Impact of Michigan’s new opioid prescribing laws on spine surgery patients: analysis of the Michigan Spine Surgery Improvement Collaborative

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  • 1 Departments of Neurosurgery and
  • | 7 Orthopaedic Surgery, University of Michigan, Ann Arbor;
  • | 2 Department of Neurosurgery, Henry Ford Hospital, Detroit;
  • | 3 Center for Health Policy and Health Service Research and
  • | 4 Public Health Sciences Department, Henry Ford Health System, Detroit;
  • | 5 Department of Orthopaedic Surgery, Beaumont Health, Troy; and
  • | 6 Department of Neurosurgery, William Beaumont Hospital, Royal Oak, Michigan
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OBJECTIVE

In 2017, Michigan passed new legislation designed to reduce opioid abuse. This study evaluated the impact of these new restrictive laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery.

METHODS

Patient data from 1 year before and 1 year after initiation of the new opioid laws (beginning July 1, 2018) were queried from the Michigan Spine Surgery Improvement Collaborative database. Before and after implementation of the major elements of the new laws, 12,325 and 11,988 patients, respectively, were treated.

RESULTS

Patients before and after passage of the opioid laws had generally similar demographic and surgical characteristics. Notably, after passage of the opioid laws, the number of patients taking daily narcotics preoperatively decreased from 3783 (48.7%) to 2698 (39.7%; p < 0.0001). Three months postoperatively, there were no differences in minimum clinically important difference (56.0% vs 58.0%, p = 0.1068), numeric rating scale (NRS) score of back pain (3.5 vs 3.4, p = 0.1156), NRS score of leg pain (2.7 vs 2.7, p = 0.3595), satisfaction (84.4% vs 84.7%, p = 0.6852), or 90-day readmission rate (5.8% vs 6.2%, p = 0.3202) between groups. Although there was no difference in readmission rates, pain as a reason for readmission was marginally more common (0.86% vs 1.22%, p = 0.0323).

CONCLUSIONS

There was a meaningful decrease in preoperative narcotic use, but notably there was no apparent negative impact on postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery despite more restrictive opioid prescribing. Although the readmission rate did not significantly increase, pain as a reason for readmission was marginally more frequently observed.

ABBREVIATIONS

ASA = American Society of Anesthesiologists; MAPS = Michigan Automated Prescription System; MCID = minimum clinically important difference; MME = morphine milligram equivalent; MSSIC = Michigan Spine Surgery Improvement Collaborative; NRS = numeric rating scale; PF = Physical Function; PHQ-2 = 2-item Patient Health Questionnaire; PRO = patient-reported outcome; PROMIS = Patient-Reported Outcomes Measurement Information System.

OBJECTIVE

In 2017, Michigan passed new legislation designed to reduce opioid abuse. This study evaluated the impact of these new restrictive laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery.

METHODS

Patient data from 1 year before and 1 year after initiation of the new opioid laws (beginning July 1, 2018) were queried from the Michigan Spine Surgery Improvement Collaborative database. Before and after implementation of the major elements of the new laws, 12,325 and 11,988 patients, respectively, were treated.

RESULTS

Patients before and after passage of the opioid laws had generally similar demographic and surgical characteristics. Notably, after passage of the opioid laws, the number of patients taking daily narcotics preoperatively decreased from 3783 (48.7%) to 2698 (39.7%; p < 0.0001). Three months postoperatively, there were no differences in minimum clinically important difference (56.0% vs 58.0%, p = 0.1068), numeric rating scale (NRS) score of back pain (3.5 vs 3.4, p = 0.1156), NRS score of leg pain (2.7 vs 2.7, p = 0.3595), satisfaction (84.4% vs 84.7%, p = 0.6852), or 90-day readmission rate (5.8% vs 6.2%, p = 0.3202) between groups. Although there was no difference in readmission rates, pain as a reason for readmission was marginally more common (0.86% vs 1.22%, p = 0.0323).

CONCLUSIONS

There was a meaningful decrease in preoperative narcotic use, but notably there was no apparent negative impact on postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery despite more restrictive opioid prescribing. Although the readmission rate did not significantly increase, pain as a reason for readmission was marginally more frequently observed.

