Opioids in 2019: Insights into New Regulations and Studies of the Epidemic

Momentum in battling the opioid crisis continues. As more states enact opioid prescribing limits, the federal government proposes new legislation, while new studies look at the impact of opioid laws and medical marijuana on lessening opioid abuse. Let’s take a look at a few recent trends.

Opioid Tapering

The Food and Drug Administration (FDA) recently announced changes to opioid analgesic labeling for tapering physically dependent patients. The requirement change aims to provide “better information for how to properly taper patients who are physically dependent on opioids.” In the press release from the FDA, the department highlights that current labeling, in conjunction with CDC guidelines for prescribing opioids, explain the “need to gradually reduce the dosage of an opioid medication over time, while monitoring carefully for signs of withdrawal.” However, the FDA acknowledges that this approach to tapering is not always used in practice. In their effort to improve the outcomes of tapering, the FDA is requiring changes to prescribing information for all outpatient opioid analgesic medications. The FDA also issued a Drug Safety Communication for providers and patients that discusses how to safely taper off opioids, including details on withdrawal symptoms for patients, instructions for health care professionals and other resources.

Opioid Antagonist Prescriptions

According to the Centers of Disease Control and Prevention (CDC), of the opioid-related overdose deaths in the United States between 2016 and 2017, bystanders were present for more than 40 percent. However, “naloxone was rarely administered by a layperson.” In a push to increase the availability and use of potentially life-saving opioid antagonists, many states are considering co-prescribing of antagonist prescriptions. Several states proposed bills in 2019 to require co-prescribing. Arizona, California, Ohio, Rhode Island, Vermont, Virginia and Washington now require physicians to offer antagonist prescriptions when prescribing opioids to patients considered at high risk of overdosing. Federally, the FDA is considering whether to require co-prescribing nationally, which would create an additional 48 million antagonist doses. Although antagonist prescriptions are becoming more common, these medications still face inflated prices like many other medications on the market. Senate investigation found that, between 2014 and 2017, the company of a branded version of an opioid antagonist had raised the price for two injectors 600 percent to $4,100. In 2019, a generic of Narcan nasal spray was released, with pricing around $40.

Learn More

Medical Marijuana and Opioids

Medical marijuana is increasingly being viewed as a potential alternative to opioids for patients experiencing pain. During the 2019 legislative sessions, several states considered legalizing medical marijuana for the first time, expanding their medical marijuana programs or legalizing recreational marijuana. However, despite the push to legalize the drug, there remains little clinical research on the purported benefits or side effects of medical marijuana, especially in the treatment of pain. A recent study measured the self-reported use of marijuana during recovery from musculoskeletal injuries, including painful disorders of muscles, tendons and nerves. This study found that the amount of opioid use was the highest among patients using marijuana during their recovery. Similar results were found for the duration of opioid prescriptions:

• Patients who did not use marijuana during their recovery used opioids for around 15 days.
• Patients who used marijuana during their recovery averaged 90 days for opioid use.

Another study looked at the rate of opioid overdoses in states with legalized marijuana, with opioid data through 2017. The researchers found that states with legal medical marijuana actually had higher rates of opioid overdose deaths, contradicting a study from 2014 that found opioid-related overdose deaths decreased in states with legalized medical marijuana. At the time of the 2014 study, thirteen states had legalized medical marijuana, whereas nearly 30 states had legalized the drug by 2017. The findings from the 2017 study call into question the belief that marijuana can help stem the opioid crisis. The results of these studies underscore the importance of more clinical research into the potential benefits and side effects of marijuana, especially as more states look to the drug to help in the opioid crisis.
 

States See Success: A Look at California

A recent study from the California Workers’ Compensation Institute (CWCI) found that non-steroidal anti-inflammatories (NSAIDs) superseded opioids as the most common therapeutic drug group prescribed to injured workers in the state. In the first half of 2018, the state saw opioids decrease to 18 percent of the total prescriptions filled, down from 30.5 percent a decade before. CWCI attributes much of this success to the efforts of utilization review, independent medical review, restrictions on payers, medical provider networks, pharmacy benefit managers and the Medical Treatment Utilization Schedule (MTUS) formulary.

States Push Back Against Opioid Limit Laws

Despite many states moving forward with opioid prescribing limit laws and other opioid-related regulations, a few states have looked at legislation pushing back against these limits. New York’s AB 102 would amend every insurance policy in the state to require the coverage of opioids, which would not require prior authorization. Additionally, the carrier would not be able to charge a different rate for any medications in the opioid class. New York has other bills running that continue on the path of limiting opioid prescribing, including a bill to limit prescribing for acute pain to a 3-day supply. Maine also had SP 165 running, which would change opioid limits from a 30-day supply to a 6-month supply if the patient is over 63 or if the patient has been prescribed medication for chronic pain continually for at least five years. This bill did not pass the state legislature. Here are the current opioid limit laws and pending bills, as of October 2019.

Conclusion

States are taking several courses of action to help battle the opioid epidemic. Although most states are looking at prescribing limit laws, antagonist co-prescribing and other opioid-related regulations, some are pushing back against the limits that have already been put in place. Studies continue to emerge on the effectiveness of opioid prescribing limits, formularies and the potential for marijuana to be used as a substitute for opioids in the management of pain. The efforts of those in the workers’ compensation industry as well as state and federal legislatures to curb opioid abuse and deaths, while still providing the best patient care, has been tireless. Hopefully we will continue to see more positive outcomes in the near future.