Summer 2017

Bridging the Gap Between Opioid Policy and Prescribing

Fast Focus

State and federal governments have taken legislative action to reduce the harm caused by the opioid epidemic, including preventive activities aimed at influencing prescriber behavior, as well as working to intervene when opioid use becomes problematic.

An influx of recent legislation has been passed to fight the opioid epidemic, and current legislative trends focus on two fronts. One approach seeks to prevent opioid misuse through prescriber education and the use of prescription limits to lower the quantity and duration of opioid prescriptions. The other front assists those who suffer the long-term effects of opioids, primarily by expanding access to opioid overdose drugs and drug treatment programs for opioid dependency.

Avoiding the long-term prescribing of opioids altogether would be a big step in reducing the damage caused by these products, and there have been many different legislative movements employed to influence prescribers’ opioid prescription patterns.


As part of a larger initiative to decrease production among Schedule I and II substances, the Drug Enforcement Administration (DEA) has reduced the amount of nearly every Schedule II opioid that may be manufactured in 2017 by 25% or more.1 Some opioids face even bigger decreases in manufacturing quotas, such as hydrocodone, which is expected to see a 66% decrease.


Theoretically, fewer opioids means fewer people can be impacted by their adverse effects, but some argue these reductions merely target a pre-existing excess of opioids that, even when counting inappropriate prescriptions, were more than enough to supply the demand for opioids. Such critics claim that this change will result in little-to-no direct impact on prescriber activity.

However, this action does send prescribers a powerful message, making it clear that there are too many opioids available, demanding more scrutiny for opioid therapy, and reiterating the need for caution and education. It is a good initial step that further echoes the demand of other legislation that also call for safer opioid prescribing.


Forty-nine states currently employ prescription drug monitoring programs (PDMPs) that record, monitor, and evaluate data for certain prescription drugs in order to better regulate them. While PDMPs have primarily operated on a voluntary basis, some states have passed legislation requiring physicians to query a PDMP when prescribing opioids.

At the end of 2015, 15 states required prescribers to check PDMPs prior to starting opioid therapy (not including Washington state, where this rule applies only to workers’ compensation),2 and in 2016, Maryland, California, and New Mexico joined those states after passing similar laws (with California’s law targeting all Schedule II-IV drugs, including opioids).3-5

Some states have passed laws requiring prescribers to check PDMPs before prescribing opioid prescriptions greater than certain lengths of time, ranging from three days to 30 days, and states such as Pennsylvania and Massachusetts have passed laws where all opioid prescriptions require a PDMP check.6-7



Mandatory PDMP queries require prescribers to take an additional step before writing the first and sometimes subsequent prescriptions. This PDMP check increases visibility into questionable patient behaviors, such as a history of seeking early refills, or the presence of multiple prescribers and/or pharmacies. These indicators may cause the prescriber to reconsider opioids, request the patient submit to a urine drug screen, or employ an alternative therapy.

This leads to increased patient safety, as well as significant cost savings from avoiding the complications that can accompany opioids. According to data collected from 2004-2014 by the National Survey of Drug Use and Health, mandatory PDMP programs have been shown to reduce doctor shopping for pain medications by 80%.9 Many individual states have seen positive outcomes as well due to their PDMPS.

In Ohio, a 20% decrease in opioids dispensed was credited to their PDMP,10 while New Hampshire attributed a 10% decrease in Schedule II pain relievers to their PDMP.11 Furthermore, 50% of prescribers who changed their prescribing patterns in Indiana credited their change to their state’s PDMP,12 and 43% of prescribers in Tennessee are less likely to prescribe controlled substances after checking PDMPs.13


Both New Mexico and Michigan have allowed insurance carriers to access PDMP data.14-15 This data can be extremely useful in analyzing patterns of prescribing, dispensing, and patient behavior, allowing payers to create intervention opportunities based on a more holistic view of care not fully present in a workers’ compensation claim. While this could lead to improved care and corresponding cost savings, it is yet to be known if more states will adopt similar legislation.


In March of 2016, Massachusetts became the first state to limit initial opioid prescriptions, restricting them to a seven-day supply.7 In the months thereafter, New York, Maine, and Connecticut followed suit,16-18 while Rhode Island implemented a morphine milligram equivalent (MME) limit of 30mg a day for a maximum of twenty doses.19

Other states such as Alaska and Delaware proposed similar laws last year just before state legislative sessions ended across the nation. As legislative sessions began earlier this year, similar bills have come forward. New Jersey recently passed a five-day opioid prescription limit,20 while Ohio and Utah have passed seven-day limits,21-22 and (as of this writing) Maryland, Indiana, Oregon, Washington, and Hawaii have expressed interest in a seven-day limit,23-27 and North Carolina has introduced legislation aiming for a five-day limit.28


Opioid prescription limits are intended to limit opioid prescribing to the short-term phase, discouraging chronic use that leads to adverse effects such as respiratory depression, high morphine equivalent dose (MED) levels, and an increased risk of dependence and misuse. These laws also encourage more interaction between patients and prescribers, allowing prescribers to better monitor opioid therapy and identify more intervention opportunities.


