By Pat Anson, PNN Editor

When the CDC’s opioid prescribing guideline was released in 2016, dozens of states began efforts to codify the guideline’s “voluntary” recommendations into laws and regulations. To date, according to The Pew Charitable Trust, 40 states limit the dose or initial supply of opioid medication, and all 50 states have implemented prescription drug monitoring programs (PDMPs) to track opioid prescriptions and the doctors who write them.

On the surface, it may appear the state policies are working, because opioid prescribing in the U.S. has plunged over 40 percent, to levels not seen in 20 years. But a large new study found that state laws regulating opioids have had very little effect on prescribing – suggesting that other factors may be at work making doctors reluctant to prescribe opioids.

Researchers at Johns Hopkins Bloomberg School of Public Health studied commercial insurance claims for nearly 7.7 million adults in 13 “treatment states” that limited prescribing, established PDMPs or targeted pill mills. The analysis included data for nearly 2 million patients diagnosed with arthritis, low back pain, headache, fiibromyalgia or neuropathic pain.

The study findings, published in Annals of Internal Medicine, show that prescribing and PDMP laws in treatment states were associated with an average change of less than 1% in the proportion of patients receiving an opioid prescription.

For example, in Idaho an estimated 9.18% of pain patients received an opioid prescription prior to the state passing a mandatory PDMP law that required doctors to look up a patient’s prescription drug history. In the first two years of the law’s implementation, that percentage fell only slightly to 9.03% of patients.

State laws have also had a negligible impact on dose and supply. Patients who received an opioid prescription in treatment states had an average change of less than one day in the supply of opioids and an average dosage change of less than 4 morphine milligram equivalents (MME) per day.

“We did not find an association between state opioid prescribing laws and receipt of opioid prescriptions or guideline-concordant nonopioid pain treatments among commercially insured adults. Across the 13 states that implemented laws, the change in treatment attributable to the law was consistently small in magnitude and not
statistically significant,” researchers reported.

“The findings suggest that the decreasing volume of opioid prescribing in the United States may be driven more by shifting clinical guidelines, professional norms, or other factors than by these laws.”

PNN asked lead author Beth McGinty, PhD, if the “other factors” that caused opioid prescribing to decline were the CDC guideline itself or the chilling effect many doctors felt from expanded investigations by state medical boards, law enforcement and the Drug Enforcement Administration.

“Our study was not designed to identify those other factors, so I can’t say for sure what has driven these declines.  Overall declines could be due to changing clinical practices nationwide in response to the CDC guidelines or many others,” McGinty replied in an email.

“Declines could also be driven by a range of other efforts to curb opioid prescribing, perhaps the DEA investigations you mention but also other efforts like health system interventions to reduce prescribing. As I said above, our study was designed to evaluate just the state laws, not these other factors, so I can’t say for sure."

“It's really hard to tell exactly what the findings here mean, despite a valiant effort on the part of the researchers,” says Bob Twillman, PhD, former Executive Director of the Academy of Integrative Pain Management.

Twillman says the CDC guideline was “weaponized” in so many ways by regulators, insurers and states that it’s difficult to measure the impact of any single policy or regulation. It was the cumulative impact of them all that drove down opioid prescribing.

“In truth, the most that you can conclude from this study is that these laws did not appear to reduce prescribing. Unfortunately, in the context of an avalanche of other policies, that conclusion doesn't paint a very accurate picture of what is happening to patients because of all the policies,” Twillman told PNN.

State Laws Failed to Reduce Overdoses

McGinty’s study is not the first to find that PDMPs have been largely ineffective – and may even be making the opioid crisis worse. A 2021 study by the Reason Foundation found that overdoses from illicit fentanyl and heroin increased in states after PDMP’s were adopted. A 2018 study by researchers at Columbia University and University of California, Davis had similar findings. 

State laws that limit the dose and quantity of prescription opioids have also failed to stop overdoses from increasing.

In 2016, Massachusetts became the first state in the nation to limit the initial supply of opioid prescriptions to 7 days. The law has had little impact on overdoses. Over 2,000 people still die annually from opioid overdoses in Massachusetts, a rate that has remained steady. The most recent data shows that illicit fentanyl was involved in 92 percent of overdose deaths in the state.

It was the 2016 CDC guideline that encouraged Massachusetts and many other states to adopt limits on initial opioid prescriptions. For short-term acute pain, the guideline said that opioids for “three days or less will often be sufficient; more than seven days will rarely be needed.”

A newly revised draft guideline drops any reference to the number of days and gives physicians more latitude, recommending that opioids be prescribed for acute pain “for no longer than the expected duration of pain severe enough to require opioids.”