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Original Investigation
December 2018

Association of Hydrocodone Schedule Change With Opioid Prescriptions Following Surgery

Author Affiliations
  • 1Department of Surgery, University of Michigan, Ann Arbor
  • 2Department of Urology, University of Michigan, Ann Arbor
  • 3Department of Anesthesiology, University of Michigan, Ann Arbor
  • 4Michigan Opioid Prescribing Engagement Network, Ann Arbor
JAMA Surg. 2018;153(12):1111-1119. doi:10.1001/jamasurg.2018.2651
Key Points

Question  Does an association exist between the October 2014 US Drug Enforcement Administration change for hydrocodone-containing medications from schedule III to II and the amount of opioid filled following surgery?

Findings  In this analysis of claims data of 21 955 privately insured surgery patients in Michigan, there was an immediate significant increase following the schedule change in the amount of opioids filled in the initial postoperative prescription, which was sustained for 1 year.

Meaning  Future efforts to curb opioid prescribing should be coupled with prescriber education and close follow-up to ensure commensurate reductions in opioid prescribing.

Abstract

Importance  In 2014, the US Drug Enforcement Administration moved hydrocodone-containing analgesics from schedule III to the more restrictive schedule II to limit prescribing and decrease nonmedical opioid use. The association of this policy change with postoperative prescribing is not well understood.

Objective  To examine the hypothesis that the amount of opioids prescribed following surgery is associated with the rescheduling of hydrocodone.

Design, Setting, and Participants  An interrupted time series analysis of outpatient opioid prescriptions was conducted to examine the trends in the amount of postoperative opioids filled before and after the schedule change. Opioid prescriptions filled between January 2012 and October 2015 were analyzed using insurance claims data from the Michigan Value Collaborative, which includes data from 75 hospitals across Michigan. A total of 21 955 adult inpatients 18 to 64 years of age who underwent 1 of 19 common elective surgical procedures and filled an opioid prescription within 14 days of discharge to home were eligible for inclusion.

Main Outcomes and Measures  The primary outcome was the trends in the mean amount of opioids filled in oral morphine equivalents (OMEs) for the initial postoperative prescriptions before and after the schedule change date of October 6, 2014, compared using interrupted time series and multivariable regression analyses. Secondary outcomes included the total amount of opioids filled and the refill rate for the 30-day postoperative period. Subgroup analyses were performed by hydrocodone prescriptions, nonhydrocodone prescriptions, surgical procedure, and prior opioid use.

Results  Data from 21 955 patients undergoing surgical procedures across 75 hospitals and 5120 prescribers were analyzed. Cohorts before and after the schedule change were equivalent with respect to sex (10 197 of 15 791 [64.6%] vs 3966 of 6169 [64.3%] female; P = .69) and mean (SE) age (47.9 [11.2] vs 47.7 [11.3] years; P = .19). After the schedule change, the mean OMEs filled in the initial opioid prescription increased by approximately 35 OMEs (β = 35.1 [13.2]; P < .01), equivalent to 7 tablets of hydrocodone (5 mg). There were no significant differences in the total OMEs filled during the 30-day postoperative period before and after the schedule change (β = 18.3 [30.5]; P = .55), but there was a significant decrease in the refill rate (β = −5.2% [1.3%]; P < .001).

Conclusions and Relevance  Changing hydrocodone from schedule III to schedule II was associated with an increase in the amount of opioids filled in the initial prescription following surgery. Opioid-related policies require close follow-up to identify and address early unintended effects given the multitude of competing factors that influence health care professional prescribing behaviors.

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