How do Providers Respond to Restrictions on Opioid Prescribing? Lessons from the Drug Enforcement Agency (DEA)’s 2014 Rescheduling of Hydrocodone

Prescription opioid-involved overdose deaths continued to rise in the United States despite large-scale supply side interventions such as the reformulation of OxyContin to an abuse-deterrent format in 2010, and implementation of state-level prescription drug monitoring programs. Even though there is growing evidence of substitution towards more dangerous substances such as heroin and fentanyl following these supply side disruptions, the most commonly abused opioid analgesic in the US is hydrocodone. Hydrocodone was initially placed in Schedule III of the categorization established by the Controlled Substance Act, but rescheduled to the more controlled Schedule II in 2014. Compared to drugs in Schedule III, Schedule II drugs are recognized to be highly addictive in nature and prescribers must exercise greater caution in prescribing these drugs. Also, unlike Schedule III drugs, refills of schedule II drugs are prohibited and therefore any long-term use of schedule II opioids entails frequent patient-prescriber contact and increased monitoring.

Using Medicare Part D claims data from 2012-2017 this study provides the first analysis of how providers respond to these new restrictions placed on hydrocodone. One possibility is that physicians interpret rescheduling as indicative of previously unknown risks of the drug and reduce prescribing across the board, selecting non-opioid pain medications as a replacement. Another possibility is that physicians continue prescribing, assuming that the rescheduling continues no new information to physicians.

Our analysis reveals evidence of a significant decline in hydrocodone prescribing following its rescheduling. Exploiting prescriber level variation in exposure to the hydrocodone rescheduling (using longitudinal data on how often a prescriber prescribed hydrocodone in the past), results show that prescribing declines were steepest for practitioners with the highest hydrocodone prescribing at baseline. Moreover, hydrocodone prescribing declined for all specialties except pain specialists. This effect is driven by continued increases in hydrocodone prescribing by pain physicians in states without pain-clinic regulations. Finally, at the prescriber level, largest declines in hydrocodone prescribing were accompanied with significant increases in prescribing of the less controlled opioid analgesic tramadol, suggesting a substitution effect.