Lawmakers, as part of their efforts to curb the opioid crisis in America, are considering possible statutory limits on how many painkillers patients can receive the first time they fill a prescription. Experts who support the idea say this could help reduce the oversupply of drugs that have killed tens of thousands of people in a year.
But some physicians argue this intrudes on the doctor-patient relationship and could disrupt needed care. And such restrictions likely won’t stop some patients from taking a large supply of pills home or change the habits of doctors who needlessly overprescribe the drugs, another expert suggested.
Legislation with some kind of limit, guidance, or requirement related to opioid prescribing has been enacted in 28 states as of April, according to the National Conference of State Legislatures. Retailers are also getting involved in the effort to cut back on how many pills are dispensed to patients for acute pain. Walmart announced last week that it would place a seven-day restriction on initial acute opioid prescriptions.
The Centers for Medicare and Medicaid Services included similar policy for “opioid naïve” Medicare Part D patients in a final regulation released in April. CMS’s move was met with pushback from the major physician-advocacy group, the American Medical Association, which called the limit “arbitrary.”
“We believe this proposal could leave patients without adequate treatment and create a great deal of confusion and anxiety at pharmacies across the country when patients go to fill their prescriptions,” the group wrote to CMS in March.
But lawmakers and other medical experts think this kind of policy could help prevent patients from becoming addicted and reduce the oversupply of the drug.
Sen. Rob Portman has spearheaded a proposal that would place a three-day limit on initial opioid prescriptions for acute pain, which he’s hoping to add to another opioid bill passed out of the Senate health committee last month.
“We also know that the [Centers for Disease Control and Prevention] guidelines are very clear on this: After the third day, the chance of an addiction increases significantly,” Portman said. “We spent a lot of time researching this and looking at it; it’s not just a date we came up with on our own.”
However, the AMA has argued that the CDC guidelines were meant to be recommendations and not prescriptive standards. Portman said he has met with the physicians’ group.
“I hope they’ll work with us on it because they’ve got a problem,” he said. “They have doctors who are still overprescribing and pharmacies that are still overprescribing. You can go back to your doctor and get another prescription. It doesn’t affect chronic pain; it doesn’t affect cancer. It’s for acute pain; it’s for having a surgery or procedure. I would ask them to think long and hard about how we got into this crisis where we have over 60,000 Americans dying every year, and I think it primarily goes back to prescription drugs.”
Although the number of opioid prescriptions has declined, the decrease has not been substantial enough to make an impact on the crisis, said Anna Lembke, associate professor and chief of addiction medicine at Stanford University School of Medicine.
“I’m a minority voice in advocating for external limits because I think that, unfortunately, prescribers have already failed the experiment of seeing whether or not—with augmented education, social-media pressure, lawsuits, you name it—that they’re still not able to rein in their prescribing at the levels needed to make a difference in this epidemic,” she said.
The number of opioids patients receive in their first prescriptions has an effect on the likelihood of them converting to chronic use, said Caleb Alexander, codirector of the Johns Hopkins Center for Drug Safety and Effectiveness. “We’ve been watching the epidemic get worse for 20 years. There are many drivers of this, but one of the important drivers has been the oversupply of opioids for routine conditions that really don’t need to be treated with an indefinite supply,” he said.
The idea makes sense, said Corey Waller, the chair of the legislative advocacy committee for the American Society of Addiction Medicine, but he added that if the government gets into the business of legislating prescriptions, it needs to effectively monitor and track any unintended consequences that stem from the policy.
“This is the first time the federal government has taken in its hands really practicing medicine and legislating it,” Waller said. “Legislating the practice of medicine is dangerous for a couple of reasons. … Information changes. So we have to change what we do many times on a monthly or weekly basis based on new research that comes out, and as we all know, legislation doesn’t change that quickly.
“If they write things that do this, they need to have a review capability or a sunset capability so that we can make sure we have a way out if things have changed or if we’re finding these unintended consequences,” he added.
But Andrew Kolodny, codirector of Brandeis University’s Opioid Policy Research Collaborative, argued that the policy may not have any effect at all. “The average prescription is written, ‘Take one or two tablets every 4 to 6 hours as needed for pain.’ And if the prescription is written that way and you give a seven-day supply, there are more than 80 pills in the prescription, so it doesn’t really have any impact on the number of pills people are walking away with,” he said.
Kolodny said that the attempt by state legislatures to place limits on prescriptions does show they are identifying an important issue: the overprescribing of opioids. He added that requiring patients to sign an informed-consent form could cut down on “casual overprescribing.”
“The risks get put on a document that the patient signs,” he said. “The benefit of going that route is it’s a little more work for the prescriber, and you also wind up with a better informed patient.”