Implementation and enforcement of state opioid prescribing laws

Background: In response to the role overprescribing has played in the U.S. opioid crisis, in the past decade states have enacted four main types of laws to curb opioid prescribing: mandatory prescription drug monitoring program (PDMP) enrollment laws requiring clinicians to register with a PDMP; mandatory PDMP query laws requiring clinicians to check a PDMP prior to prescribing opioids; pill mill laws regulating pain management clinics; and opioid prescribing cap laws limiting the dose/duration of opioid prescriptions. While 47 states now have one or more of these laws in place, little is known about implementation and enforcement strategies, facilitators, and barriers. Methods: From November 2017 to February 2019, we interviewed 114 professionals involved in state opioid prescribing law implementation and enforcement in 20 states and identified common themes. Results: Implementation efforts focused on awareness campaigns and targeted training of key front-line implementers. Enforcement strategies included active, complaint-based, and automated strategies. Collaboration across agencies and stakeholders, particularly health agencies and law enforcement, was identified as an important facilitator of implementation and enforcement. Two key interrelated barriers were identified: the complexity of state opioid prescribing laws in terms of which providers, patients, and prescriptions they applied to, and IT infrastructure. Conclusion: Despite differing approaches, our findings suggest similar barriers to implementation and enforcement across state opioid prescribing laws. Strategies are needed to ease implementation and enforcement of laws that apply only to specific sub-sets of providers, patients, or prescriptions and address issues of access and data utilization of the PDMP.