In response to the opioid abuse epidemic, the state of Michigan in 2017 passed a multibill package designed to limit the use of narcotics. These new opioid laws encompassed Public Acts 246–251.1 Public Act 250, effective March 27, 2018, mandated that clinicians provide information on substance use disorder treatments.1 Public Act 246, effective June 1, 2018, stated that a provider must educate a patient about opioids and have the patient sign an attestation prior to controlled substance prescription. Public Act 248, effective June 1, 2018, mandated that a prescriber obtain a Michigan Automated Prescription System (MAPS) report, used to track controlled substances, prior to prescribing a controlled substance. Public Act 251, effective July 1, 2018, stated that acute pain opioid prescriptions had to be limited to a 7-day supply. Public Act 247, effective January 4, 2019, mandated a bona fide provider-patient relationship prior to controlled substance prescription.1 Public Act 249 stipulated sanctions for failure to comply with MAPS usage mandates, failure to establish a bona fide provider-patient relationship, and failure to inform patients regarding risks associated with opioid medications.

Physicians, particularly non–pain care providers, were more hesitant to prescribe opioids after passage of these new opioid laws. This reluctance raised concerns that patients with legitimate pain control needs may not be appropriately treated. Among surgeons, there were fears that surgical patients would not have adequate pain control postoperatively given the 7-day supply limit of opioids upon discharge.2 In addition, inadequate pain control could potentially impact surgical outcomes, particularly in the short term, or lead to increased emergency department visits for pain control with the possibility of increased readmissions. This investigation evaluates the impact of these new laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery.

Methods

The Michigan Spine Surgery Improvement Collaborative (MSSIC) registry was utilized for analysis. The MSSIC registry is a prospective, longitudinal, multicenter, quality improvement program funded by Blue Cross Blue Shield of Michigan and Blue Care Network (Grand Rapids, Michigan).3 MSSIC encompasses 26 participating hospitals with the primary goal of improving spinal surgery clinical outcomes. Funding is used to support coordinating center staff, the registry database, data abstractors based at each hospital, data analyses and reports for participating hospitals and surgeons, and quarterly meetings.

Patients undergoing surgery for degenerative diseases of the cervical or lumbar spine are enrolled into the MSSIC registry. Demographic data, diagnoses, comorbidities, surgical indications, surgical procedure, in-hospital characteristics, complications, and readmissions are abstracted from the medical records by full-time abstractors. In addition, patient-reported outcomes (PROs) are prospectively obtained at baseline and 90 days, 1 year, and 2 years after surgery. Patients are also queried about preoperative opioid use. MSSIC registry data quality and completeness are verified by formal annual audits. Registry data are de-identified; therefore, patient consent for this research was not obtained. IRB approval was obtained to analyze the de-identified data.

Clinical Outcomes

The Patient-Reported Outcomes Measurement Information System (PROMIS) Short-Form Physical Function (PF) 4a (version 2.0) was the clinical outcome measure evaluated. PROMIS PF 4a scores reflect patient disability and correlate well with the Oswestry Disability Index, which has been the standard measure of functional compromise related to the lumbar spine.4 PROMIS PF 4a survey results were converted to T-scores, with higher values representing more normal function. T-scores of 20–30 represent severe dysfunction, 30–40 moderate dysfunction, and > 40 mild dysfunction to normal function.5

The numeric rating scale (NRS) was used to assess back and leg pain. NRS scores ranged from 0 (representing no pain) to 10 (representing the worst possible pain).

The minimum clinically important difference (MCID) is defined as the threshold for achieving meaningful symptomatic improvement.6 For cervical surgery, an increase in PROMIS PF ≥ 3 points was considered achieving MCID. For lumbar surgery, an increase in PROMIS PF ≥ 4.5 points was defined as meeting MCID.

Patient satisfaction with surgery outcomes was measured with the North American Spine Society satisfaction index, which is scored from 1 to 4.7 Scores of 1 (“The treatment met my expectations”) and 2 (“I did not improve as much as I hoped, but I would undergo the same treatment for the same outcome”) were considered “satisfied” patients. Scores of 3 (“I did not improve as much as I had hoped, and I would not undergo the same treatment for the same outcome”) and 4 (“I am the same or worse than before treatment”) were classified as “unsatisfied.”

