California legislation implemented in October 2018 mandated clinicians consult with a prescription drug monitoring program (PDMP) prior to prescribing controlled substances, and recent study findings showed the legislation was associated with immediate reductions in opioid prescribing rates across general, obstetric/gynecologic, and orthopedic surgical specialties. Findings from the study were published online in JAMA Health Forum.

The study was a cross-sectional analysis of opioid prescribing patterns within a single large healthcare system in northern California between January 2016 and February 2020. The cohort included 93,760 adults (mean age, 46.7 years; 67.9% female) who received a prescription for an opioid medication following general surgery (45,597), obstetric/gynecologic surgery (n=28,207), or orthopedic surgery (n=19,956).

Researchers examined the total quantity of opioid medications prescribed at discharge both prior to and following implementation of California’s PDMP mandate. Additionally, the researchers invested the proportion of prescriptions with a duration of >5 days.

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A total of 65,911 patients received prescriptions before implementation of the PDMP mandate, while 27,849 received prescriptions after implementation.

The investigators observed a decreasing pattern in the quantities of opioids prescribed prior to the implementation of the PDMP mandate. Total morphine milligram equivalents (MMEs) prescribed at discharge during the quarter of the PDMP mandate implementation period decreased for general surgery (β=−10.00; 95% CI, −19.52 to −0.48) obstetric/gynecologic surgery (β=−18.65; 95% CI, −22.00 to −15.30; P <.001), and orthopedic surgery (β=−30.59; 95% CI, −40.19 to −21.00).

Additionally, the total number of prescribed opioid tablets after implementation of the mandate decreased for general surgery (β=−3.02; 95% CI, −3.47 to −2.57; P <.001), obstetric/gynecologic surgery (β=−4.86; 95% CI, −5.38 to −4.34), and orthopedic surgery (β=−4.06; 95% CI, −5.07 to −3.04). The researchers noted that these reductions in opioid tablet prescriptions were not consistently observed across the most common surgeries.

While the median number of tablets prescribed for cesarean delivery decreased during the quarter of implementation (β=−10.00; 95% CI, −10.10 to −9.90; P <.001), the median MMEs did not decrease during this time (β=0; 95% CI, −9.97-9.97; P >.99). However, the researchers did find reductions in both median MMEs (β=−33.33; 95% CI, −38.48 to −28.19; P <.001) and number of tablets prescribed (β=−10.00; 95% CI, −11.17 to −8.82; P <.001) for laparoscopic cholecystectomy.

During the quarter of the mandate implementation, the proportion of prescriptions written for >5 days decreased significantly for general surgery (β=−0.53; 95% CI, −0.65 to −0.40; P <.001), obstetric/gynecologic surgery (β=−0.97; 95% CI, −0.13 to −0.07; P <.001), and orthopedic surgery (β=−0.69; 95% CI, −0.10 to −0.4; P <.001).

The investigators noted that other efforts to limit postsurgical opioid prescribing may have also contributed to declining opioid prescribing rates, particularly for knee arthroscopy. For instance, the study found that the median total MMEs were already reduced for knee arthroscopy procedures to a point that was lower than recommended guidelines in the preceding quarters. As such, the investigators suggest efforts other than the PDMP mandate may have led to these specific reductions.

While the enacted policies and electronic health record-based alerts may correspond with reductions in postoperative opioid prescription rates, the researchers suggest “they need to be well designed to optimize evidence-based opioid prescribing.”


Shenoy R, Wagner Z, Kirkegaard A, et al. Assessment of postoperative opioid prescriptions before and after Implementation of a mandatory prescription drug monitoring program. JAMA Health Forum. 2021;2(10):e212924. doi:10.1001/jamahealthforum.2021.2924