In 2019, US surgeons found themselves in the midst of a growing crisis – the opioid epidemic. With 15.5 million opioid prescriptions attributed to their profession, they accounted for 11% of all opioid prescriptions dispensed that year.
These numbers were startling, revealing a significant role that the medical community played in fueling the opioid crisis. While surgery is often a necessary and vital medical procedure, the aftermath, in terms of prescription opioids, presented an issue that demanded attention and intervention.
This article delves into the intricacies of opioid prescribing after surgery, the impact of insurance and state policies, and the ultimate goal of improving patient outcomes while reducing opioid-related harm.
The Opioid Crisis and Surgery
The opioid epidemic has been a major public health concern in the United States, with millions of lives affected by addiction, overdose, and death. Opioid overprescribing has been identified as one of the major contributing factors to this crisis. It was thus imperative to examine the role of surgeons in this crisis, specifically in terms of the opioid prescriptions they issued to patients post-surgery.
A significant proportion of surgical opioid prescriptions came from advanced practice clinicians, accounting for one-fifth of opioid prescriptions written after surgery and one-quarter of refills. This indicated the complex nature of the issue. Prescription opioid exposure after surgery was associated with increased risks, including misuse, overdose, and persistent opioid use long after the surgical pain had subsided. These consequences highlighted the urgency in finding ways to reduce unnecessary opioid prescriptions post-surgery and mitigate their role in the ongoing opioid epidemic.
State and Insurer Policies
In response to the opioid crisis, many states implemented policies aimed at restricting the duration of opioid prescriptions for acute pain and for patients without prior opioid use. These measures were seen as a way to regulate the behavior of prescribers and pharmacists. Simultaneously, several major insurers, including UnitedHealthcare, Medicare, and various state Medicaid programs, initiated their own policies to limit opioid prescriptions.
However, the effectiveness of these policies was a matter of debate. Many studies were conducted to evaluate the association between these limits and the actual prescription patterns of patients undergoing surgery, with mixed results. While some indicated modest reductions, others showed no significant changes in prescribing practices. These variations in findings highlighted the need for a more comprehensive understanding of the impact of these policies.
Addressing Knowledge Gaps
There were two essential knowledge gaps that needed to be addressed. First, few studies explored the impact of insurer limits on opioid prescribing after surgery. This was significant because insurer and state limits functioned through different mechanisms. While state limits relied on behavioral changes by prescribers and pharmacists, insurer limits had an additional layer of enforcement due to the denial of coverage at the point of dispensing. The latter had the potential to result in more stringent reductions in opioid prescribing.
Second, very few studies rigorously assessed the association between the implementation of opioid prescribing limits and patient-reported outcomes post-surgery. The challenge lay in the fact that these studies required the prospective collection of data on patient-reported outcomes both before and after limit implementation. Few organizations were collecting this data during the period when most opioid prescribing limits came into effect in the latter half of the 2010s.
The Michigan Study
To bridge these knowledge gaps, a study was conducted in Michigan, evaluating the impact of a 5-day opioid prescribing limit introduced by Blue Cross Blue Shield of Michigan (BCBSM). This large insurer covered approximately three-quarters of privately insured patients in the state. The study aimed to investigate changes in opioid prescribing, opioid dispensing, and patient-reported outcomes among adults undergoing general surgical procedures in Michigan. The study’s design utilized a statewide surgical registry with data on opioid prescribing and patient-reported outcomes, dating back to January 2017, before the BCBSM limit was implemented in February 2018. This database was linked to Michigan’s prescription drug monitoring program (PDMP) database, allowing for observation of opioid prescribing (via the registry) and opioid dispensing (via the PDMP).
The results of this extensive study were insightful. The implementation of the BCBSM’s 5-day opioid prescribing limit did not lead to worsened patient-reported outcomes. This was a crucial finding, indicating that limits, when applied to a patient population similar to the one in the study, might reduce opioid prescribing without compromising patient experiences.
Intriguingly, the study revealed that the limit did not cause prescribers to withhold opioid prescriptions at the point of discharge. However, it did lead to a significant decrease in the proportion of patients with a dispensed opioid prescription. This suggests that BCBSM, pharmacists, or a combination of both, were rejecting opioid prescriptions that did not comply with the limit, thus reducing the dispensing of opioids.
Furthermore, the limit was associated with an immediate reduction in the amount of opioids prescribed and dispensed, although the magnitude of the decrease was relatively modest – roughly equivalent to 3 to 3.5 pills. This modest reduction could be attributed to the fact that the amount of opioids prescribed and dispensed had already been declining due to factors such as heightened focus on opioid stewardship following the release of national opioid prescribing guidelines in 2016. This raised questions about the effectiveness of opioid limits, suggesting that many existing limits may be too permissive to substantially reduce opioid prescribing after surgery.
While the study found no evidence of worsened patient-reported outcomes after the implementation of the limit, it did reveal reductions in the amount of opioids prescribed and dispensed to non-opioid-naive patients, even though the limit had specifically targeted opioid-naive patients. This highlights the need to monitor for spillover effects of opioid prescribing limits. The unintended consequences of such policies could affect patient care in unexpected ways.
Limitations and Considerations
This study, despite its significant findings, has limitations. The data predominantly captured patients undergoing common surgical procedures where opioid needs are often relatively modest. The results may not be directly applicable to procedures with higher opioid needs, such as certain orthopedic surgeries and neurosurgical procedures. Limits may affect prescribing to a greater degree in such cases, potentially impacting patient-reported outcomes.
The study conducted in Michigan presents crucial insights into the impact of insurer-imposed limits on opioid prescriptions after surgery. It demonstrates that, in certain scenarios, these limits can be effective in reducing opioid prescribing without worsening patient outcomes. However, there are nuances to consider, such as the potential for spillover effects and the need for further research to assess the impact of these limits on different types of surgical procedures. In the ongoing battle against the opioid epidemic, it is clear that reducing unnecessary opioid prescriptions is a vital step, and insurer-imposed limits can play a role in achieving this goal.
The study also underscores the importance of collecting and utilizing data on patient-reported outcomes to inform and refine healthcare policies. As the opioid crisis continues to evolve, it is essential to leverage research and data to make informed decisions that balance pain management with the need to protect patients from opioid-related harm. Policymakers and insurers must consider the unique characteristics of their patient populations and the specific surgical procedures involved when implementing opioid prescribing limits.
reference link :https://jamanetwork.com/journals/jama-health-forum/fullarticle/2810447