Depression was assessed with the 2-item Patient Health Questionnaire (PHQ-2). The PHQ-2 is a validated screening tool for major depressive disorder.8 A PHQ-2 score ≥ 3 was deemed a positive screen for depression.

Pain medication usage was assessed in a questionnaire. The initial question asked prior to surgery, with a “yes” or “no” allowable response, was “Do you take opioid painkillers daily to control your pain? (prescription medications such as Vicodin, Lortab, Norco, hydrocodone, codeine, Tylenol#3 or #4, fentanyl, Duragesic, MS Contin, Percocet, Tylox, OxyContin, oxycodone, methadone, tramadol, Ultram, Dilaudid).” If the answer was “yes,” the second questions asked, “How long have you been using opioid painkillers on a daily basis?” The allowable responses were “less than 3 weeks,” “3 weeks but less than 6 weeks,” “6 weeks but less than 3 months,” “3 months but less than 6 months,” or “6 months or greater.” At the 90-day follow-up, a second questionnaire with a “yes” or “no” allowable response asked, “Are you currently taking opioid pain medication?” If the answer was “yes,” the next question with a “yes” or “no” allowable response was, “Are you taking opioid pain medication daily?”

Readmissions

Thirty- and 90-day readmissions to the hospital were recorded. Abstractors recorded reasons for readmissions and more than one reason could be identified.

Pre- and Post-Opioid Law Groups

Given that the major aspects of the opioid laws became effective on July 1, 2018, patient data from 1 year prior to and 1 year after this date were queried from the MSSIC registry. There were 12,325 and 11,988 patients treated 1 year prior to and 1 year after this date, respectively. To focus on the issue of opioid use, patients were included in this study if their preoperative opioid use was reported. A total of 7771 patients were treated in the 1 year prior to July 1, 2018, and 6798 patients were treated in the 1 year after that date. Given that prior spinal surgical history could impact narcotic use, a separate analysis dividing patients into those with and those without a history of spinal surgery was performed. Of the 7119 patients in the pre-opioid law group who answered whether they had previous surgery, 3233 (45.4%) stated “yes.” Of the 6419 patients in the post-opioid law group who answered whether they had previous surgery, 2954 (46.0%) stated “yes.”

Statistical Analysis

Descriptive statistics were used to summarize the data. Chi-square tests were used for categorical variables and t-tests were used for continuous variables to examine differences between pre- and post-opioid law patients. Demographic characteristics, surgical characteristics, PROs, surgical outcomes, opioid use, and readmissions were analyzed.

PROMIS PF, NRS pain scores, and depressive status were measured at both baseline and 90 days after surgery. Analysis of repeated measurements was conducted to compare values at baseline and 90 days after surgery for each of these variables within the pre- and post-opioid law patient groups. Patients with missing data for a variable were omitted in the analysis for that variable. All analyses were performed by using SAS (version 9.4, SAS Institute, Inc.).

Results

There were no significant differences in age, sex, percentage of Caucasians, or education level between groups (Table 1). There was a relatively small but significant difference in scoliosis diagnosis (22.04% vs 29.53%, p < 0.0001). With regard to surgical characteristics, there was also a small but significant difference in drain use (47.33% vs 50.94%, p < 0.0001). However, there were no differences in American Society of Anesthesiologists (ASA) scale grade, the region or number of spinal segments treated, or the type of surgery (fusion vs decompression; Table 2).

TABLE 1.

Patient characteristics

VariableSurgery w/in 1 Year Before the New Law (July 1, 2017, to June 30, 2018)Surgery w/in 1 Year After the New Law (July 1, 2018, to June 30, 2019)p Value
No. of patients77716798
Mean age ± SD, yrs59.25 ± 13.4659.51 ± 13.450.2361
Males3898 (50.17)3440 (50.71)*0.5155
Caucasian6370 (86.38)*5553 (86.94)*0.4057
Education0.1703
 Less than high school460 (6.31)363 (5.62)
 High school diploma or GED3570 (48.99)3127 (48.44)
 College2446 (33.57)2258 (34.98)
 Post-college811 (11.13)707 (10.95)
CAD at baseline1076 (13.85)963 (14.18)*0.5639
Current smoker1406 (18.09)1202 (17.68)0.5183
Diabetes1716 (22.09)*1561 (22.99)*0.1936
Scoliosis1712 (22.04)*1981 (29.53)*<0.0001
Ambulatory preoperative6554 (84.36)*5664 (83.43)*0.1267

CAD = coronary artery disease; GED = general educational development certificate.

