A rigorous evaluation of a Massachusetts opioid dosage law
As the opioid crisis continues, research on measures taken to alleviate it is much needed. Such research is one component of the Division of Health Policy and Insurance Research (HPI) portfolio.
Hefei Wen leads the division’s research on the implications of opioid regulation. Dr. Wen's work has been among the first to examine the behavioral health implications of Medicaid expansions, marijuana liberalization policies, prescription drug monitoring programs, opioid prescribing limit laws, and buprenorphine waiver requirements, especially in the context of the U.S. opioid crisis.
As part of his Harvard Medical School Fellowship in General Medicine and Primary Care, Bryant Shuey worked under the mentorship of Dr. Wen and Visiting Professor Frank Wharam on research focused on substance use disorders in vulnerable populations. Through learning how to analyze the effects of health policies on health outcomes, Dr. Shuey led work recently published in Health Affairs Scholar, on which Dr. Wen served as senior author. The paper, Massachusetts’ opioid limit law associated with a reduction in postoperative opioid duration among orthopedic patients, was published in early December.
Now an assistant professor in the Department of General Internal Medicine at the University of Pittsburgh, and Clinician Investigator in the Center for Research on Health Care, Dr. Shuey took time to answer questions about this recent work conducted at the Institute.
Q: What sparked your interest in studying substance use disorders?
Dr. Shuey: I became interested in providing care for people who use drugs after shadowing a family medicine physician in Albuquerque, New Mexico who prescribed buprenorphine, a life-saving medicine, for people with opioid use disorder. I saw the beneficial impact this medication had on a patient (“I feel like I can be the mother I want to be”) but also witnessed how restrictions on buprenorphine prescribing limited the impact this medication could have on others. Later, during my internal medicine residency in Tampa, Florida, I was supported by awesome mentors in creating a clinic that offered medications for substance use disorders, and in researching physician attitudes towards prescribing buprenorphine. I felt like I could make a difference on the individual level by providing non-judgmental care for people who use drugs, and on a larger level by evaluating policies affecting the prevention and treatment of substance use disorders.
Dr. Wen: My belief in human dignity and the possibility of redemption is the driving force behind my research commitment. Today Americans are no longer viewing substance use and addiction as a moral failure but a chronic condition that deserves care and compassion. I hope with future development of treatment and policy, people with substance use history will not only be patients, but survivors.
We know that opioid prescribing declined over the last decade, but teasing out the effects of opioid limit laws has been more challenging.
- Bryant Shuey, MD, MPH
Q: Can you tell us more about the prescribing policies that states have implemented to address the opioid crisis? What do we know (or not know) about their efficacy?
Dr. Shuey: In response to the rise in opioid overdose deaths beginning in the 1990s that accelerated in the 2010s, states moved to limit opioid prescribing. Massachusetts was the first state that implemented a 7-day duration limit for first-time opioid prescriptions in March 2016. This law provides a professional judgment exception to prescribe longer durations if medically indicated. The CDC also released guidelines in 2016 recommending shorter duration opioid prescriptions when prescribed for acute pain. Since then, 38 other states have followed by enacting duration and/or dosage limit laws.
We know that opioid prescribing declined over the last decade, but teasing out the effects of opioid limit laws has been more challenging.
Q: What is unique about this study?
Dr. Shuey: Our study was unique in two ways.
First, we exclusively studied patients undergoing orthopedic procedures, which are often painful procedures that are treated with higher doses of pain medication than other types of surgeries.
Second, we took advantage of Massachusetts’ “first mover” position before other state or health plan opioid limit policies went into effect. This gave us a “clean” analysis window where we could study what happened to patients receiving opioid prescriptions after orthopedic procedures in Massachusetts compared to New Hampshire, a state without such laws during the study period.
Q: What did the study findings show? Were you surprised by these findings?
Dr. Shuey: We found that among Massachusetts compared to New Hampshire patients undergoing orthopedic procedures, the Massachusetts 7-day limit was associated with an immediate 33% overall reduction in opioids greater than 7-days duration.
We were surprised to find that this reduction was not driven by the more painful procedures like hip or knee replacements, and instead was driven by shorter prescriptions among patients undergoing less painful surgeries like toe or wrist procedures. This suggests that surgeons performing less painful surgeries prescribed shorter durations while surgeons performing more painful procedures took advantage of the professional judgment exception and did not change prescribing practice.
Q: What are the potential implications of this study for public health, clinicians, and policymakers? How might states approach new or amend existing opioid prescription policies?
Dr. Shuey: Our findings suggest that 7-day limits may help to reduce prescriptions longer than 7-day durations for acute, post-operative pain. Our findings are important for policymakers who are considering state strategies for opioid prescribing considering the 2022 CDC guidelines which emphasize individualizing a patient’s pain control needs while de-emphasizing rigid limitations. We discourage policymakers from applying our findings to patients on chronic long-term opioids, as patients may be harmed by tapering off long-term opioids when that decision is not made between the patient and their doctor. Instead, our findings may assist in crafting “balanced” policies that seek to reduce longer duration prescribing to patients at risk of becoming dependent on opioids, like those in the post-operative setting, without adversely affecting patients on long-term opioids for chronic pain management.
Our findings may assist in crafting 'balanced' policies that seek to reduce longer duration prescribing to patients at risk of becoming dependent on opioids, like those in the post-operative setting, without adversely affecting patients on long-term opioids for chronic pain management.
- Dr. Shuey
Q: What future studies are you and your team considering to expand on this work?
Dr. Shuey: We aim to study how federal laws and regulations affect opioid prescribing among the non-elderly disabled population.
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