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More US states pursue limits on opioid prescriptions

To Republican Arizona Gov. Doug Ducey, the math was simple. The Centers for Disease Control and Prevention says the risk that people will become addicted to opioids spikes five days after starting on the prescription painkillers.

"Addiction skyrockets after five days," Ducey said at a Feb. 24 roundtable discussion in Washington, D.C., where dozens of governors discussed their states' approaches to attacking the opioid epidemic.

So he proposed barring physicians in most cases from prescribing more than an initial five-day supply of the medication.

When the state's House and Senate unanimously approved the proposal in January, Arizona joined 15 other states that have restricted the initial supply of opioid painkillers that patients can receive, with limits ranging from three to 14 days, according to a National Conference of State Legislatures, or NCSL, tally.

At least eight other states California, Colorado, Florida, Hawaii, New Jersey, New York, Oklahoma and South Carolina were also actively considering similar measures on opioid restrictions, according to an NCLS database.

The states' moves come on the heels of CDC guidance in August 2017 that did not specify the quantity of opioids that should be given to patients starting on the painkillers. But citing its study, CDC said doctors should prescribe the lowest possible dosage at an amount appropriate for the expected duration of the pain. "Three days or less will often be sufficient; more than seven days will rarely be needed," the CDC said.

Federal and state authorities have been grappling with the national opioid epidemic, which kills more than 100 people a day. In Washington this week, U.S. lawmakers and prosecutors unveiled new actions aimed at holding drug manufacturers and distributors accountable for their role in the crisis. Congress is holding hearings and authorized $6 billion in funding to fight opioid addiction.

Ohio, Alabama and Kentucky are among the states that have sued drug manufacturers and distributors including Purdue Pharma LP, McKesson Corp., AmerisourceBergen Corp. and Cardinal Health Inc. In September 2017, a bipartisan coalition of 41 states expanded its probe into companies' opioid marketing and sales practices.

Restricting supply to combat the epidemic has created a debate among states, with some lawmakers saying they are hesitant to tie the hands of physicians.

'A philosophical issue'

"It's a philosophical issue. We don't think government should be involved what a physician should or shouldn't do," Tennessee state Rep. Cameron Sexton, a Republican, said in an interview.

A Tennessee House subcommittee earlier this month approved a bill that Sexton proposed as an alternative to a five-day limit put forward by the state's Republican Gov. Bill Haslam.

Citing the CDC study, Haslam's proposal would allow a second 10-day prescription in exceptional cases and sets a limit of 40-milligram morphine equivalent, or MME, per dose.

Sexton's plan, in comparison, would allow physicians to prescribe higher doses, up to 700 MME, to give doctors the discretion to start patients in pain with a higher amount if necessary. His bill would not restrict the supply that a doctor can prescribe. To try to keep patients from getting more pills than they need, however, the bill would bar pharmacies from dispensing more than an initial five-day supply. Patients would have to go back for refills.

The less restrictive approach, Sexton said, "doesn’t treat doctors and patients like they’re bad people."

Iowa's House of Representatives also decided against setting strict limits when it unanimously approved a measure Feb. 26 that would require prescriptions to be filed electronically to prevent forgeries.

Iowa lawmakers, however, did not want to limit how much doctors could prescribe. "The relationship between a physician and his or her patient was most critical in providing the right care at the right time for a patient, especially while working with a patient with chronic pain," one of the bill's supporters, Republican Rep. Shannon Lundgren, said in an email.

Those supporting limits on supply say the regulations would have some flexibility. Arizona's new laws would not apply to individuals working with their physician on a pain management program, or to others, such as cancer patients and those at the end of their life.

Backing seven-day limits in September 2017, Stephen Ubl, president and CEO of industry lobbying group Pharmaceutical Research and Manufacturers of America, said in a statement: "Too often, individuals receive a 30-day supply of opioid medicines for minor treatments or short-term pain. Overprescribing and dispensing can lead to patients taking opioids longer than necessary or to excess pills falling into the wrong hands."

At the annual National Governors Association conference roundtable, Republican Massachusetts Gov. Charlie Baker said allowing patients to get a 30-day supply of opioid painkillers "makes no sense at all."

The seven-day limit the state passed in 2016 helped bring an 8.3% decline in opioid deaths in Massachusetts in 2017 the first year that opioid deaths had declined in the state since 2010.

Kentucky Gov. Matt Bevin, whose state enacted a three-day limit in 2017, said 353 million doses of opioid painkillers were dispensed in Kentucky in 2015. "That's 79 pills for every man, woman and child," the Republican said.

"We're just not in that much pain in Kentucky," he said.