State Efforts to Control Opioid Misuse Combine Prescription Limits and Provider/Patient Education

opioid misuse

A 2019 Government Accountability Agency (GAO) study of “Patient Options for Safe and Effective Disposal of Unused Opioids” noted that prescription size contributes to opioid misuse. “The majority of patients who received prescriptions for opioids often do not use a large portion of the drugs dispensed.”  Unused opioids in the home may be misused by others and present a poisoning danger to children and pets. Other studies have cited the danger of over-prescribing opioid painkillers to treat post-surgical pain and relatively minor illnesses and injuries, such as sprained ankles.

Former FDA Commissioner Scott Gottlieb recognized these issues when he wrote in 2018:

“Many people who become addicted to opioids will first be exposed to these drugs through a lawfully prescribed medication. Unfortunately, the fact remains that there are still too many prescriptions being written for opioids. And too many prescriptions are written for longer durations of use than are appropriate for the medical need being addressed.”

Current solutions include state-imposed limits on prescription size and dosages as well as increased education efforts about opioid dangers and safe disposal options.

Large Prescription Sizes and Leftover Pills Contribute to Opioid Misuse

Kaiser Health News and Johns Hopkins School of Public Health examined Medicare prescription claims data between 2011 and 2016:

“Some surgeons wrote prescriptions for more than 100 opioid pills in the week following the surgery, often with instructions to take one to two pills every four to six hours, as needed. The total amounts frequently exceeded current guidelines from several academic medical centers, which call for zero to 10 pills for many of the procedures in the analysis, and up to 30 for cardiac bypass surgery.”

Additionally, the GAO study found that excess medications in the home can also lead to opioid misuse:

“SAMHSA estimates that 85 percent of opioid misuse occurs with the patient’s knowledge or active participation, either through the patient misusing his or her own prescription by taking the drug for pain other than for which it was prescribed or by giving or selling the prescribed opioids to another person.”

Some State Efforts to Reduce Opioid Prescriptions Show Positive Results

In the past several years, state legislators and regulators began setting legislative guidelines on how opioid prescriptions are written and dispensed. As of 2019, 15 states had passed laws governing opioid prescribing limits.

A 2016 Maine law limited the morphine milligram equivalent (MME) to 100 mg per day on new prescriptions and 300 MME per day for existing ones. It also limited prescription duration to 7-day and 30-day increments. A 2018 report on the law published by the Maine Medical Association highlighted the progress made in the state:

  • Maine’s prescribing declined 32% from 2013-2017, the fifth-largest drop in opioid prescriptions nationwide.
  • In 2017 alone, Maine saw a decline of 13.2% in opioid prescribing.
  • In 2017 Maine had the largest decline in opioid dosing in the nation.

Maine lawmakers also included veterinarians in the law’s requirements. As it becomes more difficult to obtain opioid prescriptions, some veterinarians have reported cases where people misused their pet’s medications or even injured their pets to get painkillers.

In 2018, Florida limited opioid prescriptions to three days for acute pain and quickly saw results. A University of Florida study published in February 2020 found:

“UF researchers found the number of new opioid users per month dropped 16 percent immediately after the law was implemented, and the number of new users continues to decrease each month. Additionally, the average days’ supply fell from 5.4 days prior to the law to three days. The law was also associated with an immediate decrease in the use of hydrocodone, the most commonly used Schedule II opioid.”

Other state laws have been less effective. A 2020 University of Michigan study found wide variation in the efficacy of state efforts and noted specific issues that can limit effectiveness:

  • Prescription limits that are still too high
  • Limits that restrict the duration of prescriptions but fail to restrict daily dosage levels
  • Voluntary limits
  • Non-compliance by clinicians

Opioids for Sprained Ankles? “Over-Prescribing Is Part of the Problem”

Some researchers have criticized physicians for prescribing opioids in situations where alternatives might be safer and just as effective. Even short-term exposure to opioids increases the risk of misuse. A study published in JAMA Surgery found that “the incidence of new persistent opioid use after surgical procedures was 5.9% to 6.5%” in the U.S.

The use of opioids to treat relatively minor complaints like ankle sprains is especially alarming. One study of 30,000 opioid-naive patients treated for ankle sprains in hospital emergency departments found that 25.1% received opioid prescriptions with an average of 15 tablets. After three months, 8.4% of those patients exhibited new, persistent opioid use.

