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Impact of state legislation in Tennessee on opioid prescribing practices of orthopedic surgeons

Corey Guidry, PharmD, BCPS, Blerim Dema, BSc, Corinne Allen, PharmD, MBA, David Stewart, PharmD, BCPS


Objective: Post-operative patients are at increased risk of becoming chronic users of opioids, and overprescribing can lead to abuse and diversion. Though data have shown a decrease in opioid prescriptions nationally, limited studies have specifically evaluated the influence of state legislation on this trend. This study aimed to assess the impact of legislation in the state of Tennessee on opioid prescribing amongst orthopedic surgeons.

Design: This retrospective cohort analysis evaluated patients who received opioids post-orthopedic surgery before and after the state legislation was passed. Setting: A community teaching hospital.

Patients and participants: Two hundred and three post-orthopedic surgery patients were included, with 101 in the prelegislation and 102 in the post-legislation groups.

Interventions: State legislation in Tennessee limiting amounts of prescribed opioids went into effect in July 2018.

Main outcome measure(s): The primary outcome was total morphine milligram equivalents (MMEs) prescribed, with secondary outcomes of days’ supply, dosage units, and MME per day.

Results: Orthopedic surgery patients in the post-legislation arm were prescribed significantly fewer MME than those in the prelegislation arm (median MME 375 vs. 562.5; p < 0.001). Prescription days’ supply, number of dosage units, and MME per day were also significant lower in the post-legislation group.

Conclusions: After orthopedic surgery, patients in the post-legislation arm were prescribed a median 187.5 MME less than those in the prelegislation arm. Our findings suggest that state opioid legislation is associated with a reduction in the amount of opioids prescribed in certain orthopedic surgery patients, though further studies evaluating adequacy of pain control are warranted.


opioid, opioid epidemic, post-operative pain, legislation

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Guy GP, Zhang K, Bohm MK, et al.: Vital signs: Changes in opioid prescribing in the United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017; 66(26): 697-704. DOI: 10.15585/mmwr.mm6626a4.

Centers for Disease Control and Prevention: Prescribing practices. Available at Accessed October 8, 2020.

Dart RC, Surratt HL, Cicero TJ, et al.: Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015; 372(3): 241-248. DOI: 10.1056/NEJMsa1406143.

Scholl L, Seth P, Kariisa M, et al.: Drug and opioid-involved overdose deaths—United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2018; 67(5152): 1419-1427. DOI: 10.15585/mmwr.mm675152e1.

Levy B, Paulozzi L, Mack KA, et al.: Trends in opioid analgesic-prescribing rates by specialty, US, 2007-2012. Am J Prev Med. 2015; 49(3): 409-413. DOI: 10.1016/j.amepre.2015.02.020.

Alam A, Gomes T, Zheng H, et al.: Long term analgesic use after low-risk surgery: A retrospective cohort study. Arch Intern Med. 2012; 172(5): 425-430. DOI: 10.1001/archinternmed.2011.1827.

Sun EC, Carnall BD, Baker LC, et al.: Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016; 176(9): 1286-1293. DOI: 10.1001/jamainternmed.2016.3298.

Madras BK: The surge of opioid use, addiction, and overdoses: Responsibility and response of the US health care system. JAMA Psychiatry. 2017; 74(5): 441-442. DOI: 10.1001/jamapsychiatry.2017.0163.

Shah A, Hayes CJ, Martin BC: Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017; 66(10): 265-269. DOI: 10.15585/mmwr.mm6610a1.

Howard R, Fry B, Gunaseelan V: Association of opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg. 2019; 154(1): e184234. DOI: 10.1001/jamasurg.2018.4234.

Brat G, Angiel D, Beam A, et al.: Post-surgical opioid prescription duration and the association with overdose and abuse. J Am Coll Surg. 2017; 225(4): S2: e29. DOI: 10.1016/j.jamcollsurg.2017.07.597.

