Disappointing Early Results From Opioid Prescribing Limits for Acute Pain

Abstract

Between 2016 and 2019, the United States experienced a rapid proliferation of limits restricting the duration or number of doses in opioid prescriptions for acute pain. 1 As of October 2019, such limits have been enacted by 34 states; large payers, such as Medicare, several state Medicaid programs, Aetna, and United-Health; pharmacy chains, such as Sam's Club/Walmart; and major pharmacy benefit managers, such as CVS CareMark, ExpressScripts, and OptumRx, which collectively manage drug benefits for 180 million Americans.The goal of these limits is to curb opioid prescribing that exceeds patient need, thereby decreasing the number of unused opioids available for misuse and diversion. However, early evidence suggests that implementing limits has only been associated with at best modest reductions in opioid prescribing. One study found that the implementation of 7-day supply limits in 3 states was only associated with an immediate halfday reduction in the duration of initial opioid prescriptions for opioid-naive patients with acutely painful nonsurgical conditions, no immediate change in opioid dosage per prescription, and a small decrease in the quarterly trend for opioid dosage per prescription. 2 Another study found that the implementation of 11 state lim-VIEWPOINT

Surgeons and perioperative opioid prescribing: An underappreciated contributor to the opioid epidemic

“…Recognizing these issues, several organizations have taken aim at addressing excess opioid prescribing for acute pain. Thirty‐four states have enacted limits, which range from 3 to 7 days, on the duration of initial prescriptions 28‐30 . Similar programs have been implemented by large payers, including Medicare, some Medicaid plans, Aetna, and UnitedHealth as well as major pharmacy providers 8,29 .…”

“…Thirty‐four states have enacted limits, which range from 3 to 7 days, on the duration of initial prescriptions 28‐30 . Similar programs have been implemented by large payers, including Medicare, some Medicaid plans, Aetna, and UnitedHealth as well as major pharmacy providers 8,29 . Prescription drug monitoring programs, state‐run electronic databases that collect real‐time information about the prescribing and dispensing of controlled substances, have been implemented in 49 states (all but Missouri) 31 .…”

“…Prescription drug monitoring programs, state‐run electronic databases that collect real‐time information about the prescribing and dispensing of controlled substances, have been implemented in 49 states (all but Missouri) 31 . Unfortunately, because of the nonspecific nature of these policies, prescribing limits have had little effect, with most evidence pointing to single‐digit percent decreases 28,29 . Similarly, a mandatory review of prescription drug monitoring program records by prescribers does not appear to significantly affect prescriber behavior for acute 32 or chronic opioid prescribing 33 .…”

“…Similarly, a mandatory review of prescription drug monitoring program records by prescribers does not appear to significantly affect prescriber behavior for acute 32 or chronic opioid prescribing 33 . Although there has been an encouraging reduction in opioid prescribing after surgery in recent years, current evidence suggests that this trend is not associated with the current policies enacted 28,29 …”

Addressing (over)prescribing of opioids in surgery

“…While some progress has been made in decreasing surgical opioid prescribing, 6 data also suggests that results so far are on the whole disappointing. 7 We argue that continued efforts are needed targeting all surgical pain management practices, and a maintained focus of quality improvement efforts across the board is essential. Optimizing pain management is complex and demands a complex response.…”