Impact of Sequential Opioid Dose Reduction Interventions in a State Medicaid Program Between 2002 and 2017

J Pain. 2019 Aug;20(8):876-884. doi: 10.1016/j.jpain.2019.01.008. Epub 2019 Jan 26.


Policies that address opioid dose limits may help to decrease high-risk opioid prescribing. We evaluated 3 sequential and progressive decreases in high-dose (HD) opioid limits implemented by Massachusetts Medicaid over 15 years. The study population included members ages 18 to 64 years with ≥1 claim for a schedule II opioid between January 2002 and March 2017. The 3 interventions consisted of prior authorization requirements for prescriptions exceeding the morphine equivalent dose (MED) HD dose limits: >360 mg (intervention 1a and 1b), >240 mg (intervention 2), and >120 mg (intervention 3). A segmented regression evaluated the change in natural log of the average daily MED (AD_MED). The natural log of the AD_MED decreased during the 6 quarters after intervention 1a (P < .001), immediately after intervention 1b (P = .0002), and continued to decrease over the following 8 quarters (P = .023). The natural log of the AD_MED decreased immediately after intervention 2 (P = .002) and again after intervention 3 (P < .001). The percentage of users exceeding the HD limits of 360 mg, 240 mg, and 120 mg MED decreased by 87.3%, 79.8%, and 75.2% from baseline, respectively. The natural log of the AD_MED decreased among members after implementation of 3 sequential and progressive HD prior authorization limits, as did the percentage of members exceeding each of the HD limits. PERSPECTIVE: This study demonstrates the longitudinal impact of a prior authorization policy-based HD limit in a Medicaid population. This study contributes to options for policymakers and other Medicaid programs as a potential strategy to assist in addressing the opioid epidemic.

Keywords: Medicaid; Opioid; epidemic; high dose; morphine equivalent dose; policy; prior authorization.

MeSH terms

  • Adolescent
  • Adult
  • Analgesics, Opioid / administration & dosage*
  • Analgesics, Opioid / therapeutic use
  • Dose-Response Relationship, Drug
  • Female
  • Humans
  • Male
  • Medicaid
  • Middle Aged
  • Pain / drug therapy*
  • Practice Patterns, Physicians'*
  • United States
  • Young Adult


  • Analgesics, Opioid