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Opioid limits are gaining popularity, but do they actually work?
Many state legislatures are enacting or evaluating limits for opioid prescriptions-usually mandating a maximum number of days for a first prescription-as a step in slowing the opioid crisis. These laws specifically exclude prescriptions for patients with chronic pain, but there are some who worry that the new rules will have unintended consequences and whether they will help in the long run.
Arizona, Connecticut, Delaware, Maine, Massachusetts, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont have various limits on the number of opioids for an acute pain situation. Many states have set a 7-day limit for the initial opioid prescriptions, but Kentucky has lowered the bar to 3 days. While most specify prescription lengths in days, some limit the number of morphine equivalent doses being prescribed for an acute pain condition.
On the federal level, Senators John McCain (R-AZ) and Kirsten Gillibrand (D-NY) have introduced legislation to limit an initial prescription of opioids for acute pain to 7 days.
In addition to the benefit of limiting the number of pills available in the community, recent research is showing that longer initial prescriptions make long-term opioid use more likely. Bradley Martin, PharmD, and his colleagues at the University of Arkansas for Medical Science in Little Rock found that the risks of long-term opioid use went up with the length of the initial prescription, with increased risk starting in as little as 3 days.
The idea of shorter initial prescriptions is sound, said Martin, a professor at the UAMS College of Pharmacy. “You are going to have fewer persons becoming long-term users,” he said.
But some patients who suffer chronic pain or who have longer-lasting acute pain may have difficulties getting the pain relief they need, he noted. “Some patients are undoubtedly going to have to endure some levels of pain or will probably be less than adequately treated as a result of these policies,” Martin said.
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“These limits are arbitrary-while they are defensible and I am not saying they are bad-they are certainly not an overall management plan,” said Norman P. Tomaka, CRPh, FAPhA, a consultant pharmacist in Melbourne, FL, who works with a health system and in private practice. “Any management, if it is going to be effective, needs to be proactive, not reactive, and needs to have multiple facets, including education and guidelines.”
Efforts need to be made to curb the opioid crisis, but whether quantity or time limits for opioids will help remains to be seen, Tomaka stressed. “Sometimes when we see a problem and it is so large and overbearing, and frankly overwhelming, we reach for what seems to be effective, large initiatives.” However, any regulations or initiatives need to put the patient front and center, he said.
“We have yet to see if the net impact is positive or negative with these quantity limits,” said Antonio Ciaccia, Director of Government Affairs for the Ohio Pharmacists Association, which supported the push for a 7-day state limit.
One issue with these laws is how to deal with patients who need to transition from acute treatment to long-term pain management. “We have to see what that transition looks like from acute to chronic,” Ciaccia said. “There is no doubt that there is an overprescribing problem, but when you try to develop these one-size-fits-all approaches, inevitably you have people impacted negatively.”
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Some of the new laws allow a refill prescription, after the initial supply, but may put up a red flag with that second prescription, Martin said. “There are going to be restrictions, but usually there are going to be avenues in place that will allow you to get around it. The burden is on the prescribers for this.”
Another question is where the cut-off point should be for an initial opioid prescription. A 3-day prescription limit may just be too short, said Ciaccia. “I understand the desire to want to try everything and it’s definitely understandable in light of opioid crisis, but inevitably we hit a point where folks with legitimate needs are way overburdened.”
“Our data shows that the risk of long-term opioid use goes up after the third day of a prescription, but it doesn’t go up a lot until after the fifth day,” Martin said. Three-day prescriptions might work for the majority of acute pain patients, he noted, but allowing quantities in the 5-to-7 day range “is probably a more reasonable approach.”