Laws limiting prescribing and dispensing of opioids in the United States, 1989–2019

Abstract

Background and AimsOpioid overdose is a public health emergency in the United States. In an attempt to reduce potentially inappropriate opioid prescribing, many US states have adopted legal restrictions on the ability of medical professionals to prescribe or dispense opioids for pain. This review describes the major elements of relevant US state laws and the ways in which they have changed over time. Methods Systematic legal review in which two trained legal researchers collected and reviewed all US state laws that limit the amount or duration of opioids that medical professionals may prescribe or dispense for pain. These laws were then coded on a set of pre-selected measures, including when the law was enacted, dosage and duration limits imposed, circumstances in which the restrictions do not apply and whether additional requirements or restrictions apply to prescriptions issued to minors. Results The number of US states with opioid limitation laws increased from 10 in 2016 to 39 by the end of 2019. The provisions of these laws vary between states and have shifted within states over time. At the end of 2019 the modal duration limit was 7 days, with a range of 3 to 31. Fourteen states imposed limits on the dosage of opioids that can be prescribed, ranging from 30 morphine milligram equivalents (MME) to a 120 MME daily maximum. In 16 states, different limits apply to prescriptions issued to minors. ConclusionsThe number of US states with opioid limitation laws nearly quadrupled between 2016 and 2019, with a great amount of heterogeneity between state restrictions and changes over time.

Changes in Schedule II oral opioid volume dispensed in a private health plan following Florida’s Acute Pain Opioid Restriction Law

“…In response to the opioid epidemic in the United States, 39 states have enacted policies limiting the days supply or morphine milligram equivalents (MMEs) of opioid prescriptions by the end of 2019. [1][2][3] Policy evaluations of the different restrictions from these state laws have resulted in mixed findings thus far, with evidence suggesting that meaningful decreases in prescription opioid supply is only observable when the strictest restrictions are implemented. 4,5 The state of Florida enacted House Bill 21 (HB21), which went into effect on July 1, 2018, restricting prescriptions for Schedule II opioids to 3 days for patients with acute pain.…”

Prescription Opioids Dispensed to Patients with Cancer with Bone Metastasis: 2011–2017

“…The declines observed among privately insured patients aged 18–64 accelerated in the second half of 2016, shortly after the publication of the CDC Guideline. The accelerated declines may also be partially attributable to recent policies addressing opioid prescribing, for example, state legislative limits on the duration or dosage of the initial opioid prescription to a patient or opioids for acute pain, which took effect in 26 states between March 2016 and December 2017 [9]. These laws largely exempt patients with active cancer or cancer treatment.…”

Toward Safer Opioid Prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial

“…The U.S. Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain [ 3 ] (CDC guideline) was published in the Journal of the American Medical Association (JAMA) in 2016 and despite some initial controversy [ 4 ], was generally praised as a major acheivement, and a needed correction to overly liberal opioid prescribing practices [ 5 , 6 ]. In the ensuing years, access to prescription opioids was reduced due to changes in the behavior of individual prescribers and pharmacies [ 7 – 9 ], as well as larger scale policies instituted by third-party payers and regulatory authorities [ 10 , 11 ]. Although these changes were often based on the content of the CDC Guideline, there were important inconsistencies.…”

“…Although these changes were often based on the content of the CDC Guideline, there were important inconsistencies. For example, a recommendation to carefully assess risk and benefit before increasing opioid doses above 50 mg morphine equivalents (MME) and avoiding increasing above 90 MME, was implemented by some states as strict dosing limits, with some as low as 30 MME [ 10 ]. Extensive anecdotal and some quantitative data have since suggested that these changes have had a negative impact on people living with chronic pain (CP), particularly those on long term opioid therapy (LTOT) [ 12 – 14 ].…”