Marilyn Bulloch, PharmD, BCPS, FCCM
Marilyn Novell Bulloch, PharmD BCPS, is an Associate Clinical Professor of Pharmacy Practice at the Auburn University School of Pharmacy and an Adjunct Associate Professor at the University of Alabama-Birmingham School of Medicine and the University of Alabama College of Community Health Sciences . She completed a post-graduate pharmacy practice residency at the University of Alabama-Birmingham Hospital and a post-graduate specialty residency in critical care pharmacy at Charleston Area Medical Center in Charleston, West Virginia. Dr. Bulloch also completed a Faculty Scholars Program in geriatrics through the University of Alabama-Birmingham Geriatric Education Center in 2011. She serves on multiple committees and in leadership positions for many local, state, and national pharmacy and interdisciplinary medical organizations.
Opioid overdose is a continuing public health crisis, and states have taken steps attempting to reduce overuse of these medications. These attempts include imposing strict limitations on the amount or duration that opioids may be prescribed to patients with acute pain, as well as who may prescribe them.
Mid-level practitioners (MLPs) are able to prescribe controlled substances, but their ability to prescribe opioids varies from state to state. Of all the MLPs, nurse practitioners, physician assistants, and optometrists have the highest authority among states to prescribe opioids.1
In 2016, Massachusetts became the first state in the nation to pass a law limiting first time opioid prescriptions to 7 days.2 Since then, over half of all states have enacted laws that restrict the prescribing or dispensing of opioids for acute pain. To date, there is no data on whether and to what extent these laws mediate opioid-related morbidity and mortality, nor regarding whether they are associated with negative unintended outcomes. Further research into these questions is needed, but states are moving forward with restrictions.
Fifteen states have passed laws limiting opioid prescribing for acute pain in an opioid naive patient to a 7-day supply. These states include Alaska, Hawaii, Colorado, Utah, Oklahoma, Louisiana, Missouri, Indiana, West Virginia, South Carolina, Pennsylvania, New York, Maine, Connecticut, Massachusetts. In addition, Arizona, North Carolina, and New Jersey limit initial prescribing to 5 days.2
Following surgical procedures, Arizona allows for a 14 day supply and North Carolina a 7-day supply. Nevada is the only state with an initial 14-day prescription limit.2 The strictest limits are in Tennessee, Kentucky, and Florida where initial prescribing is limited to 3 to 4 days.2 Minnesota also has a 4-day limit, but only for acute dental or ophthalmic pain.2
When addressing risks for drug overdose, studies support the need to monitor not only duration of initial therapy, but also total daily dosing for patients. This is particularly important for those patients who are receiving 50 to 99 daily morphine milligram equivalents (MME) or more per day.3 Nevada and Arizona have limited prescribing doses of opioids to 90 MMEs per day.3 Maine’s limit is 100 MME per day and Rhode Island limits prescriptions to 50 MME per day.3 Tennessee allows 60 MME per day if it is for 3 days or less, otherwise the prescriptions are restricted to 50 MME daily.3
While the majority of states focus on general opioid prescribing limits, Alaska, Connecticut, Indiana, Louisiana, Massachusetts, Nebraska, Pennsylvania and West Virginia also set requirements regarding opioid prescribing to minors, such as discussing their risk with the minor and parent or guardian.3
Rather than setting opioid limits in statute, a few state laws direct or authorize other entities to do so (e.g. New Hampshire, Ohio, Oregon, Vermont, Virginia, Washington and Wisconsin). These entities may include the Department of Health, a designated state health official, or regulatory boards, such as the Board of Medicine, Nursing and/or Dentistry. Other states, such as Rhode Island and Utah, have prescribing limits in statute, and allow other entities to adopt prescribing policies.
In addition, state laws may provide guidance or direction related to opioid prescribing. Maryland requires providers to prescribe the lowest effective dose of an opioid for a quantity that is not greater than that needed for the expected duration of pain.2 Utah, in addition to its 7-day prescribing limit, authorizes commercial insurers, the state Medicaid program, workers’ compensation insurers and public employee insurers to implement policies for prescribing certain controlled substances.2 The policies must include evidence-based guidelines for prescribing opioids. Separately, some managed care companies and corporate pharmacies have implemented policies restricting initial opioid supplies, regardless of what is prescribed.4-6
State legislators, health care providers, patients and families continue to confront the opioid epidemic. It remains a challenge to treat pain and ensure access to effective treatments, while also preventing misuse, addiction and death. In the past few years, state leaders in at least 33 states have adopted guidelines, limits or other requirements for prescribing opioids.7 Most of these laws were passed in 2017, suggesting that more states will adopt such restrictions in the near future.
To date, there is no data on whether and to what extent these laws mediate opioid-related morbidity and mortality, as well as whether they are associated with negative unintended outcomes. In the absence of more evidence, it is premature to rely on prescription limitation laws to make the type of impact on the opioid epidemic that is desperately needed to save lives.7
This article was co-authored by Rebecca Whitmore and David Whisenant, both 2019 PharmD Candidates at Harrison School of Pharmacy, Auburn University.
- Drug Enforcement Agency/Diversion Control Division. Mid-Level Practitioners Authorized by State. USDOJ/DEA Diversion Control Division website. https://www.deadiversion.usdoj.gov/drugreg/practioners/mlp_by_state.pdf. Published September 11, 2018. Accessed January 10, 2019.
- National Conference of State Legislators. Prescribing Policies: States Confront Opioid Overdose Epidemic. NCSL website. http://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx. Published October 31, 2018. Accessed January 10, 2019.
- Liang Y, Turner BJ. Assessing risk for drug overdose in a national cohort: role for both daily and total opioid dose?. J Pain. 2014;16(4):318-25.
- Blue Cross Blue Shield of Alabama. Blue Cross and Blue Shield of Alabama Launching New Opioid Management Strategy to Help Battle Opioid Epidemic in Alabama BCBS website. https://www.bcbsal.org/web/about/press.html Published March 20, 2018. Accessed January 31, 2019.
- Medical Association of the State of Alabama. CVS Pharmacy, others to limit prescriptions for opioids. MASA website. http://smartandsafeal.org/cvs-pharmacy-others-to-limit-prescriptions-for-opioids/ Published November 9, 2017. Accessed January 31, 2019.
- Greene J. Blue Cross to limit opioid scripts to 30-day supply. Crain's Detroit Business. https://www.crainsdetroit.com/article/20171208/news/647161/blue-cross-to-limit-opioid-scripts-to-30-day-supply Published December 8, 2017. Accessed January 31, 2018
- Davis C, Lieberman A, Hernando-Delgado H, Suba C. Laws limiting the prescribing or dispensing of opioids for acute pain in the United States: A national systematic legal review. Elsevier. 2018 Nov 3. https://doi.org/10.1016/j.drugalcdep.2018.09.022