extracted from a large multi-specialty orthopaedic group's surgical billing database using Current Procedural Terminology codes 27130 and 27447. Any patients undergoing revision procedures, same-day bilateral arthroplasties, or a second primary THA or TKA in the 3-month followup period were excluded. Secondary data were confirmed by reviewing individual electronic medical records in the associated hospital system which included three major hospital sites. We evaluated 1125 patients. In accordance with the state's department of health guidelines, patients were defined as opioid-tolerant if they had filled any prescription for an opioid medication in the 30-day preoperative period. Data on age, gender, and the proportion of patients who were defined as opioid tolerant preoperatively were collected and found to be no different between the pre-law and post-law groups. The state's prescription drug monitoring program database was used to collect data on prescriptions for all controlled substances filled between 30 days preoperatively and 90 days postoperatively. The primary outcomes were the mean morphine milligram equivalents of the initial outpatient postoperative opioid prescription after discharge and the mean cumulative morphine milligram equivalents at the 30- and 90-day postoperative intervals. Secondary analyses included subgroup analyses by procedure and by preoperative opioid tolerance. After the law was implemented, the first opioid prescriptions were smaller for patients who were opioid-naïve (mean 156 ± 106 morphine milligram equivalents after the law's passage versus 451 ± 296 before, mean difference 294 morphine milligram equivalents; p < 0.001) and those who were opioid-tolerant (263 ± 265 morphine milligram equivalents after the law's passage versus 534 ± 427 before, mean difference 271 morphine milligram equivalents; p < 0.001); however, for cumulative prescriptions in the first 30 days postoperatively, this was only true among patients who were previously opioid-naïve (501 ± 416 morphine milligram equivalents after the law's passage versus 796 ± 597 before, mean difference 295 morphine milligram equivalents; p < 0.001). Those who were opioid-tolerant did not have a decrease in the cumulative number of 30-day morphine milligram equivalents (1288 ± 1632 morphine milligram equivalents after the law's passage versus 1398 ± 1274 before, mean difference 110 morphine milligram equivalents; p = 0.066). The prescription-limiting law was associated with a decline in cumulative opioid prescriptions at 30 days postoperatively filled by patients who were opioid-naïve before total joint arthroplasty. This may substantially impact public health, and these policies should be considered an important tool for healthcare providers, communities, and policymakers who wish to combat the current opioid epidemic. However, given the lack of a discernible effect on cumulative opioids filled from 30 to 90 days postoperatively, further investigations are needed to evaluate more effective policies to prevent prolonged opioid use after total joint arthroplasty, particularly in patients who are opioid-tolerant preoperatively. Level III, therapeutic study.

Addressing the opioid crisis: An assessment of clinicians' training experience, practices, and attitudes within a large healthcare organization.

To assess provider practices and attitudes toward addiction care and pain management within a large healthcare system, as well as to determine the impact of prior training and perceived effectiveness of organizational implementation strategies. A cross-sectional study. Large healthcare organization comprising 21 hospitals. Three hundred and thirteen healthcare providers within a large healthcare organization. Training, practices, and attitudes toward opioid-related care. One thousand providers including physicians (MD/DO) and physician extenders (NP/PA) were contacted via email request. The Mann-Whitney test or Fisher's exact test, as appropriate, was used for comparisons of continuous and categorical variables, respectively. Providers lacked prior pain management (36 percent), addiction (38 percent), or buprenorphine training (92 percent). Few providers were confident in treating opioid use disorders (OUD) (19 percent) and opioid tapering (24 percent) but interested in safe prescribing practices (81 percent). While most providers preferred to refer patients for OUD (89 percent), only a small portion felt appropriate services were readily available (22 percent). Trained providers appear significantly more engaged in checking Prescription Drug Monitoring Program database [median = 1 (Q1 = 1, Q3 = 2) vs 2(1, 3); p < 0.001], comfortable obtaining urine drug screens [2(2, 3) vs 3(2, 4); p < 0.002], and willing to treat OUD with additional support [3(2, 4) vs 4(3, 4); p < 0.022] compared to non-trained providers. Primary care providers were more likely to view OUDs in their scope of practice [4(2, 5) vs 4(3, 5); p < 0.016] and willing to treat OUD with additional support [3(2, 3) vs 3(2, 4); p < 0.0007] compared to specialists. Buprenorphine providers appear to have more confidence in skills for OUD [2(1, 3) vs 4(3, 4); p < 0.0001] and tapering [2(1, 2) vs 4(3, 5); p < 0.0001], and diminished preference to refer [2(1, 5) vs 1(1, 2); p < 0.0009] compared to non-buprenorphine providers. Providers within a large healthcare system lack training and confidence in management of opioid-related care. Buprenorphine training positively modified key attitudes toward addiction care, yet engagement in medication-assisted treatment remains limited. Providers are concerned about opioid risks, and view guideline implementation and direct input from addiction specialists as effective organizational strategies. Further research is needed to clarify the efficacy of such approaches.