Effect of a High Dosage Opioid Prior Authorization Policy on Prescription Opioid Use, Misuse, and Overdose Outcomes

Hartung, Daniel; Kim, Hyunjee; Ahmed, Sharia M.; Middleton, Luke; Keast, Shellie L.; Deyo, Richard A.; Zhang, Kun; McConnell, K. John

doi:10.1080/08897077.2017.1389798

Cited by 23 publications

(33 citation statements)

References 38 publications

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“…Although we observed changing patterns of access for high‐strength opioids through public and private payers, we found no evidence of complete opioid discontinuation following the policy. These findings are similar to an Oregon study evaluating the impact of a prior authorization policy for opioid prescriptions exceeding 120 MME per day, which reported a 20.3% decline in the probability of receiving a high‐dose opioid prescription . However, in contrast to our study, the study by Hartung et al did not examine the impact on dose received and was unable to measure the extent to which prescriptions were paid out of pocket.…”

Section: Discussionsupporting

confidence: 80%

“…Given these concerns, the current guidelines for opioid use for chronic noncancer pain in Canada and the United States recommend against escalating beyond 90 mg of morphine or equivalent (MME) per day and suggest carefully tapering high doses when harms outweigh benefits. To regulate the availability of high‐strength opioids in communities and help reduce high opioid doses, some jurisdictions in Canada and the United States have restricted access to high‐strength opioid formulations or prescriptions with high daily doses . A 2017 petition to the US Food and Drug Administration (FDA) called for banning opioid formulations that could achieve daily doses of 90 MME or more when taken as directed…”

Section: Introductionmentioning

confidence: 99%

“…To regulate the availability of high-strength opioids in communities and help reduce high opioid doses, some jurisdictions in Canada and the United States have restricted access to highstrength opioid formulations 14 or prescriptions with high daily doses. 15 A 2017 petition to the US Food and Drug Administration (FDA) called for banning opioid formulations that could achieve daily doses of 90 MME or more when taken as directed. 16 In Ontario, Canada, 40% of long-acting opioid prescriptions dispensed in 2016, a period immediately preceding the release of the new Canadian guidelines, were for daily doses exceeding 90 MME, 17 and approximately 4% of newly treated patients were initiated on a dose exceeding this threshold.…”

Section: Introductionmentioning

confidence: 99%

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Impact of delisting high‐strength opioid formulations from a public drug benefit formulary on opioid utilization in Ontario, Canada

Martins

Khuu²,

Tadrous

et al. 2019

Pharmacoepidemiology and Drug

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Purpose High‐strength opioid formulations were delisted (removed) from Ontario's public drug formulary in January 2017, except for palliative patients. We evaluated the impact of this policy on opioid utilization and dosing. Methods We conducted a longitudinal study among patients receiving publicly funded, high‐strength opioids from August 2016 to July 2017. The primary outcome measure was weekly median daily opioid dose (in milligrams of morphine or equivalent; MME) of (1) publicly funded and (2) all opioid prescriptions irrespective of funding source, evaluated using interrupted time series analyses and stratified by palliative care status. Results Following policy implementation, the weekly median daily dose of publicly funded opioids decreased immediately among non‐palliative patients by 10 MME (95% confidence limit [CL], −16.8 to −3.1) from a pre‐intervention dose of 424.5 MME (95% CL, 417.8‐431.2) and fell gradually among palliative patients by 3.9 MME per week (95% CL, −5.5 to −2.3) from a pre‐intervention dose of 450.1 MME (95% CL, 432.5‐467.7). In contrast, among all opioid prescriptions, gradual reductions in weekly median daily doses were observed only for non‐palliative patients, which decreased by 0.7 MME per week (95% CL, −1.3 to −0.2) from a pre‐intervention dose of 426.2 MME (95% CL, 420.9‐431.5). Conclusion The delisting of publicly‐funded, high‐strength opioids was accompanied by changes in funding source and small reductions in the weekly median daily doses dispensed. Although observed dose reductions of less than 1 MME weekly are likely not clinically relevant, safety implications of these changes require further monitoring.