Data are given as number (%) unless otherwise indicated. Boldface type indicates statistical significance.

Variables missing some data.

TABLE 2.

Surgical characteristics

VariableSurgery w/in 1 Year Before the New LawSurgery w/in 1 Year After the New Lawp Value
Surgical location0.8450
 Lumbar5522 (71.06)4801 (70.62)
 Cervical2242 (28.85)1991 (29.29)
 Both7 (0.09)6 (0.09)
Surgical procedure0.9776
 Fusion4843 (64.32)4247 (64.34)
 Decompression2687 (35.68)2354 (35.66)
No. of levels0.1752
 Single3552 (46.82)3035 (45.69)
 Multiple4034 (53.18)3608 (54.31)
ASA grade >24012 (51.63)3602 (53.03)*0.0903
Drain use3678 (47.33)3460 (50.94)*<0.0001

Data are given as number (%) unless otherwise indicated. Boldface type indicates statistical significance.

Variables missing some data.

The distribution of opioid usage duration prior to surgery is shown in Table 3, with the majority of patients in the pre- (58.49%) and post-opioid (58.97%) law groups taking narcotics for ≥ 6 months. Regardless of the duration of opioid use, there were no significant differences between groups. In contrast, there was a notable, significant difference in patients’ daily opioid use, with 48.68% of patients in the pre-opioid law group consuming opioids daily versus 39.69% of patients in the post-opioid law group (p < 0.0001). Table 4 shows that both patients with and those without prior spinal surgery history also had significant decreases in daily opioid use (55.7% to 47.0%, p < 0.0001, and 44.1% to 34.5%, p < 0.0001, respectively).

TABLE 3.

Preoperative opioid usage

Opioid UsageSurgery w/in 1 Year Before the New LawSurgery w/in 1 Year After the New Lawp Value
Take opioids daily to control pain<0.0001
 No3988 (51.32)4100 (60.31)
 Yes3783 (48.68)2698 (39.69)
Length of using opioid painkillers*0.1968
 <3 wks395 (10.74)309 (12.08)
 3 wks but <6 wks356 (9.68)255 (9.96)
 6 wks but <3 mos389 (10.57)238 (9.3)
 3 mos but <6 mos387 (10.52)248 (9.69)
 ≥6 mos2152 (58.49)1509 (58.97)

Data are given as number (%) unless otherwise indicated. Boldface type indicates statistical significance.

If the response was “yes” for the first question.

TABLE 4.

Daily opioid usage in patients with or without a history of previous spinal surgery

GroupSurvey w/in 1 Year Before the New LawSurvey w/in 1 Year After the New Lawp Value
Patients w/ previous spine surgery
 Take opioid painkillers daily to control pain<0.0001
  Yes1800 (55.68)1389 (47.02)
  No1433 (44.32)1565 (52.98)
Patients w/o previous spine surgery
 Take opioid painkillers daily to control pain<0.0001
  Yes1713 (44.08)1194 (34.46)
  No2173 (55.92)2271 (65.54)

Data are given as number (%) unless otherwise indicated. Boldface type indicates statistical significance.

