Evaluating opioid analgesic prescribing limits: A narrative review

Abstract

Purpose: In response to the opioid crisis, opioid analgesic guidelines and prescribing limits have proliferated. The purpose of this narrative review is to examine evidence from studies evaluating the patient or public health impact of federal and state opioid analgesic prescribing guidelines and laws, describe gaps and challenges in current research, and highlight opportunities for improving future research.

Methods: We focused on evidence from a literature review covering 2013 through 2019. We identified 30 studies evaluating opioid analgesic thresholds based on federal policies and guidelines, state laws, and Medicaid state plans that attempt to influence the course of patient care at or when the limit is exceeded (e.g., prior authorization).

Results: Most studies evaluated changes in prescribing or dispensing patterns of opioid analgesics, largely finding decreases in prescribing after policy enactment. Fewer studies evaluated patient or public health outcomes beyond changes in prescribing and dispensing patterns; results were infrequently stratified by potentially important sociodemographic and clinical factors. No studies assessed the potential for adverse patient outcomes for which we have emerging evidence of harms.

Conclusions: We describe knowledge gaps and propose opportunities for future research to sufficiently assess the potential impact and unintended consequences of opioid analgesic prescribing laws, regulations, guidelines, and policies.

Keywords: opioid analgesic; prescribing limit.

FIGURE 1

Number of newly enacted federal, state, and medicaid opioid analgesic prescribing limits with a days' supply, dose (MME), or quantity restriction, by Year.^a Source: See Table S1.^a The newly enacted prescribing limits displayed in Figure 1 are restricted to opioid analgesic prescribing limits with a days' supply, dose, or quantity restriction, often with requirements for some action (e.g., prior authorization, point of sale edits) at the limits. These limits are not cumulative, and some may be updates to opioid analgesic prescribing limits enacted in previous years. This figure is intended to provide context to illustrate the large number of policies enacted during the last 4 years; it is not representative of the increase in cumulative opioid analgesic prescribing limits over time. Limits on benzodiazepine and opioid analgesic co-prescribing were included if the limit was based on a days' supply, dose, or quantity restriction for the opioid analgesic. We did not include general requirements for PDMP checks or naloxone co-prescribing laws (requirements prior to prescribing any opioid analgesic), or universal prior authorizations (e.g., prior authorization required prior to prescribing any long-acting opioid analgesic). Prescribing limits for medications for opioid use disorder (e.g., buprenorphine/naloxone, methadone) were not included. We included PDMP checks triggered by a specific OA prescribing limit. Best practices documents or guidelines from state workgroups or professional associations were not included. Federal agencies, states, and state Medicaid programs that enacted more than one opioid analgesic prescribing limit with a days' supply, dose, or quantity component in 1 year were only counted once for that specific year

FIGURE 2

Percent of studies evaluating the impact of federal or state-level opioid analgesic prescribing limits on opioid prescribing and dispensing characteristics and select outcomes, 2013–2019. Total studies included: N = 30; studies may include additional outcomes not captured in this figure (e.g., metrics on tapering, all-cause mortality, provider use of an electronic list for preferred prescriptions). Number of studies and examples of outcomes included in each category: (1) Stigmatization (n = 0): patient-reported feeling of stigmatization by healthcare provider or other; (2) provider burden (n = 0): provider-reported satisfaction, burden, or time requirements; (3) access to care (n = 0): challenges with accessing medical care to address acute or chronic pain (e.g., inability to find a provider or to make or attend appointments, financial restrictions preventing payment for medical visits or multiple prescriptions); (4) mental health status (n = 0): patient-reported changes in mental health (e.g., depression, anxiety, suicidal ideation); (5) use of illicit substances (n = 0): patient-reported use of illicit opioids (e.g., illicit fentanyl, heroin) or other substances to manage pain; (6) patient pain scores or quality of life (n = 2): patient self-reported pain score or quality of life on Likert Scale; (7) opioid overdose hospitalizations (n = 3): emergency department visits and hospitalizations due to overdose involving opioids; (8) number of unique prescribers or pharmacies (n = 3): number of unique prescribers or use of multiple pharmacies; (9) high-risk co-prescribing (n = 5): measures of opioid analgesic and benzodiazepine overlapping prescriptions; (10) new initiation of prolonged opioid use (n = 6): postoperative opioid use among new initiates; (11) non-opioid or adjunct pain medications (n = 6): prescribing and use of NSAIDs or other adjunct pain medications; (12) refills or unscheduled healthcare contact (n = 6): measures of additional opioid analgesic prescriptions, follow-up visits or phone calls, emergency department visits (some studies specified for pain); (13) opioid prescribing and dispensing characteristics (n = 29): changes in dose, quantity of tablets, number of patients with an opioid prescription, number or percent over a specific dose, number of opioid prescribers, changes in prescribing extended-release/long-acting opioids, prescription opioid distribution, and other related outcomes