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State Medical Board Policy and Opioid Prescribing: A Controlled Interrupted Time Series

Published:December 09, 2020DOI:https://doi.org/10.1016/j.amepre.2020.09.015

      Introduction

      In March 2016, the Centers for Disease Control and Prevention issued opioid prescribing guidelines for chronic noncancer pain. In response, in April 2016, the North Carolina Medical Board launched the Safe Opioid Prescribing Initiative, an investigative program intended to limit the overprescribing of opioids. This study focuses on the association of the Safe Opioid Prescribing Initiative with immediate and sustained changes in opioid prescribing among all patients who received opioid and opioid discontinuation and tapering among patients who received high-dose (>90 milligrams of morphine equivalents), long-term (>90 days) opioid therapy.

      Methods

      Controlled and single interrupted time series analysis of opioid prescribing outcomes before and after the implementation of Safe Opioid Prescribing Initiative was conducted using deidentified data from the North Carolina Controlled Substances Reporting System from January 2010 through March 2017. Analysis was conducted in 2019–2020.

      Results

      In an average study month, 513,717 patients, including patients who received 47,842 high-dose, long-term opioid therapy, received 660,912 opioid prescriptions at 1.3 prescriptions per patient. There was a 0.52% absolute decline (95% CI= −0.87, −0.19) in patients receiving opioid prescriptions in the month after Safe Opioid Prescribing Initiative implementation. Abrupt discontinuation, rapid tapering, and gradual tapering of opioids among patients who received high-dose, long-term opioid therapy increased by 1% (95% CI= −0.22, 2.23), 2.2% (95% CI=0.91, 3.47), and 1.3% (95% CI=0.96, 1.57), respectively, in the month after Safe Opioid Prescribing Initiative implementation.

      Conclusions

      Although Safe Opioid Prescribing Initiative implementation was associated with an immediate decline in overall opioid prescribing, it was also associated with an unintended immediate increase in discontinuations and rapid tapering among patients who received high-dose, long-term opioid therapy. Better policy communication and prescriber education regarding opioid tapering best practices may help mitigate unintended consequences of statewide policies.
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      REFERENCES

        • Scholl L
        • Seth P
        • Kariisa M
        • Wilson N
        • Baldwin G
        Drug and opioid-involved overdose deaths—United States, 2013-2017.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 1419-1427
        • Dunn KM
        • Saunders KW
        • Rutter CM
        • et al.
        Opioid prescriptions for chronic pain and overdose: a cohort study.
        Ann Intern Med. 2010; 152: 85-92
        • Miller M
        • Barber CW
        • Leatherman S
        • et al.
        Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy.
        JAMA Intern Med. 2015; 175: 608-615
        • Bohnert AS
        • Valenstein M
        • Bair MJ
        • et al.
        Association between opioid prescribing patterns and opioid overdose-related deaths.
        JAMA. 2011; 305: 1315-1321
        • Dasgupta N
        • Funk MJ
        • Proescholdbell S
        • Hirsch A
        • Ribisl KM
        • Marshall S
        Cohort study of the impact of high-dose opioid analgesics on overdose mortality [published correction appears in Pain Med. 2016;17(4):797–798].
        Pain Med. 2016; 17: 85-98
        • Jones CM
        • Logan J
        • Gladden RM
        • Bohm MK
        Vital signs: demographic and substance use trends among heroin users - United States, 2002-2013.
        MMWR Morb Mortal Wkly Rep. 2015; 64: 719-725
      1. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. https://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf. Published September.

      2. Centers for Disease Control and Prevention. Annual surveillance report of drug-related risks and outcomes—United States, 2017. Atlanta, GA: Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf. Published 2017. Accessed December 12, 2017.

        • Lovegrove MC
        • Dowell D
        • Geller AI
        • et al.
        U.S. emergency department visits for acute harms from prescription opioid use, 2016-2017.
        Am J Public Health. 2019; 109: 784-791
      3. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf. Published 2019. Accessed March 1, 2020.

        • Florence CS
        • Zhou C
        • Luo F
        • Xu L
        The economic burden of prescription opioid overdose, abuse and dependence in the United States, 2013.
        Med Care. 2016; 54: 901-906
        • Dasgupta N
        • Beletsky L
        • Ciccarone D
        Opioid crisis: no easy fix to its social and economic determinants.
        Am J Public Health. 2018; 108: 182-186
        • Dowell D
        • Haegerich TM
        • Chou R
        CDC guideline for prescribing opioids for chronic pain–United States, 2016.
        JAMA. 2016; 315: 1624-1645
      4. North Carolina Medical Board. 2016 North Carolina Medical Board annual report. Raleigh, NC: North Carolina Medical Board. https://www.ncmedboard.org/images/uploads/disciplinary_reports/2016_Annual_Report1.pdf. Published 2016. Accessed January 1, 2019