Bicket MC, Long JJ, Pronovost PJ, et al.: Prescription opioid analgesics commonly unused after surgery: A systematic review. JAMA Surg. 2017; 152(11): 1066-1071. DOI: 10.1001/jamasurg.2017.0831.

Maxwell JS: The prescription drug epidemic in the United States: A perfect storm. Drug Alcohol Rev. 2011; 30(3): 264-270. DOI: 10.1111/j.1465-3362.2011.00291.x.

Hill MV, McMahon ML, Stucke RS, et al.: Wide variation and excessive dosage of opioid prescriptions for common general surgery procedures. Ann Surg. 2017; 265(4): 709-714. DOI: 10.1097/SLA.0000000000001993.

Passik SD, Kirsh KL, Casper D: Addiction-related assessment tools and pain management: Instruments for screening, treatment planning, and monitoring compliance. Pain Med. 2008; 9: S145-S166. DOI: 10.1111/j.1526-4637.2008.00486.x.

Butler SF, Zacharoff K, Charity S, et al.: Electronic opioid risk assessment program for chronic pain patients: Barriers and benefits of implementation. Pain Pract. 2014; 14(3): E98-E105. DOI: 10.1111/papr.12141.

Yorkgitis BK, Brat GA: Postoperative opioid prescribing: Getting it RIGHTT. Am J Surg. 2018; 215(4): 707-711. DOI: 10.1016/j.amjsurg.2018.02.001.

Griggs CA, Weiner SG, Feldman JA: Prescription drug monitoring programs: Examining limitations and future approaches. West J Emerg Med. 2015; 16(1): 67-70. DOI: 10.5811/westjem.2014.10.24197.

Pharmacy Times: Opioid prescribing limits across the states. Available at Accessed August 10, 2019.

US Department of Health and Human Services: Factsheet: Tennessee's oversight of opioid prescribing and monitoring of opioid use. Available at Accessed August 2, 2019.

Dowell D, Haegerich TM, Chou R: CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016; 65(1): 1-49. DOI: 10.15585/mmwr.rr6501e1.

Tan WH, Yu J, Feaman S, et al.: Opioid medication use in the surgical patient: An assessment of prescribing patterns and use. J Am Coll Surg. 2018; 227(2): 203-211. DOI: 10.1016/j.jamcollsurg.2018.04.032.

CMS: Opioid morphine equivalent conversion factors. Available at Accessed October 8, 2020.

Meisenberg BR, Grover J, Campbell C, et al.: Assessment of opioid prescribing practices before and after implementation of a health system intervention to reduce opioid overprescribing. JAMA Netw Open. 2018; 1(5): e182908. DOI: 10.1001/jamanetworkopen.2018.2908.

Weiner SG, Baker O, Poon SJ, et al.: The effect of opioid prescribing guidelines on prescriptions by emergency physicians in Ohio. Ann Emerg Med. 2017; 70(6): 799-808. DOI: 10.1016/j.annemergmed.2017.03.057.

Lin LA, Bohnert ASB, Kerns RD, et al.: Impact of the opioid safety initiative on opioid-related prescribing in veterans. Pain. 2017; 158(5): 833-839. DOI: 10.1097/j.pain.0000000000000837.

Losby JL, Hyatt JD, Kanter MH, et al.: Safer and more appropriate opioid prescribing: A large healthcare system's comprehensive approach. J Eval Clin Pract. 2017; 23(6): 1173-1179. DOI: 10.1111/jep.12756.

Beaudoin FL, Banerjee GN, Mello MJ: State-level and system-level opioid prescribing policies: The impact on provider practices and overdose deaths, a systematic review. J Opioid Manag. 2016; 12(2): 109-118. DOI: 10.5055/jom.2016.0322.

Wainwright TW, Gill M, McDonald DA: Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthop. 2020; 91(1): 3-19. DOI: 10.1080/17453674.2019.1683790.

Tennessee State Government: HB1831/SB2257 Amendment 01582. Available at Accessed August 3, 2019.



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