State and Federal Legislation Surrounding Initial Opioid Prescriptions

March 08, 2018|3:38 p.m.| ASTHO Staff

Late last month, a bill to address issues around the current opioid epidemic was introduced in Congress. The CARA 2.0 Act of 2018 includes provisions for neonatal abstinence syndrome, first responder training, expanding access to medication assisted treatment, and more. Another of the provisions would establish a three-day limit for the initial prescription of opioids for acute pain based on the CDC’s recommended guidelines for treatment of acute pain. Exceptions to the limit include: prescriptions for chronic pain, cancer treatment, end of life and hospice care, as well as substance use treatment medications. By the time the federal legislation was introduced, almost half of states had enacted laws or adopted rules dictating the length (or dosage) of initial opioid prescriptions for acute pain. Several other states are considering such provisions during their current legislative sessions, as described in the chart below.

Length of Initial Opioid Prescriptions by State Infographic

The vast majority of state policies allow for a seven day initial opioid prescription for acute pain. While most states exclude conditions found in the federal proposal (e.g., chronic pain, cancer treatment, etc.), many allow additional exclusions to initial prescription limits. For example, Rhode Island, New Jersey, and Vermont exclude prescriptions beyond the initial limits for residents of long-term care facilities. In addition, they allow health departments to add additional conditions for exclusion. It should also be noted that unlike the federal proposal, some states do not have an exclusion for medication used to treat substance use disorders (e.g., buprenorphine, methadone, and naltrexone). This is a potential oversight that could impact those in need of medication assisted treatment.

Several states also allow exceptions to the initial limit even when the prescription is for acute pain. For example, many allow longer initial prescriptions based on the prescriber’s professional judgement paired with patient education about the risks of opioids. Additionally, North Carolina allows a 14 day initial prescriptions for acute pain following a surgical procedure, and Maryland requires that a prescription be based on the lowest effective dose rather than length of time.

As the federal government increases efforts to address the opioid epidemic, it is important that it not impair state efforts that are already underway. It was only a couple of years ago that the initial prescription policies began to be implemented. The overall impact and efficacy of the policies are yet to be seen. State public health should be aware of the potential impact of federal efforts, especially when they risk overriding state authority. ASTHO will continue to monitor federal legislation and inform members on how it impacts states.