In early October of 2016, Ohio initiated new a rule in the workers’ comp setting that only allows opioids to be reimbursed in the workers’ comp setting if they follow best medical practices, which would include an individualized treatment plan, risk assessment, and close monitoring of patient progress.29

Vermont initiated a similar rule in November, allowing workers’ comp payers to deny payment for opioids that do not follow treatment guidelines,30 and now New Jersey is interested in enacting a similar rule.31

States like New York and Minnesota have already implemented similar legislation in the past, while other states include such opioidrelated rules within their formularies, such as Texas and Washington, with California soon to join them. As the effects of the opioid epidemic continue to show themselves, it is likely more states will push for treatment that falls in line with evidence-based medicine.


Encouraging the use of evidence-based medicine has been shown to cause prescribers to adjust their prescription behavior.32 Furthermore, legislation that calls for increased communication and patient monitoring may also lead to improved care. Guidelines may require that patients be made more aware of the risks associated with opioid therapy, and close patient monitoring prompts prescribers to further scrutinize their patients’ progress with opioid therapy, which could lead to discontinuation or weaning.


In December 2016, President Obama signed the 21st Century Cures Act. The act impacted many different long-reaching healthcare initiatives, but among them it allocated $1 billion to help fight the opioid epidemic.33

The funds will be divided equally between 2017 and 2018, granted to individual states for the following purposes:

  • Improving state PDMPs
  • Implementing activities that prevent opioid abuse, as well as evaluating how effective those strategies are
  • Training healthcare professionals on opioid best practices, pain management, and more
  • Any other appropriate public health activities related to addressing the opioid epidemic


The funds from this act can strengthen current initiatives that show promise, while also supporting the creation of new opioid prevention strategies that may filter into workers’ compensation.

Furthermore, evaluating the effectiveness of opioid prevention strategies will inform stakeholders on which strategies do and do not work. This allows resources to be devoted to more efficient strategies and programs, avoiding wasted effort and leading to the highest possible patient safety improvement, which would also lead to cost savings.


While it is best to prevent patients from experiencing the adverse effects of opioids in the first place, it is still important to have a plan in place for when opioid use grows problematic. Key legislation has increased access to treatment for opioid dependence while also expanding efforts to counteract opioid overdose, hoping to help patients struggling with opioids.



$1 billion approved to fight the opioid epidemic with grants that:

  • Train healthcare professionals to recognize signs of substance abuse
  • Support access to healthcare services for opioid-use disorders
  • Improve opioid overdose prevention


  • $25 million granted to expand access to medication-assisted treatments for opioid dependency
  • $25 million granted to expand access to naloxone, the opioid antidote that reverses opioid overdoses, as well as increased naloxone training and education


47 states have expanded access to naloxone, the opioid antidote that reverses overdose and saves lives35
The New York Workers’ Compensation Board will allow insurers to request special hearings to determine if injured workers be weaned off opioids36
Massachusetts will fast track certain opioid-addicted injured workers to a voluntary mediation program designed to wean them off opioids37


  • $11 million provided to 11 states to expand access to medicationassisted treatment services for persons with opioid-use disorders38
  • $11 million provided to 12 states to reduce opioid overdoserelated deaths38
    • Funds the purchase and distribution of naloxone
    • Supports training on overdose prevention
  • Increased access to buprenorphine, a drug used to treat opioiduse disorders
    • Qualified prescribers may prescribe buprenorphine to 275 patients, an increase from a 100-patient limit, assisting more people suffering from opioid dependence39
    • Nurse practitioners and physician assistants may prescribe buprenorphine after initial training, further increasing access to opioid-dependence treatment34


As workers’ comp professionals continue to fight for education, awareness, and evidence-based medicine, it is often the enacting of legislation that empowers these practices at various stages of opioid therapy. It is therefore crucial that payers, PBMs, and other workers’ compensation stakeholders not only follow opioid legislation as it develops, but that they be involved in the development of legislation that seeks to improve patient outcomes.