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Section: Discussionsupporting

confidence: 80%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Impact of delisting high‐strength opioid formulations from a public drug benefit formulary on opioid utilization in Ontario, Canada

Martins

Khuu²,

Tadrous

et al. 2019

Pharmacoepidemiology and Drug

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show abstract

“…Two rigorous evaluations observed that prior authorization policies were associated with decreases in multiple pharmacy or prescriber use. Hartung and colleagues observed a small decrease in multiple pharmacy visits following policy implementation . Among persons with high‐risk opioid use, Keast and colleagues identified a reduction in multiple prescriber use associated with the 2008 Oklahoma Medicaid policy …”

Section: Resultsmentioning

confidence: 99%

The Association of State Opioid Misuse Prevention Policies With Patient‐ and Provider‐Related Outcomes: A Scoping Review

2019

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This scoping review reveals a growing literature on the effects of certain state opioid misuse prevention policies, but persistent gaps in evidence on other prevalent state policies remain. Policymakers interested in reducing the volume and dosage of opioids prescribed and dispensed can consider adopting robust prescription drug monitoring programs with mandatory access provisions and drug supply management policies, such as prior authorization policies for high‐risk prescription opioids. Further research should concentrate on potential unintended consequences of opioid misuse prevention policies, differential policy effects across populations, interventions that have not received sufficient evaluation (eg, Good Samaritan laws, naloxone access laws), and patient‐related outcomes. Context In the midst of an opioid crisis in the United States, an influx of state opioid misuse prevention policies has provided new opportunities to generate evidence of policy effectiveness that can inform policy decisions. We conducted a scoping review to synthesize the available evidence on the effectiveness of US state interventions to improve patient and provider outcomes related to opioid misuse and addiction. Methods We searched six online databases to identify evaluations of state opioid policies. Eligible studies examined legislative and administrative policy interventions that evaluated (a) prescribing and dispensing, (b) patient behavior, or (c) patient health. Findings Seventy‐one articles met our inclusion criteria, including 41 studies published between 2016 and 2018. These articles evaluated nine types of state policies targeting opioid misuse. While prescription drug monitoring programs (PDMPs) have received considerable attention in the literature, far fewer studies addressed other types of state policy. Overall, evidence quality is very low for the majority of policies due to a small number of evaluations. Of interventions that have been the subject of considerable research, promising means of reducing the volume and dosages of opioids prescribed and dispensed include drug supply management policies and robust PDMPs. Due to low study number and quality, evidence is insufficient to draw conclusions regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws. Conclusions Recent research has improved the evidence base on several state interventions targeting opioid misuse. Specifically, moderate evidence suggests that drug supply management policies and robust PDMPs reduce opioid prescribing. Despite the increase in rigorous evaluations, evidence remains limited for the majority of policies, particularly those targeting patient health–related outcomes.

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“…No differences in opioid overdose were observed. 11 These analyses underline the importance of policy evaluation to understand whether the intent is being met and if there are unintended consequences that should be addressed.…”

Section: Discussionmentioning

confidence: 99%

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

García

Lenz

Greenwood

et al. 2019

The Journal of Pain

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Effect of a High Dosage Opioid Prior Authorization Policy on Prescription Opioid Use, Misuse, and Overdose Outcomes

Abstract: Oregon's prior authorization policy was effective at reducing high dosage opioid prescriptions. While multiple pharmacy use also declined, no changes in opioid overdose were observed.

Cited by 23 publications

References 38 publications

Impact of delisting high‐strength opioid formulations from a public drug benefit formulary on opioid utilization in Ontario, Canada

Impact of delisting high‐strength opioid formulations from a public drug benefit formulary on opioid utilization in Ontario, Canada

The Association of State Opioid Misuse Prevention Policies With Patient‐ and Provider‐Related Outcomes: A Scoping Review

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

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