Clinical outcomes were assessed for each group (Table 5). For the pre-opioid law group, there were significant improvements from baseline to 90 days postoperatively in mean PROMIS PF (35.43 vs 41.65, p < 0.0001), mean NRS back pain (7.06 vs 3.48, p < 0.0001), mean NRS leg pain (6.77 vs 2.72, p < 0.0001), mean NRS neck pain (6.52 vs 3.53, p < 0.0001), mean NRS arm pain (5.70 vs 2.65, p < 0.0001), and those screening positive for depression (34.67% vs 16.81%, p < 0.0001). Similarly, for the post-opioid law group, there were significant improvements in mean PROMIS PF (35.55 vs 42.05, p < 0.0001), mean NRS back pain (6.94 vs 3.36, p < 0.0001), mean NRS leg pain (6.66 vs 2.65, p < 0.0001), mean NRS neck pain (6.48 vs 3.23, p < 0.0001), mean NRS arm pain (5.75 vs 2.34, p < 0.0001), and positive depression screening (31.97% vs 14.47%, p < 0.0001). Most importantly, when comparing outcomes between pre- and post-opioid law groups, there were no significant differences in PROMIS PF, NRS back pain, NRS leg pain, NRS neck pain, or NRS arm pain at 90 days postoperatively.

TABLE 5.

Clinical outcomes within the pre- and post-opioid law groups

Surgery w/in 1 Year Before the New LawSurgery w/in 1 Year After the New Law
nAt BaselinenAt 90 Daysp ValuenAt BaselinenAt 90 Daysp Value
Depression (PHQ-2)260334.67%78316.81%<0.0001209731.97%56114.47%<0.0001
PROMIS PF766535.43 ± 5.94465041.65 ± 7.57<0.0001645235.55 ± 6.58362342.05 ± 8.92<0.0001
NRS scale
 Back pain*51147.06 ± 2.5533593.48 ± 2.92<0.000142806.94 ± 2.5526463.36 ± 2.89<0.0001
 Leg pain*50606.77 ± 2.7233212.72 ± 3.07<0.000142416.66 ± 2.7425942.65 ± 3.03<0.0001
 Neck pain20386.52 ± 2.8312503.53 ± 2.97<0.000117126.48 ± 2.7510093.23 ± 2.84<0.0001
 Arm pain20045.70 ± 3.1512392.65 ± 3.03<0.000116865.75 ± 3.059902.34 ± 2.87<0.0001

Data at baseline and at 90 days are given as mean ± SD unless otherwise indicated. Boldface type indicates statistical significance.

Only asked for lumbar patients.

Only asked for cervical patients.

Pre- and postoperative clinical outcomes are shown in Table 6. The proportions of patients achieving MCID (56.11% vs 57.94%) were similar, as were the numbers of patients satisfied (84.37% vs 84.69%) with surgery. The post-opioid law group did have a smaller number of depressed patients at baseline and 90 days, and the difference was significant (34.67% vs 31.97%, p = 0.0007; 16.81% vs 14.47%, p = 0.0031). There was no difference in readmission rates at 30 or 90 days postoperatively. However, pain as a reason for readmission significantly increased (0.86% vs 1.22%, p = 0.0323).

TABLE 6.

Pre- and post-opioid law clinical outcomes

OutcomeSurgery w/in 1 Year Before the New LawSurgery w/in 1 Year After the New Lawp Value
Preop
 Depression (PHQ-2) at baseline2603 (34.67)*2097 (31.97)*0.0007
 PROMIS PF at baseline35.43 ± 5.9435.55 ± 6.580.2815
 NRS scale at baseline
  Back pain7.06 ± 2.556.94 ± 2.550.0271
  Leg pain6.77 ± 2.726.66 ± 2.740.0582
  Neck pain6.52 ± 2.836.48 ± 2.750.6155
  Arm pain5.70 ± 3.155.75 ± 3.050.6150
Postop
 Depression (PHQ-2) at 90 days783 (16.81)*561 (14.47)*0.0031
 PROMIS PF at 90 days41.65 ± 7.5742.05 ± 8.920.0322
 NRS scale at 90 days
  Back pain3.48 ± 2.923.36 ± 2.890.1156
  Leg pain2.72 ± 3.072.65 ± 3.030.3595
  Neck pain3.53 ± 2.973.23 ± 2.840.0147
  Arm pain2.65 ± 3.032.34 ± 2.870.0149
 Reach MCID at 90 days2466 (56.11)*1937 (57.94)*0.1068
 Satisfaction w/ surgical outcomes at 90 days3844 (84.37)*3248 (84.69)*0.6852
 Readmission w/in 30 days258 (3.32)241 (3.55)0.4420
 Readmission w/in 90 days454 (5.84)423 (6.24)*0.3202
 Pain as readmission reason w/in 90 days67 (0.86)83 (1.22)0.0323
 Length of stay >3 days1324 (17.05)*1174 (17.29)*0.7085

Data are given as mean ± SD or number (%). Boldface type indicates statistical significance.