        • Kroenke K
        • Alford DP
        • Argoff C
        • et al.
        Challenges with implementing the Centers for Disease Control and Prevention opioid guideline: a consensus panel report.
        Pain Med. 2019; 20: 724-735
        • CDC advises against misapplication of the guideline for prescribing opioids for chronic pain
        Centers for Disease Control and Prevention.
        2019 (Updated June 5,)
        • Sullivan MD
        • Bauer AM
        • Fulton-Kehoe D
        • et al.
        Trends in opioid dosing among Washington State Medicaid patients before and after opioid dosing guideline implementation.
        J Pain. 2016; 17: 561-568
        • Chou R
        • Turner JA
        • Devine EB
        • et al.
        The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop.
        Ann Intern Med. 2015; 162: 276-286
        • Tennant F
        • Hermann L
        Intractable or chronic pain: there is a difference.
        West J Med. 2000; 173: 306
      5. Merskey H, Bogduk N. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl. 1986;3:S1–S226. https://s3.amazonaws.com/rdcms-iasp/files/production/public/Content/ContentFolders/Publications2/FreeBooks/Classification-of-Chronic-Pain.pdf. Accessed May 4, 2020.

        • Gwira Baumblatt JA
        • Wiedeman C
        • Dunn JR
        • Schaffner W
        • Paulozzi LJ
        • Jones TF
        High-risk use by patients prescribed opioids for pain and its role in overdose deaths.
        JAMA Intern Med. 2014; 174: 796-801
        • Data Resources: analyzing prescription data and morphine milligram equivalents (MME)
        Centers for Disease Control and Prevention.
        2020 (Updated October 9,)
        • Walley AY
        • Xuan Z
        • Hackman HH
        • et al.
        Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis.
        BMJ. 2013; 346: f174
        • Lopez Bernal J
        • Cummins S
        • Gasparrini A
        The use of controls in interrupted time series studies of public health interventions.
        Int J Epidemiol. 2018; 47: 2082-2093
        • Ranapurwala SI
        • Carnahan RM
        • Brown G
        • Hinman J
        • Casteel C
        Impact of Iowa's prescription monitoring program on opioid pain reliever prescribing patterns: an interrupted time series study 2003-2014 [published correction appears in Pain Med. 2019;20(9):1879].
        Pain Med. 2019; 20: 290-300
        • Goedel WC
        • Marshall BDL
        • Spangler KR
        • et al.
        Increased risk of opioid overdose death following cold weather: a case-crossover study.
        Epidemiology. 2019; 30: 637-641
        • Compton WM
        • Jones CM
        • Baldwin GT
        Relationship between nonmedical prescription-opioid use and heroin use.
        N Engl J Med. 2016; 374: 154-163
        • Amrhein V
        • Greenland S
        • McShane B
        Scientists rise up against statistical significance.
        Nature. 2019; 567: 305-307
        • Wasserstein RL
        • Lazar NA.
        The ASA's statement on p-values: context, process, and purpose.
        J Am Stat Assoc. 2016; 70: 129-133
        • Garcia AM.
        State laws regulating prescribing of controlled substances: balancing the public health problems of chronic pain and prescription painkiller abuse and overdose.
        J Law Med Ethics. 2013; 41: 42-45
        • Fishman SM
        • Papazian JS
        • Gonzalez S
        • Riches PS
        • Gilson A
        Regulating opioid prescribing through prescription monitoring programs: balancing drug diversion and treatment of pain.
        Pain Med. 2004; 5: 309-324
        • Goldenbaum DM
        • Christopher M
        • Gallagher RM
        • et al.
        Physicians charged with opioid analgesic-prescribing offenses.
        Pain Med. 2008; 9: 737-747
        • Hoffmann DE
        • Tarzian AJ.
        Achieving the right balance in oversight of physician opioid prescribing for pain: the role of state medical boards.
        J Law Med Ethics. 2003; 31: 21-40
        • von Gunten CF.
        The pendulum swings for opioid prescribing.
        J Palliat Med. 2016; 19: 348
        • Mark TL
        • Parish W.
        Opioid medication discontinuation and risk of adverse opioid-related health care events.
        J Subst Abuse Treat. 2019; 103: 58-63
        • Chou R
        • Ballantyne J
        • Lembke A
        Rethinking opioid dose tapering, prescription opioid dependence, and indications for buprenorphine [published correction appears in Ann Intern Med. 2019;171(9):684].
        Ann Intern Med. 2019; 171: 427-429
        • Dowell D
        • Haegerich T
        • Chou R
        No shortcuts to safer opioid prescribing.
        N Engl J Med. 2019; 380: 2285-2287
        • Dowell D
        • Compton WM
        • Giroir BP
        Patient-centered reduction or discontinuation of long-term opioid analgesics: the HHS Guide for Clinicians.
        JAMA. 2019; 322: 1855-1856
        • Bohnert ASB
        • Jr Guy GP
        • Losby JL
        Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention's 2016 opioid guideline.
        Ann Intern Med. 2018; 169: 367-375