Opioid and non-opioid analgesic prescribing before and after the CDC's 2016 opioid guideline

Abstract

The U.S. has addressed the opioid crisis using a two-front approach: state regulations limiting opioid prescriptions for acute pain patients, and voluntary federal CDC guidelines on shifting chronic pain patients to lower opioid doses and non-opioids. No opioid policy research to date has accounted for this two-pronged approach in their research design. We develop a theory of physician prescribing behavior under this two-pronged incentive structure. Using the Medical Expenditure Panel Survey, we empirically corroborate the theory: regulations and guidelines have the intended effects of reducing opioid prescriptions for acute and chronic pain, respectively, as well as the predicted unintended effects-income effects cause regulations on acute pain treatment to increase chronic pain opioid prescriptions and the chronic pain treatment guidelines spillover to reduce opioids for acute pain. Moreover, we find that the guidelines worked as intended in terms of the reduced usage, with chronic pain patients shifting to non-opioids and also tapering opioid doses. For those who discontinued opioids under regulations and guidelines, we find no harm in terms of increased work limitations due to pain a year after discontinuing opioids. Finally, we observe an unexplained dichotomy-regulations reduce opioid use by causing fewer new starts, whereas guidelines reduce opioid use by discontinuing current users, with no impact on new starts.

Keywords: Guidelines; Incentives; Opioids; Physician prescribing behavior.

Fig. 1

The effects of state regulations and the CDC guidelines on starting opioids versus using only non-opioids among adults with acute pain, 2014–2017. Nationally representative estimates of the effects of the 2016 CDC guidelines and state regulations (caps on number of prescription, pill mill laws, and comprehensive PDMPs) on current year opioids use or non-opioids analgesics-only among adults with acute pain with no opioids in prior year, excluding cancer patients. See Appendix 2 Table 5 for full state-fixed multinomial regression. *** (**) (*) statistically significant difference compared to the no state regulations/no guidelines case at the p < 0.01 (p < 0.05) (p < 0.1) level. Sources: Authors’ calculations using MEPS

Fig. 2

The effects of state regulations and the CDC guidelines on discountinuing opioids and using non-opioids analgesics after starting opioids among adults with acute pain, 2014–2017. Nationally representative estimates of the effects of the 2016 CDC guidelines and state regulations (caps on number of prescription, pill mill laws, and comprehensive PDMPs) on the percent of prior year opioids users (starting in first half of the prior year) who discontinue opioids in the current year with nothing else used, or with non-opioids analgesics only, or continue with opioids, for those with acute pain, excluding cancer patients. See full state fixed effect multinomial logit regression result in Appendix 2 Table 7. *** (**) (*) statistically significant difference compared to the no state regulations/no guidelines case at the p < 0.01 (p < 0.05) (p < 0.1) level. Sources: Authors’ calculations using MEPS

Fig. 3

The effects of state regulations and the CDC guidelines on starting opioids versus using only non-opioids among adults with chronic pain, 2014–2017. Nationally representative estimates of the effects of the 2016 CDC guidelines and state regulations (caps on number of prescription, pill mill laws, and comprehensive PDMPs) on current year opioids use or non-opioids analgesics-only among adults with chronic acute pain with no opioids in prior year, excluding cancer patients. See Appendix 2 Table 5 for full state-fixed multinomial regression. *** (**) (*) statistically significant difference compared to the no state regulations/no guidelines case at the p < 0.01 (p < 0.05) (p < 0.1) level. Sources: Authors’ calculations using MEPS

Fig. 4

The effects of state regulations and the CDC guidelines on discountnuing opioids and using non-opioids analgesics among adults with chronic acute pain, 2014–2017. Nationally representative estimates of the effects of the 2016 CDC guidelines and state regulations (caps on number of prescription, pill mill laws, and comprehensive PDMPs) on the percent of prior-year opioids users discontinue opioids in the current year with nothing else used, or with non-opioids analgesics only, or continue with opioids, for those with chronic pain, excluding cancer patients. See full state fixed effect multinomial logit regression result in Appendix 2 Table 7. *** (**) (*) statistically significant difference compared to the no state regulations/no guidelines case at the p < 0.01 (p < 0.05) (p < 0.1) level. Sources: Authors’ calculations using MEPS

Fig. 5

Work limitation due to pain after discontinuing opioids under state regulations and the CDC guidelines among adults with acute pain, 2014–2017. Nationally representative estimates of the effects of the 2016 CDC guidelines and state regulations (caps on number of prescription, pill mill laws, and comprehensive PDMPs) on the change in work limitation due to pain from year 1 to 2 year among adults with acute pain and opioid use in prior year, excluding cancer patients. Stopping is interacted with guidelines and regulations. See Appendix 2 Table 13 for full state-fixed multinomial regression. *** (**) (*) statistically significant difference compared to the no state regulations/no guidelines case at the p < 0.01 (p < 0.05) (p < 0.1) level. Sources: Authors’ calculations using MEPS

Fig. 6

Work limitation due to pain after discontinuing opioids under state regulations and the CDC guidelines among adults with chronic pain, 2014–2017. Nationally representative estimates of the effects of the 2016 CDC guidelines and state regulations (caps on number of prescription, pill mill laws, and comprehensive PDMPs) on the change in work limitation due to pain from year 1 to year 2 among adults with chronic pain and opioid use in prior year, excluding cancer patients. Stopping is interacted with guidelines and regulations. See Appendix 2 Table 13 for full state-fixed multinomial regression. *** (**) (*) statistically significant difference compared to the no state regulations/no guidelines case at the p < 0.01 (p < 0.05) (p < 0.1) level. Sources: Authors’ calculations using MEPS

Fig. 7

The effects of state regulations and the CDC guidelines on discontinuing opioids and using non-opioids analgesics among long term opioids users with chronic pain, 2014–2017. Note that less than 0.1% discontinue with nothing used, so that option is not estimated. Thus, we report nationally representative logit estimates of the effects of the 2016 CDC guidelines and state regulations (caps on number of prescription, pill mill laws, and comprehensive PDMPs) on percent year of long term opioids users discontinuing opioids with non-opioids analgesics versus continuing with opioids, for those with chronic pain, excluding cancer patients and with long-term opioid use for two or more years. See full state fixed effect logit regression results in Appendix 2 Table 10. *** (**) (*) statistically significant difference compared to the no state regulations/no guidelines case at the p < 0.01 (p < 0.05) (p < 0.1) level. Sources: Authors’ calculations using MEPS