The Impact of Increased Hydrocodone Regulation on Opioid Prescribing in an Urban Safety-Net Health Care System

Abstract

Background: Hydrocodone-combination analgesics were changed from Schedule III to Schedule II to discourage the prescribing of these analgesics. Our primary aim was to explore the effect of hydrocodone rescheduling on opioid prescribing within an urban safety-net health care system.Methods and Design: Data were extracted from electronic records of ambulatory patients (N ‫؍‬ 82,432 patients) prescribed hydrocodone-combination, codeine-combination, or tramadol opioid analgesics (N ‫؍‬ 200,675 prescriptions) between October 6, 2013 and October 6, 2015. Data analyses modeled predicted probabilities of hydrocodone-combination prescriptions (HCPs). Chronic opioid therapy (COT) for chronic pain (ie, >3 opioid prescriptions/12 months) and morphine milligram equivalency (MME) levels were also examined.Results: The probability of providers writing HCPs decreased significantly from pre-to postrescheduling (0.525 vs 0.158, respectively, P < .0001). However, this coincided with large probability increases in codeine-combination (0.064 vs 0.269) and tramadol prescriptions (0.412 vs 0.573). The probability of HCPs varied across physician specialty (P < .0001), patient diagnoses (P < .0001), COT versus non-COT patients (P < .0001), and patient characteristics (sex, race/ethnicity, and age; P < .05). COT patients received significantly more opioid prescriptions in the postrescheduling period (M ‫؍‬ 4.81 vs M ‫؍‬ 4.27; P < .0001). Patients on <20 MME/day increased slightly from pre-to postrescheduling (P < .0001).Discussion: Significant declines in HCPs occurred after rescheduling; however, one third of patients prescribed opioids remained on doses >20 MME/day. Codeine-and tramadol-prescription probabilities increased significantly and providers may have an increased perception of safety about these medications. Physicians and health care systems must reduce their overreliance on opioids in treating pain, especially chronic pain, as all opioids incur some level of risk.(J Am Board Fam Med 2019;32: 362-374.)

Competitive Effects of Federal and State Opioid Restrictions: Evidence from the Controlled Substance Laws

“…The tramadol scheduling law is thus a unique case as it was first enacted at the state level and then at the federal level, in identical form. 3 Previous descriptive research suggests that federal up-scheduling of HCPs is associated with decreases in its prescribing (Jones et al, 2016;Bernhardt et al, 2016;Fleming et al, 2017;Gudin and Lee, 2013;Murimi et al, 2019;Northrup et al, 2019); a similar finding occurs in the first economic study of HCPs' up-scheduling (Beheshti, 2019), which finds improved labor market conditions in areas with baseline high intensity of HCP reliance. However, there is no study to date that examines the spillover hypothesis to the closest competitor, tramadol.…”

Variations in Long‐term Opioid Therapy Definitions: A Systematic Review of Observational Studies Using Routinely Collected Data (2000‐2019)

“…One‐quarter of studies did not impose age restrictions (32 studies 23–53 ), while 83 studies included adults only, 11 studies 54–64 focused exclusively on the elderly (aged 65+ years) and two studies 65,66 focused on adolescents and young adults (13‐29 years old). Study populations varied substantially in size, ranging from 121 67 to 48 million people 68 .…”

Impact of Hydrocodone Rescheduling on Dental Prescribing of Opioids

“…However, substitution effects varied across studies. Eight studies observed an increase in prescribing codeine (Schultz et al 2016;Seago et al 2016;Bernhardt et al 2017;Kuschel and Mort 2017;Raji et al 2018;Shumway et al 2018;Liu et al 2019;Northrup et al 2019) and tramadol (Schultz et al 2016;Seago et al 2016;Bernhardt et al 2017;Northrup et al 2019), while 6 studies found no significant changes in codeine (Chumpitazi et al 2017) or tramadol prescribing (Kuo et al 2018;Raji et al 2018;Shumway et al 2018;Liu et al 2019). Only 2 studies reported increased prescribing of oxycodone (Bernhardt et al 2017;Kuschel and Mort 2017).…”

“…Since the rescheduling of hydrocodone in 2014, several studies have evaluated the impact of the regulation on hydrocodone prescribing (Usmani et al 2020). Most of these studies, focused on physicians, reported a substantial reduction in hydrocodone prescriptions after the regulation took effect in 2014 (Jones et al 2016; Oehler et al 2016; Schultz et al 2016; Seago et al 2016; Bernhardt et al 2017; Chumpitazi et al 2017; Kuschel and Mort 2017; Tran et al 2017; Kuo et al 2018; Raji et al 2018; Shumway et al 2018; Liu et al 2019; Northrup et al 2019; Usmani et al 2020). However, substitution effects varied across studies.…”