Chronic Opioid Utilization After Enactment of Prescription Supply Restrictions

This illustration image shows tablets of opioid painkiller Oxycodon delivered on medical prescription taken on September 18, 2019 in Washington,DC. – Millions of Americans sank into addiction after using potent opioid painkillers that the companies churned out and doctors freely prescribed over the past two decades. Well over 400,000 people died of opioid overdoses in that period, while the companies involved raked in billions of dollars in profits. And while the flood of prescription opioids into the black market has now been curtailed, addicts are turning to heroin and highly potent fentanyl to compensate, where the risk of overdose and death is even higher. (Photo by Eric BARADAT / AFP) (Photo by ERIC BARADAT/AFP via Getty Images)
Effects of a law implemented to limit prescriptions for Schedule II opioids in Florida on patients receiving chronic opioid therapy were assessed.

Although fewer patients received chronic opioid therapy (COT) after Florida House Bill 21 (HB21) was implemented in July 2018, and the average morphine milligram equivalents (MME) per day and per prescription likewise decreased, a slight increase was seen in the average monthly rate of days supplied per prescription, according to findings published in Pain Physician. According to researchers, this likely indicates that the patients who continued on COT experienced no changes in treatment regimens.

Florida HB21 was implemented to limit prescriptions for Schedule II opioids for the treatment of acute pain to a 3-day supply. Study investigators aimed to assess how HB21 impacted opioid utilization measures among a cohort of patients taking COT (defined as having at least 1 chronic episode during the study’s time frame).

Opioid prescription claims data were taken from a large university and affiliated Florida health system providing insurance for over 40,000 patients; investigators analyzed data on medications dispensed between January 1, 2015, and June 31, 2019. Outcomes were assessed via 4 monthly indicators: (1) proportion of enrollees receiving COT, (2) average number of days supplied per prescription, (3) average MMEs per day per patient, and (4) the average total MMEs per prescription among patients.

A total of 56,544 opioid prescriptions was dispensed to 15,310 COT patients. After HB21 implementation, the average monthly rate of COT per 1000 patients decreased from 7.70 to 5.54, the MME per day per COT patient decreased from 94.31 to 76.64, and the total MME per prescription decreased from 2125.59 to 1866.00. However, a slight increase was seen in the average monthly rate of days supplied per prescription, from 28.66 to 29.18.

After implementation, a significant 25% reduction occurred in COT-receiving patients per 1000 patients (pre-HB21 relative risk [RR], 0.95; 95% CI, 0.93-0.96 vs post-HB21 RR, 0.70; 95% CI, 0.65-0.76) and a significant immediate 8% decrease (RR 0.92; 95% CI, 0.88-0.97) for the monthly COT prevalence per 1000 patients. There was also a significant immediate 1% increase in the monthly number of days supplied per prescription after implementation (RR, 1.01; 95% CI, 1.00-1.02), although no significant change in the trend was observed (overall RR trend, 1.00; 95% CI, 1.00-1.01).

A significant 8% increase in per COT patient day monthly MMEs after HB21 implementation (RR, 1.08; 95% CI, 1.02-1.14), while no significant change in the trend was observed (overall RR trend, 0.88; 95% CI, 0.87-0.90). Although there was a significant 10% increase in total MMEs per prescription post-implementation (RR, 1.10; 95% CI, 1.04-1.15), no significant change in the trend was observed (overall RR trend, 0.91; 95% CI, 0.89-0.92).

Although the study was limited by using data from a private, employer-based health insurance plan and by not adjusting for implementation lag by including a longer post-policy period, investigators nevertheless concluded that patients continuing to receive COT for chronic pain did not encounter significant changes in opioid supply following implementation of this law.

The study authors also noted that “more research is warranted to assess whether the patients who were removed from COT underwent appropriate tapering or were converted to appropriate opioid-alternative pain management therapies, as well as if reduced initiation of COT signals improvements in alternative pain management strategies or in reduced access to care for chronic pain patients.”


Shen Y, Hincapie-Castillo JM, Vouri SM, Dewar MA, Sumfest JM, Goodin AJ. Chronic opioid therapy utilization following an acute pain prescription supply restriction law: an interrupted time series analysis. Pain Physician. 2021 Sep;24(6):417-424.