Staggering numbers of American are diagnosed with opioid addiction, and tens of thousands succumb to fatal opioid overdose each year. I have previously noted state efforts to increase layperson access to naloxone and pass Good Samaritan laws to facilitate emergency assistance for people suffering from drug overdose. As opioid dependence and overdose continues to rise, states are increasingly recognizing the role of providers in both driving and curtailing the epidemic.
Medical providers are the initial source of prescription opioids for most Americans, but often report that their education did not prepare them to adequately treat pain and addiction. In 2010, almost 20 percent of physician office visits for non-cancer pain and approximately 31 percent of all emergency department visits resulted in an opioid prescription. Unfortunately, these opioid prescriptions are frequently written for chronic pain conditions, amounts, or lengths of time that are not supported by evidence, increasing patient risk for opioid dependence and overdose without a corresponding increase in pain relief.
In an attempt to limit such prescribing, and in accordance with the CDC’s recent guidance to “start low and go slow,” states are acting through legislation, regulation and provider guidance to limit initial opioid prescriptions or require physician monitoring for chronic opioid use. At least four states (Maine, Massachusetts, New York and Rhode Island) now have laws imposing direct limits on the amount or duration of first-time adult opioid prescriptions for acute pain, and legislation is pending in at least two more (Connecticut and New Jersey). Tennessee and Delaware also limit opioid prescriptions more broadly. The Maine law limits both the amount and duration of most opioid prescriptions to seven days for acute pain, 30 days for chronic pain, and 100 morphine milligram equivalents (MME) per day.
Other states have also limited opioid prescriptions by regulation or have imposed specific oversight requirements on physicians who prescribe opioids. For example, in Indiana, physicians are required to utilize evaluations, risk stratifications, face-to-face visits, a treatment agreement, and drug monitoring testing for patients who are prescribed certain medications in specified doses for more than three consecutive months. Both the Maine law and the Indiana regulations do not apply to terminally ill patients, hospice programs, inpatient facilities, or inpatient or outpatient palliative care programs.
Finally, several states have issued voluntary guidelines for the use of controlled substances for pain. For example, the Nebraska Board of Medicine and Surgery issued guidelines for physicians for patients using controlled substances for chronic pain. The guidelines require documentation of medical history and physical examination and recommend a written treatment plan, working with the patient to obtain informed consent and a treatment agreement, and using periodic review and outside consultation as needed.
Given the state efforts to limit opioid prescriptions, there is no data available to evaluate these recent legislative and regulatory efforts. Public health professionals should review addiction and overdose data from states that limit opioid prescriptions to determine whether these laws and regulations reduce overdose risk and whether they negatively impact pain management.
This post was developed by Sandhya Gopal, Legal Fellow, and reviewed by Corey Davis, Deputy Director, at the Network for Public Health Law – Southeastern Region at the National Health Law Program.
The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this post does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.
Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not necessarily represent the views of, and should not be attributed to, RWJF.