Variables missing some data.

Only asked for lumbar patients.

Only asked for cervical patients.

Discussion

This study shows that overall there was an approximately 10% decrease in daily opioid usage after passage of the opioid laws. Even when taking into account prior spinal surgery, similar significant reductions in daily opioid usage were observed. This notable decrease is not surprising given the added barriers to obtaining a controlled substance prescription. The MSSIC registry did not collect data on opioid usage postoperatively during the period of analysis. However, given the fact that there is a 7-day supply limit on prescribed narcotics for acute pain, there was likely an overall decrease in the prescribing and use of opioids postoperatively.

One of the major concerns with passage of the opioid laws was whether inadequate postoperative pain control after discharge would negatively impact surgical recovery and outcomes. This study found that there were similar amounts of postsurgical symptomatic improvement after passage of the opioid laws. The PROMIS PF is a measure of disability. Both pre- and post-opioid law patients were observed to have comparable improvements in the PROMIS PF as well as in achieving the MCID for PROMIS PF. In addition, both cohorts had similar degrees of pain improvement, as reflected in the NRS back and leg pain scores. Overall, patient satisfaction after surgery was high, i.e., 84.37% in pre-opioid law patients and 84.69% in post-opioid law patients. These results suggest that the new restrictive opioid laws and resultant decreased narcotic usage did not negatively impact postsurgical recovery or clinical outcomes.

Depression was assessed by the PHQ-2, which is a rapid screening tool for depression. The PHQ-2 has been validated extensively. In one study of 6000 patients, the PHQ-2, using a threshold score ≥ 3, was found to have a sensitivity of 83% and specificity of 90% for major depression.9 In another investigation involving 2642 patients, the PHQ-2 had a sensitivity of 61% and specificity of 92%.8 For both groups in this study, there was a significant decrease in the number of patients who screened positive for depression after surgery. This may be related to improvement in pain and disability. Notably, there was a slightly lower percentage of patients with a positive depression screen within the post-opioid law group, but this was also true preoperatively. A more restricted narcotic usage did not appear to adversely impact the prevalence of depression.

Another concern with the new opioid laws was that readmissions could increase after surgical discharge due to inadequate pain control. Notably, this investigation found that the rates of readmissions did not appreciably change. Interestingly, pain as a reason for readmission was significantly more common within the post-opioid law group. This difference, however, was small (0.36%) and may not be of clinical significance. Unfortunately, the MSSIC registry lacks the details required to understand how pain and opioid usage impacted readmissions.

The finding of decreased narcotic usage in this study is consistent with other recent investigations evaluating the impact of new state opioid laws. Reid et al.10 evaluated the impact of Rhode Island’s opioid laws on patients undergoing either lumbar discectomy, laminectomy, or posterior fusion. A total of 241 patients were in the pre-law group and 311 patients were in the post-law group. Significant reductions in number of pills and morphine milligram equivalents (MMEs) provided in the first prescription as well as mean MMEs filled in the 30 days after surgery were found in the post-law group. In a separate study, the same investigators analyzed the impact of Rhode Island’s prescribing laws on 211 patients who underwent anterior cervical decompression and fusion.11 Similar significant reductions in number of pills and MMEs with the first prescription and total mean MMEs within 30 days of surgery in the post-law group were observed. In addition, there were no significant differences in emergency room visits within 30 days of surgery, readmissions, or reoperations between the pre- and post-law groups. Neither of these other investigations, however, evaluated the effect of opioid prescribing limits on PROs and satisfaction, as was done in this study.