  1. Established aggregate production quotas for schedule I and II controlled substances and assessment of annual needs for the list I chemicals ephedrine, pseudoephedrine, and phenylpropanolamine for 2017. Federal Register; 81:193. 2016.
  2. Mandatory PDMP use. Prescription Drug Monitoring Program Training and Technical Assistance Center. Published 2015.
  3. House Bill 0437 – Ch 147. Department of health and mental hygiene – prescription drug monitoring program – modifications. General Assembly of Maryland. April 26, 2016.
  4. Senate Bill No. 482 – Ch 708. Controlled substances: CURES database. California legislative information. Sep 27, 2016.
  5. Management of pain and other conditions with controlled substances. New Mexico Register. Vol XXVII, Issue 22. Nov 30, 2016.
  6. Senate Bill No. 1202, Session of 2015. An Act providing for prescription drug monitoring; creating the ABC-MAP board; establishing the achieving better care by monitoring all prescriptions program; and providing for unlawful acts and penalties. The general assembly of Pennsylvania. Oct, 25, 2016.
  7. House Bill 4056 – An act relative to substance use, treatment, education and prevention. The 190th general court of the commonwealth of Massachusetts. March 2016.
  8. Injury prevention & control: opioid overdose. Centers for Disease Control and Prevention web site. Accessed Feb 15, 2016.
  9. Ali MM, Dowd WN, Classen T, Mutter R, Novak SP. Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: Evidence from the National Survey of Drug Use and Health. Addict Behav. June 2017; 69: 65-77.
  10. Ohio automated rx reporting system: 2016 annual report. State of Ohio board of pharmacy. January 2017.
  11. Prescription drug monitoring program: annual report – October 1, 2015 – September 30, 2016. New Hampshire prescription drug monitoring program. 2016.
  12. Key findings and recommendations from the 2013 IPLA INSPECT knowledge and use survey. Center for Health Policy. June 2014.
  13. Controlled substance monitoring database 2016 report to the 109th Tennessee general assembly. Tennessee Department of Health. Feb 1, 2016.
  14. New Mexico Legislature 16.19.29.D.13. November 2016.
  15. House Bill No. 5326 – Act No. 383. State of Michigan 98th Legislature Regular Session of 2016. Dec 28, 2016.
  16. Assembly Bill 10727. New York State Assembly. June 2016.
  17. L.D 1646 – An act to prevent opiate abuse by strengthening the controlled substances prescription monitoring program. State of Maine. April 22, 2016.
  18. House Bill No. 5053 – Public Act No. 16-42: An act concerning opioids and access to overdose reversal drugs. Connecticut general assembly. June 2016.
  19. S 2823: Relating to food and drugs -- uniform controlled substances act-regulation of manufacturing, distributing, prescribing, administering, and dispensing controlled substances. Rhode Island general assembly. June 28, 2016.
  20. SB No. 3 – An act concerning substance use disorders and revising and supplementing various parts of the statutory law. State of New Jersey 217th Legislature. Feb 2017.
  21. New limits on prescription opiates will save lives and fight addiction. Communications Department of John R. Kasich, Governor of the State of Ohio. March 2017.
  22. House Bill 50 – Opioid Prescribing Regulations. 2017 general session state of Utah. February 2017.
  23. Governor Hogan, Lt. Governor Rutherford announce 2017 heroin and opioid prevention, treatment, and enforcement initiative. Office of Governor Larry Hogan website. Published January 24, 2017. Accessed Feb 15, 2017.
  24. Senate Bill 226. Indiana general assembly. 2017 session.
  25. House Bill 2114 – Relating to prescription drugs. Oregon state legislature. 2017 regular session.
  26. House Bill 1339 – An act relating to restrictions on prescriptions for opiod drugs; and adding a new section to chapter 69.41. RCW. State of Washington 65th Legislature 2017 Regular Session. Jan 2017.
  27. H.B. No. 666 – A bill for an act relating to controlled substances. House of Representatives Twenty-Ninth Legislature, 2017 State of Hawaii. Feb 2017.
  28. H.B. 243 – Strengthen Opioid Misuse Prevention (STOP) Act. General Assembly of North Carolina. Session 2017. March 2017.
  29. Opioid prescribing rule and guidelines. Ohio bureau of workers’ compensation web site. Oct 1, 2016.
  30. S.243 (Act 173) – An act relating to combating opioid abuse in Vermont. Vermont general assembly. June 8, 2016.
  31. Senate Bill 2703. State of New Jersey 217th legislature. Nov 3, 2016.
  32. Impact of the Texas pharmacy closed formulary: a preliminary report based on 12-month injuries with 24-month services and legacy status. Texas Department of Insurance Workers’ Compensation Research and Evaluation Group. February 2015.
  33. H.R.34 - 21st Century Cures Act. 114th Congress. Dec 13, 2016.
  34. Comprehensive Addiction and Recovery Act of 2016. S.524 – 114th Congress (2015-2016).
  35. Legal interventions to reduce overdose mortality: naloxone access and overdose good Samaritan laws. The Network for Public Health Law. June 2016.
  36. Board Announces New Hearing Purpose for Opioid Weaning Issues. New York Workers’ Compensation website. Oct 2016.
  37. Governor Baker Unveils Workers’ Compensation Pilot for Opioid-Related Cases. The Official Website of the Governor of Massachusetts. Dec 2016.
  38. HHS awards $53 million to help address opioid epidemic. SAMHSA website. Aug 2016.
  39. Final rule expanding access to medication-assisted treatment. SAMHSA website. July 11, 2016.


Since 2010, the semi-annual RxInformer clinical journal has been a trusted source of timely information and guidance for workers’ comp payers on how best to manage the care of injured worker claimants and plan for the challenges that lay ahead. The publication is an important part of Healthesystems’ proactive approach to advocating for quality care of injured workers while managing the costs associated with treatment.