Opioids are medications that have the ability to alleviate pain. They also have other properties that allow them to impact emotions and our sense of pleasure, which can make them addictive. Regulations around opioid prescribing vary greatly from state to state, and are even influenced by some large organizations like Medicare and Medicaid. Unfortunately, at this time, there are no federally mandated regulations on opioid prescribing, making consistency from place to place and from provider to provider a huge issue.1
In order to prescribe an opioid, a prescriber must have a license with the US DEA (United States Drug Enforcement Administration). A DEA license is state-specific, meaning if a provider practices in more than one state, they must have a separate license for each state. The DEA has a classification scale, called a drug schedule, that separates medications into categories based on their potential for abuse and dependency. A Schedule I (one) drug has a high potential for abuse and is not medically used. A Schedule V (five) medication has a very low potential for abuse. Schedules II (two), III (three), and IV (four) fall in between. Many opioids are considered Schedule II drugs. The providers who can prescribe Schedule II drugs may vary from state to state. Drugs that fall on the scheduling scale are often referred to as controlled substances.2
Regulations in the works
Some states have strict regulations for the length of time an opioid can be prescribed and in what context it should be used. For example, North Carolina has recently passed the STOP (Strengthen Opioid Misuse Prevention) Act which enforces a 5-day or 7-day limit on opioids for acute pain. However, it does not place limits on prescriptions for chronic pain.3 Characteristics like these can vary from state to state, with some states having no limits on opioid prescriptions.1
Legislation has been proposed in order to reduce these variations and provide more regulations on the national level. Most recently, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act was passed. This act aims to increase education on best pain-management practices, investigate trends in prescribing limits to determine what regulations are providing an impact in states with opioid prescribing laws, provide better support to individuals battling addiction, increase access to drug disposal centers, and more.4,5
CDC guidelines for prescribers
Although there are no national requirements for opioid prescribing, and even fewer requirements at the state level for the use of opioids for long-term chronic pain, the CDC (Centers for Disease Control and Prevention) has released a set of guidelines providers can use when determining the best pain management plan. There are 12 recommendations in the guidelines that center around determining when to use opioids for chronic pain, what opioids to use, how long to use an opioid-containing medication, how to follow-up with individuals taking these medications, and how to assess the risks and identify harms of taking opioids. Several of the recommendations include the following:6,7
Talking about the risks and benefits of opioid medications before starting treatment.
Establishing realistic treatment goals before starting opioids for chronic pain and letting individuals taking the medications know that opioid medications will be stopped if risks outweigh benefits.
Prescribing the lowest possible dosage that might provide pain relief before prescribing higher dosages.
Evaluating individual characteristics that might increase an individual’s risk of poor outcomes from treatment. Some of these characteristics may include pregnancy, a history of sleep apnea or disordered breathing, increasing age over 65, or a history of kidney or liver problems. All of these may impact the way an opioid is processed by the body and could lead to worse outcomes.
Monitoring an individual’s medications within state prescription drug monitoring programs (PDMP). PDMP’s allow providers across the country to log and monitor an individual’s medications, specifically controlled substances, to determine if an individual is receiving opioids from other providers as well as other medications that might be dangerous if used with opioids.
These requirements should be considered when making any decisions on whether or not to prescribe an opioid for chronic pain relief. In the case of end-of-life, palliative, or active cancer care, these guidelines may not apply. For a full list of the CDC’s recommendations, see the CDC’s Guideline for Prescribing Opioids for Chronic Pain.8
2018 Annual Surveillance Report of Drug-Related Risks and Outcomes: United States. Centers for Disease Control and Prevention: US Department of Health and Human Services. https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf. Published August 31, 2018. Accessed December 1, 2018.
Drug Scheduling. United States Drug Enforcement Administration. https://www.dea.gov/drug-scheduling. Accessed December 1, 2018.
Understanding the STOP Act’s 5- and 7-day Prescribing Limits. North Carolina Medical Board. https://www.ncmedboard.org/images/uploads/article_images/STOPAct-focusedFAQs-June2018.pdf. Published June 25, 2018. Accessed December 1, 2018.
The SUPPORT for Patients and Communities Act (H.R. 6). American Society of Addiction Medicine. https://www.asam.org/advocacy/the-support-for-patients-and-communities-act-(h.r.-6). Accessed December 1, 2018.
Congress Passes Bipartisan Opioid Legislation. American Dental Association.
https://www.ada.org/en/publications/ada-news/2018-archive/october/congress-passes-bipartisan-opioid-legislation/. Published October 4, 2018. Accessed December 1, 2018.
CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm. Published March 18, 2016. Accessed December 1, 2018.
Prescription Drug Monitoring Programs (PDMPs). Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/pdf/PDMP_Factsheet-a.pdf. Accessed December 1, 2018.
Guideline for Prescribing Opioids for Chronic Pain. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf. Accessed December 1, 2018.