Time-limited opioid prescriptions: the benefits of a customized approach

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How can states best address the spread of opioid addiction? Many have tried by limiting the number of days’ supply for all first-time opioid prescriptions, regardless of setting or the patient’s circumstances. But a new study finds that a more tailored approach to prescribing limits could be more effective in minimizing patients’ exposure to opioids.

In 2018 West Virginia, one of the states hit hardest by the opioid epidemic, introduced setting-specific limits for first-time opioid prescriptions: seven days for adults treated in outpatient hospital- or office-based practices, four days for adults treated in emergency departments, and three days for pediatric patients—those younger than 18--regardless of clinical setting.

The study’s authors examined prescribing patterns from 2017 through 2019 for about 45,000 West Virginia Medicaid enrollees to see whether a patient’s initial opioid prescription exceeded the number of days in the 2018 limit for a given care setting before and after the limit’s implementation. They found a 56.8% reduction in prescription length for patients in hospital and outpatient settings, a 37.5% reduction for prescriptions written in emergency department settings, and a 26.5% reduction for pediatric patients.

The researchers also looked at whether doctors were writing more or stronger follow-up prescriptions to compensate for the time limits, but found none. Instead, the limits were associated with fewer high-dose and follow-up prescriptions in the adult outpatient setting. The authors speculate this may be due to the law discouraging clinicians’ willingness to write follow-up prescriptions.

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The clinical impact of limiting opioid prescribing is not yet known.

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Another possible explanation, they say, is that longer initial prescriptions may have led to patients’ building tolerance for opioids, thus inducing demand for subsequent prescriptions. But with reduced prescription length subsequent prescriptions were not needed or requested.

The authors acknowledge that the clinical impact of limiting opioid prescribing is not yet known. They cite one study estimating that even substantial prevention of prescription opioid misuse would result in a decrease of 3.8% to 5.3% in opioid-related overdose deaths.

“Against this small potential benefit, policymakers must weigh the likelihood of unintended consequences of duration limits,” they write. "Reducing the supply of prescription opioids may increase the number of patients with uncontrolled pain, which has been shown to increase suicide risk.” Moreover, limits could cause patients to use more lethal forms of opioids, such as heroin or fentanyl, which could in turn increase opioid-related morbidity and mortality.

The study, Opioid Prescribing Patterns After Imposition of Setting-Specific Limits on Prescription Duration, was published online January 19, 2024 in JAMA Health Forum.