When are opioid prescription limits effective in reducing prescription length?

Many states have passed new laws that place restrictions on the duration of first-time opioid prescriptions to help address the opioid epidemic.

While most laws are one-size-fits-all, policies more tailored to the patient, such as their age or clinical setting (outpatient clinic, emergency room, etc.), were more effective at reducing the length of opioid prescriptions, reports a new Northwestern Medicine study.

It is the first study to examine the effectiveness of setting-specific opioid prescribing durations.

The study analyzed 2017 to 2019 data from West Virginia, a state at the epicenter of the opioid crisis that in 2018 instituted a unique, setting-specific approach to prescription-duration limits. These included a seven-day limit for adult patients in outpatient hospital departments and offices; a four-day limit for adult patients in emergency departments and a three-day limit for pediatric patients in any clinical service location.

This is in contrast to other states, which imposed the same prescription-duration limit for all patients (e.g. Kentucky, three days or Pennsylvania, seven days), regardless of their clinical setting or age.

The study found tailored duration limits helped reduce the length of opioid prescriptions. There was a 56.8% reduction in prescription length amid patients in hospital and outpatient settings (seven-day limit); a 37.5% reduction in prescription length amid patients in emergency department settings (four-day limit); and a 26.5% reduction in prescription length amid pediatric patients (three-day limit).

“We have clear results that an opioid duration-limiting policy can work to reduce the length of prescriptions, but not as most states have designed them,” said corresponding author Lindsay Allen, assistant professor of emergency medicine at Northwestern University Feinberg School of Medicine.

The study will be published Jan. 19 in JAMA Health Forum. 

A reduction in high-dose and follow-up prescriptions

The study also found reduced prescription lengths did not result in physicians writing stronger or more follow-up prescriptions for adults as a way of compensating for shorter prescription durations, which was a potential concern, Allen said. Instead, the policy was associated with reductions in high-dose and follow-up prescriptions in the outpatient setting.

“This could be because the law heightened concerns about lengthy opioid use, which in turn drove down doctors’ willingness to write follow-up prescriptions,” Allen said. “Also, prior to the 2018 policy, longer initial prescriptions may have built up tolerance in patients, which did not happen with shorter initial prescriptions.”

Origin of prescription-duration limits

To help fight America’s opioid epidemic, the U.S. Centers for Disease Control and Prevention (CDC) in 2016 issued recommended guidelines to help primary care clinicians weigh benefits and risks of opioid treatment for chronic pain. That guidance led to states setting their own prescribing limits, which were often one-size-fits-all (not tailored to patients’ unique circumstances), and a misapplication of the CDC guidelines.

“This is what happens when we have legislators making laws without consulting medical or policy experts,” Allen said. “The laws were not based on any evidence about what the ‘right’ opioid duration limit is. That’s why we had some states making a three-day limit while others made a 14-day limit. It was a mess.”

Because of these inconsistencies, there have been mixed findings on the effectiveness of these policies, Allen said. In 2022, the CDC updated its guidelines.

A focus on pediatric and Medicaid-enrollee prescriptions

Pediatric patients have not been independently studied in prior work on prescribing limits. This is an important knowledge gap, given recently documented increases in opioid-associated deaths in the pediatric population, Allen said.

The study also focused on Medicaid enrollees, who have been disproportionately affected by the opioid epidemic. Medicaid patients are prescribed more opioids than non-enrollees, largely reflecting that those who qualify for the program (whether through disability or not) are more likely to have chronic conditions and comorbidities that require pain relief.

Participants in the study were between 12 and 64 years old, did not actively have cancer and were not covered by Medicare. The sample included 44,703 individuals before the 2018 policy was imposed and 16,746 after the 2018 policy went into effect.

Allen said the next steps in the research are to look at potential risks of such limits.

“We know that reduced prescription length is associated with reduced risk for opioid dependence, which, in theory, is good, but we need to do more research to determine if these limits actually reduce downstream opioid use disorder or if they could result in unintended consequences, like seeking out pain relief from illicit opioids,” Allen said.