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State-level and system-level opioid prescribing policies: The impact on provider practices and overdose deaths, a systematic review

Francesca L. Beaudoin, MD, MS, Geetanjoli N. Banerjee, MPH, Michael J. Mello, MD, MPH


Objective: In response to persistent public health concerns regarding prescription opioids, many states and healthcare systems have implemented legislation and policies intended to regulate or guide opioid prescribing. The overall impact of these policies is still uncertain. The aim of this systematic review was to examine the existing evidence of provider-level and patient-level outcomes preimplementation and postimplementation of policies and legislation constructed to impact provider prescribing practices around opioid analgesics.

Design: A systematic search of MEDLINE, EMBASE, the Web of Science, and the Cochrane Database of Systematic Reviews was conducted to identify studies evaluating the impact of opioid prescribing policies on provider-level and patient-level outcomes. The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results: Eleven studies were included in the review. A meta-analysis was not possible due to between-study heterogeneity. Six of the studies assessed state-level policies, and five were at the level of the healthcare system or hospital. Studies showed temporal associations between policy implementation and reductions in opioid prescribing, as well as opioid-related overdoses. Results were mixed regarding the impact of policies on misuse. The majority of the studies were judged to be of low quality based on the GRADE criteria.

Conclusions: There is low to moderate quality evidence suggesting that the presence of opioid prescribing policy will reduce the amount and strength of opioid prescribed. The presence of these policies may impact the number of overdoses, but there is no clear evidence to suggest that it reduces opioid misuse.


opioids, prescription drug misuse, inappropriate prescribing, overdose, policy, legislation

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Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. Available at Accessed February 12, 2016.

Volkow ND: Prescription Opioid and Heroin Abuse. Washington, DC: National Institute on Drug Abuse, 2014. Available at Accessed February 12, 2016.

Manchikanti L, Helm S II, Fellows B, et al.: Opioid epidemic in the United States. Pain Physician. 2012; 15(3 suppl): ES9-E38.

Raymond Y, Francisco T, Andrés F: International Narcotics Control Board Report 2008. United Nations Pubns. 2009: 20.

Dart RC, Surratt HL, Cicero TJ, et al.: Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015; 372(3): 241-248.

Nuckols TK, Anderson L, Popescu I, et al.: Opioid prescribing: A systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med. 2014; 160(1): 38-47.

Gomes T, Mamdani MM, Dhalla IA, et al.: Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011; 171(7): 686-691.

Franklin GM, Fulton-Kehoe D, Turner JA, et al.: Changes in opioid prescribing for chronic pain in Washington State. J Am Board Fam Med. 2013; 26(4): 394-400.

Mack KA, Zhang K, Paulozzi L, et al.: Prescription practices involving opioid analgesics among Americans with Medicaid, 2010. J Health Care Poor Underserved. 2015; 26(1): 182-198.

Bohnert A, Valenstein M, Bair M, et al.: Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011; 305(13): 1315-1321.

King NB, Fraser V, Boikos C, et al.: Determinants of increased opioid-related mortality in the United States and Canada, 1990-2013: A systematic review. Am J Public Health. 2014; 104(8): e32-e42.

Ziegler S: The proliferation of dosage thresholds in opioid prescribing policies and their potential to increase pain and opioid- related mortality. Pain Med. 2015; 16: 1851-1856.

Sigler K, Guernsey B, NB I, et al.: Effect of a triplicate prescription law on prescribing of Schedule II drugs. Am J Health Syst Pharm. 1984; 41(1): 108-111.

Reifler LM, Droz D, Bailey JE, et al.: Do prescription monitoring programs impact state trends in opioid abuse/misuse? Pain Med. 2012; 13(3): 434-442.

Trescot A, Boswell M, Atluri S, et al.: Opioid guidelines in the management of chronic non-cancer pain. Pain Physician. 2006; 9: 1-40.

Chou R, Fanciullo GJ, Fine PG, et al.: Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009; 10(2): 113-130.

Moher D, Liberati A, Tetzlaff J, et al.: Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA statement. BMJ. 2009; 339: b2535.

Balshem H, Helfand M, Schunemann HJ, et al.: GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011; 64(4): 401-406.

Fox TR, Li J, Stevens S, et al.: A performance improvement prescribing guideline reduces opioid prescriptions for emergency department dental pain patients. Ann Emerg Med. 2013; 62(3): 237-240.

Saunders K, Shortreed S, Thielke S, et al.: Evaluation of health plan interventions to influence chronic opioid therapy prescribing. Clin J Pain. 2015; 31(9): 820-829.

Westanmo A, Marshall P, Jones E, et al.: Opioid dose reduction in a VA health care system—Implementation of a primary care population-level initiative. Pain Med. 2015; 16: 1-8.

Holman J, Stoddard G, Horwitz D, et al.: The effect of preoperative counseling on duration of postoperative opiate use in orthopaedic trauma surgery: A surgeon-based comparative cohort study. J Orthop Trauma. 2014; 28: 502-506.

Naliboff BD, Wu SM, Schieffer B, et al.: A randomized trial of 2 prescription strategies for opioid treatment of chronic nonmalignant pain. J Pain. 2011; 12(2): 288-296.

Franklin GM, Mai J, Turner JA, et al.: Bending the prescription opioid dosing and mortality curves: Impact of the Washington State opioid dosing guideline. Am J Ind Med. 2012; 55: 325-331.

Johnson H, Paulozzi LJ, Porucznik C, et al.: Decline in drug overdose deaths after state policy changes—Florida, 2010-2012. MMWR Morb Mortal Wkly Rep. 2014; 63(26): 569-574.

Surratt HL, O’Grady C, Kurtz SP, et al.: Reductions in prescription opioid diversion following recent legislative interventions in Florida. Pharmacoepidemiol Drug Saf. 2014; 23(3): 314-320.

Garg RK, Fulton-Kehoe D, Turner JA, et al.: Changes in opioid prescribing for Washington workers’ compensation claimants after implementation of an opioid dosing guideline for chronic noncancer pain: 2004 to 2010. J Pain. 2013; 14(12): 1620-1628.

Fischer B, Ialomiteanu A, Kurdyak P, et al.: Reductions in non-medical prescription opioid use among adults in Ontario, Canada: Are recent policy interventions working? Subst Abuse Treat Prev Policy. 2013; 8(7): 1-4.

Victor TW, Alvarez NA, Gould E: Opioid prescribing practices in chronic pain management: Guidelines do not sufficiently influence clinical practice. J Pain. 2009; 10(10): 1051-1057.

Vanderweele TJ, Vansteelandt S: Odds ratios for mediation analysis for a dichotomous outcome. Am J Epidemiol. 2010; 172(12): 1339-1348.

Blanch B, Buckley NA, Mellish L, et al.: Harmonizing postmarket surveillance of prescription drug misuse: A systematic review of observational studies using routinely collected dated (2000-2013). Drug Saf. 2015; 38(6): 553-564.



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