Dr. James R. Holmes, associate professor of orthopaedic surgery at Michigan Medicine, expressed concern about those results:

“The opioid epidemic is well documented in this country. Physician prescribing and over-prescribing is part of the problem. Several evidence-based recommendations for the treatment of ankle sprains exist and include treatments such as cryotherapy, nonsteroidal anti-inflammatory drugs, functional support and exercise. No evidence-based treatment guidelines for ankle sprains include prescribing opioids.”

Provider and Patient Education

In a 2019 article, the AMA Journal of Ethics called for better physician education to combat the problem of opioid over-prescribing. Some states now require both provider and/or patient education about opioid dangers and alternative pain management options:

  • Florida requires certain healthcare providers to inform patients about non-opioid alternatives and discuss the advantages and disadvantages of non-opioid alternatives with patients prior to prescribing an opioid drug listed as a Schedule II controlled substance. Patients also receive a printed pamphlet with information about non-opioid alternatives.
  • Maine’s 2016 law included a requirement for continuing education. To prescribe opioids, prescribers must complete three hours of Continuing Medical Education (CME) on the prescription of opioid medication every two years.
  • North Dakota’s ONE Rx program provides pharmacists “with tools to screen for opioid use disorder, identify patient needs and provide counseling and resources to safely use prescribed opioids.
  • Michigan’s OPEN (Opioid Prescribing Engagement Network) initiative is supported by state agencies, insurance providers, and the University of Michigan. It’s working to create evidence-based prescribing guidelines for providers and educate patients about the safe use and disposal of opioids.

There are also education efforts at the federal level, the GAO study reported:

“As part of FDA’s REMS requirements for outpatient opioids, manufacturers must make training available to health care providers involved in the treatment and monitoring of patients who receive opioids, which includes information about the need to communicate with patients about disposal of unused drugs.”

Safe Disposal Methods Help Protect Patients and Communities

A 2019 study published in the Journal of Pain Research found “a clear need to increase patient awareness about the importance and methods of proper medication disposal, and a great opportunity for health care providers to increase patient education efforts.

The combination of provider/patient education and safe, convenient disposal options can help reduce opioid misuse. For example:

  • Sharps Compliance partnered with the North Dakota Board of Pharmacy in 2017 to offer MedSafe kiosks at participating pharmacies at the same time the state launched its OneRx pharmacist and patient education program.
  • In 2018, Montana and Sharps worked together to place MedSafe receptacles across the state. At the same time, some healthcare providers also began providing educational materials about opioids and safe disposal.

Although there are in-home disposal products available to patients, the GAO report noted questions about the products’ effectiveness in rendering some medications harmless – particularly opioids. DEA officials explained that the difficulty is “because the drugs have a variety of chemical and physical properties and potencies.” Pharmaceutical chemicals disposed of in the regular trash have negative impacts on both the environment and public health.

Federal agencies recommend drug take-back options as the preferred disposal medication disposal method. Patients can utilize drug take-back programs/mailers and permanent collection sites in their communities in order to dispose of medications in the safest way possible. Sharps Compliance offers both.

  • TakeAway Medication Recovery System envelopes come with prepaid USPS shipping labels for DEA-compliant disposal of Schedules II-V drugs and non-controlled medications.
  • Over 5,700 MedSafe Medication Disposal kiosks allow ultimate users to safely dispose of controlled (Schedules II-V) and non-controlled medications in convenient public locations, such as retail pharmacies and hospitals.

Sharps Compliance is committed to helping fight the opioid crisis. Our MedSafe and TakeAway systems support safe, sustainable drug disposal that helps protect both the public and the environment.

 

Lindsey Murrile-Hawkins

Author: Lindsey Murrile-Hawkins

Lindsey earned her Bachelor of Science in Nursing from Excelsior College and is board certified in Medical-Surgical Nursing from the ANCC. She has over 15 years of direct patient care experience working within the US Army, trauma, long-term care, medical-surgical, and telemetry. As a Clinical Specialist, she works to ensure customers are aware of and compliant with the most current federal, state, and tribal regulations specific to medical and pharmaceutical waste.