Limitations

Analysis was limited to the data set collected by the MSSIC registry. With respect to the study sample, the data used here only included patients who had reported their preoperative opioid use in order to allow us to compare the difference of preoperative opioid use before and that after the new opioid law. The response rate to this question was approximately 60%. The patients who reported their preoperative opioid use might be different from those who did not. Consequently, specific information that would have been pertinent to this investigation, such as quantity and dosage of narcotics, was unavailable. Given the large sample sizes, there were variables that were found to be statistically significant, but the actual difference was marginal. For example, the PROMIS PF score was a mean of 41.65 in the pre-opioid law patients versus a mean of 42.05 in the post-opioid law patients. Although statistically significant, this difference was likely not clinically relevant. Finally, opioid laws in Michigan were implemented in tiers starting on March 27, 2018. The pre-opioid analysis included patients up to July 1, 2018, and therefore a small fraction of the pre-opioid group had at least one of the new opioid laws in effect. However, the July time point was selected because the most restrictive aspects of the opioid laws, including the 7-day prescribing limit, became effective at that time. The present analysis would, if anything, underestimate the true effect of implementation of all opioid laws.

Conclusions

There was a meaningful decrease in preoperative narcotic use after implementation of the new opioid laws. More restricted opioid prescribing and likely usage after surgery, particularly with the 7-day prescribing limit, however, did not negatively affect postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery. In addition, readmission rates did not significantly increase, although pain as a reason for readmission was slightly more frequently observed.

Disclosures

Dr. Oppenlander reports being a consultant for Globus Medical, DePuy Spine, and LifeNet Health. Dr. Park reports being a consultant for Globus and NuVasive; receiving royalties from Globus; and receiving grants paid to his institution from DePuy and the International Spine Study Group. Dr. Chang reports being a consultant to Globus Medical and receiving clinical or research support for the study from Blue Cross Blue Shield of Michigan. Dr. Schwalb reports receiving support of non–study-related clinical or research effort from Medtronic, Neuros, and StimWave; being a consultant for NeuroPoint Alliance and Jackson & Campbell, PC; and receiving salary support from Blue Cross Blue Shield of Michigan for his role as co-director of MSSIC. Dr. Abdulhak reports being a consultant for SeaSpine and Ulrich Medical USA. Dr. Perez-Cruet reports direct stock ownership in Thompson MIS. Dr. Aleem reports being an executive member of the MSSIC Committee.

Author Contributions

Conception and design: Park, Chang, Schwalb. Acquisition of data: Park, Chang, Schwalb, Schultz, Abdulhak, Easton, Perez-Cruet, Kashlan, Oppenlander, Szerlip, Swong, Aleem. Analysis and interpretation of data: all authors. Drafting the article: Park, Yeh. Critically revising the article: Park, Yeh, Schwalb, Nerenz, Schultz, Abdulhak, Easton, Perez-Cruet, Kashlan, Oppenlander, Szerlip, Swong, Aleem. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Park. Statistical analysis: Yeh. Study supervision: Park.

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    Reid DBC, Patel SA, Shah KN, et al. Opioid-limiting legislation associated with decreased 30-day opioid utilization following anterior cervical decompression and fusion. Spine J. 2020;20(1):6977.

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Images showing severe global coronal malalignment preoperatively and after correction using posterior instrumentation and a kickstand rod on the side of coronal malalignment. See the article by Buell et al. (pp 399–412).

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    Schwalb JM. New 7-day opioid law will burden Michigan’s patients, doctors. Detroit Free Press. June 8, 2018. Accessed August 19, 2020. https://www.freep.com/story/opinion/contributors/2018/06/08/new-7-day-opioid-law-burden-michigans-patients-doctors/637330002/

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    PROMIS score cut points. HealthMeasures.net. Accessed August 19, 2020. http://www.healthmeasures.net/score-and-interpret/interpret-scores/promis/promis-score-cut-points

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    Mummaneni PV, Bydon M, Alvi MA, et al. Predictive model for long-term patient satisfaction after surgery for grade I degenerative lumbar spondylolisthesis: insights from the Quality Outcomes Database. Neurosurg Focus. 2019;46(5):E12.

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    Arroll B, Goodyear-Smith F, Crengle S, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348353.

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  • 11

    Reid DBC, Patel SA, Shah KN, et al. Opioid-limiting legislation associated with decreased 30-day opioid utilization following anterior cervical decompression and fusion. Spine J. 2020;20(1):6977.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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