Association of State Opioid Duration Limits With Postoperative Opioid Prescribing

Published in: JAMA Network Open, Volume 2, Number 12 (December 2019). doi: 10.1001/jamanetworkopen.2019.18361

Posted on on April 29, 2020

by Sunil Agarwal, John D. Bryan, Hsou Mei Hu, Jay S. Lee, Kao-Ping Chua, Rebecca Lee Haffajee, Chad M. Brummett, Michael J. Englesbe, Jennifer F. Waljee

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Since the Centers for Disease Control and Prevention published opioid prescribing guidelines in March 2016, 31 states have implemented legislation to restrict the duration of opioid prescriptions for acute pain. However, the association of these policies with the amount of opioid prescribed following surgery remains unknown.


To examine the association of opioid prescribing duration limits with postoperative opioid prescribing in Massachusetts and Connecticut, the first 2 states to implement limits after March 2016.

Design, Setting, and Participants

This interrupted time series analysis and cross-sectional study examined immediate level and slope changes in monthly outcomes after prescribing limit implementation in Massachusetts and Connecticut. These states implemented 7-day limits on initial opioid prescriptions on March 14, 2016, and July 1, 2016, respectively. Using the 2014 to 2017 IBM MarketScan Research Database, 16,281 opioid-naive adults in these states who filled a prescription within 3 days of surgery between July 1, 2014, and November 30, 2017, were identified. Data were analyzed from December 2018 to June 2019.

Main Outcomes and Measures

The primary outcome was the prescription size in oral morphine equivalents (OMEs) for the initial postoperative opioid prescription (one 5/325 mg hydrocodone-acetaminophen pill = 5 OMEs). Secondary outcomes included days supplied in the initial prescription and the proportion of initial prescriptions exceeding a 7-day supply.


In total, 16,281 opioid-naive patients (9,708 [59.6%] female; median [interquartile range] age range, 45–54 [35–44 to 55–64] years) undergoing surgical procedures were included. In Massachusetts, there were 5,340 and 5,435 patients in the preimplementation and postimplementation periods, respectively. In Connecticut, there were 2,869 and 2,637 patients in the preimplementation and postimplementation periods, respectively. Limit implementation in Massachusetts was associated with an immediate mean level decrease in prescription size (–38 OMEs [95% CI, –44 to –32 OMEs]) and with a mean decrease in slope (–1.5 OMEs/mo [95% CI, –2.1 to –0.9 OMEs/mo]). Implementation was also associated with an immediate mean level decrease in days supplied (–0.4 days [95% CI, –0.6 to –0.2 days]) and the proportion of prescriptions exceeding a 7-day supply (–5.9 percentage points [95% CI, –7.9 to –3.9 percentage points]). In contrast, limit implementation in Connecticut was not associated with level or slope changes in any outcome.

Conclusions and Relevance

Opioid prescribing duration limits had a variable association with postoperative opioid prescribing in Massachusetts and Connecticut. The mean opioid prescription size filled, days supplied, and prescribing exceeding a 7-day supply decreased after limit implementation in Massachusetts only. Given the potential differences in policy dissemination and uptake, efforts to reduce opioid prescribing should also include surgeon education and evidence-based prescribing recommendations.

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