Opioid Prescribing Laws Having an Impact

Megan Brooks

August 11, 2021

State laws capping initial opioid prescriptions to 7 days or less have led to a reduction in opioid prescribing, a new analysis of Medicare data shows.

While overall opioid prescribing has decreased, the reduction in states with legislation restricting opioid prescribing was "significantly greater than in states without such legislation," study investigator Michael Brenner, MD, University of Michigan Medical School, Ann Arbor, told Medscape Medical News.

The study was published online August 9 in JAMA Internal Medicine.

Significant but Limited Effect

Because of rising concern around the opioid crisis, 23 states representing 43% of the US population passed laws from 2016 through 2018 limiting initial opioid prescription to 7 days or less.

Using Medicare data from 2013 through 2018, Brenner and colleagues conducted a before-and-after study to assess the effect of these laws.

They found that on average, the number of days an opioid was prescribed for each Medicare beneficiary decreased by 11.6 days (from 44.2 days in 2013 to 32.7 days in 2018) in states that imposed duration limits, compared with 10.1 days in states without these laws (from 43.4 days in 2013 to 33.3 days in 2018).

Prior to the start of duration limits in 2016, days an opioid was prescribed were comparable among states.

After adjusting for state-level differences in race, urbanization, median income, tobacco and alcohol use, serious mental illness and other factors, state laws limiting opioid prescriptions to 7 days or less were associated with a reduction in prescribing of 1.7 days per enrollee, "suggesting a significant but limited outcome" for these laws, the researchers note.

The largest decrease in opioid prescribing occurred in primary care, but this was not significantly different in states with limit laws vs those without.  However, state laws limiting duration led to a significant reduction in days of opioid prescribed among surgeons, dentists, pain specialists, and other specialists.

Inadequate Pain Control?

The researchers note the study was limited to Medicare beneficiaries; however, excess opioid prescribing is prevalent across all patient populations.

In addition, it's not possible to tell from the data whether acute pain was adequately controlled with fewer pills.

"The question of adequacy of pain control is a crucial one that has been investigated extensively in prior work but was not possible to evaluate in this particular study," said Brenner.

However, "ample evidence supports a role for reducing opioid prescribing and that such reduction can be achieved while ensuring that pain is adequately controlled with fewer pills," he noted.

"A persistent misconception is that opioids are uniquely powerful and effective for controlling pain. Patients may perceive that effective analgesia is being withheld when opioids are not included in a regimen," Brenner added.

"Yet, the evidence from meta-analyses derived from large numbers of randomized clinical trials finds that [nonsteroidal anti-inflammatory drugs] NSAIDS combined with acetaminophen provide similar or improved acute pain when compared to commonly prescribed opioid regimens, based on number-needed-to-treat analyses," he added.

In a related editorial, Deborah Grady, MD, MPH, with University of California, San Francisco, and Mitchell H. Katz, MD, president and CEO of NYC Health + Hospitals, New York City, say the decrease in opioid prescribing with duration limits was "small but probably meaningful." 

Restricting initial prescriptions to 7 or fewer days is "reasonable because patients with new onset of pain should be re-evaluated in a week if the pain continues," they write. 

However, Grady and Katz "worry" that restricting initial prescriptions to shorter periods, such as 3 or 5 days, as has occurred in six states, "may result in patients with acute pain going untreated or having to go to extraordinary effort to obtain adequate pain relief."

In their view, the data from this study suggest that limiting initial prescriptions to 7 or fewer days is "helpful, but we would not restrict any further given that we do not know how it affected patients with acute pain."

The study had no specific funding. Brenner, Grady, and Katz have disclosed no relevant financial relationships.

JAMA Intern Med. Published online August 9, 2021. Research Letter, Editor's Note

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