How have opioid prescribing limits for acute pain impacted overprescribing and misuse? IHPI investigators analyze evidence suggesting that limits have had modest effects and discuss potential reasons and policy considerations.
As the opioid epidemic continues to impact millions of lives across the United States, a growing number of state governments, private insurers, and pharmacies have implemented opioid prescribing limits with hopes of curbing overprescribing and misuse.
As of October 2019, 34 U.S. states, at least one major pharmacy chain, and the three largest pharmacy benefit managers in the country — which collectively manage drug benefits for 180 million Americans — had enacted opioid prescribing limits. The limits vary widely among states, differing in duration, the types of prescriptions affected, and permitted exclusions. Early evidence of their effectiveness shows just modest results, according to a new JAMA Surgery Viewpoint article by a University of Michigan research team.
The authors, Kao-Ping Chua, assistant professor of pediatrics, Chad Brummett, associate professor of anesthesiology and co-director of the Michigan Opioid Prescribing Engagement Network, and Lauren Kimmel, research assistant at the Susan B. Meister Child Health Evaluation and Research Center, analyzed literature from several states that have enacted opioid prescribing limits for acute pain. In their review, the researchers conclude that “current evidence does not collectively support the notion that limits have substantially decreased opioid prescribing for acute pain.”
Chua and team outline a series of potential reasons for these disappointing early results, including failure of clinicians to apply limits when appropriate and the ambiguous design of limits. For example, many limits restrict the duration of prescriptions, but few concurrently restrict daily dosage. This means that under a new seven-day supply limit with no daily dosage restrictions, clinicians who normally prescribe 84 pills could continue to do so, as this quantity could represent either a seven- or 14-day supply depending on whether prescriptions are written for one versus two pills every four hours.
What more can be done to address excessive opioid prescribing? Chua and team discuss a variety of policy considerations, such as coupling restrictions on duration with restrictions on daily dose, designing limits that target initial prescriptions over prescriptions for acute pain, and developing limits that are based on patient consumption data and are tailored to specific conditions.
Overall, the researchers emphasize that a strategy relying on limits alone is unlikely to reduce substantially reduce excessive opioid prescribing, at least not without increasing the risk of worsened pain control for some patients.