The opioid epidemic is fueled by misuse of prescription and illicit opioids (e.g., heroin and fentanyl). Research indicates that the majority of illicit users first misused prescription opioids. According to the Centers for Disease Control and Prevention (CDC), there has been a significant increase in opioid prescriptions for pain since 1999, while the amount of pain that Americans report has not changed much overall. While new research found that the amount of opioids prescribed decreased between 2010 and 2015, it remains about three times higher than in 1999.
In response to the epidemic, the CDC released the “Guideline for Prescribing Opioids for Chronic Pain” in March 2016. The guideline offers primary care providers a set of voluntary, evidence-based recommendations for prescribing opioids to patients 18 years or older in primary care settings. It focuses on chronic pain treatment, and does not apply to patients in active cancer treatment, palliative care or end-of-life care. The recommendations are based on existing scientific evidence. For example, higher doses of opioids are associated with higher risk of overdose and death. Even relatively low dosages—considered to be 20 to 50 morphine milligram equivalents (MME) per day—increase risk. As such, the guideline recommends starting with the lowest effective dosage, and carefully considering dosages above 50 or 90 MMEs per day. For treating acute pain, the guideline recommends a quantity no greater than what is needed for the expected duration of pain severe enough to require opioids, specifying that three days or less will often be sufficient and more than seven days will rarely be needed.
Using opioids to treat acute pain can lead to long-term use. The likelihood of long-term use increases based on the length of the initial prescription, according to the CDC. In fact, the likelihood of long-term use increases sharply after the third and fifth days of taking a prescription, and spikes again after the 31st day. According to the CDC, long- term use also increases with a second prescription or refill, a 700 morphine milligram equivalents (MME) cumulative dose, and an initial 10- or 30-day supply.
Improving prescribing practices and the way pain is treated is one avenue to help prevent misuse, addiction and overdose, while ensuring legitimate access to pain management. In recent years, a number of states have enacted policies related to prescribing opioids, some of which align with certain recommendations in the CDC Guideline.

State Legislation
Legislation limiting opioid prescriptions debuted early in 2016, with Massachusetts passing the first law in the nation. Among other provisions in the comprehensive act, the state set a seven-day supply limit for initial (first-time) opioid prescriptions. Prior to Massachusetts’ law, some states had passed bills related to prescribing, such as Washington’s legislation directing five professional boards and commissions to adopt rules related to chronic, non-cancer pain management, but none had set such a short time limit in statute.
By the end of 2016, seven states had passed legislation limiting opioid prescriptions, and the trend continued in 2017. More than 30 states considered at least 130 bills related to opioid prescribing in 2016 and 2017. According to NCSL’s tracking, 33 states had enacted legislation with some type of limit, guidance or requirement related to opioid prescribing by October 2018.

Most of this legislation limits first-time opioid prescriptions to a certain number of days’ supply—seven days is most common, though some laws set limits at three, five or 14 days. In a few cases, states also set dosage limits (morphine milligram equivalents, or MMEs). Nearly half the states with limits specify that they apply to treating acute pain, and most states set exceptions for chronic pain treatment.
In addition to exceptions for chronic pain, most laws also exempt treatment for cancer and palliative care from prescription limits. Many also allow exceptions for the treatment of substance use disorder or medication-assisted treatment (MAT), or for the professional judgment of the provider prescribing the opioid. Many laws stipulate that any exceptions must be documented in the patient’s medical record.
While the majority of states focus on general opioid prescribing, Alaska, Connecticut, Indiana, Louisiana, Massachusetts, Nebraska, Pennsylvania and West Virginia also set limits specifically for minors. These laws set limits for any opioid prescription (versus the initial opioid prescription for adults) and may also specify other requirements, such as discussing opioid risks with the minor and parent or guardian.
Rather than setting opioid prescription limits in statute, a few state laws direct or authorize other entities to do so (such as New Hampshire, Ohio, Oregon, Vermont, Virginia, Washington and Wisconsin). These entities may include the department of health/state health official, or provider regulatory boards such as the board of medicine, nursing and/or dentistry. Other states, such as Rhode Island and Utah, have prescribing limits in statute, and allow other entities to adopt prescribing policies.
In addition, state laws—such as those in Maryland and Utah—may provide guidance or direction related to opioid prescribing. Maryland’s law requires providers to prescribe the lowest effective dose of an opioid for a quantity that is not greater than that needed for the expected duration of pain. Utah, in addition to its seven-day prescribing limit, authorizes commercial insurers, the state Medicaid program, workers’ compensation insurers and public employee insurers to implement policies for prescribing certain controlled substances. The policies must include evidence-based guidelines for prescribing opioids.
Other State Strategies
In addition to prescribing policies, state leaders are tackling prescription drug misuse with various approaches. When attempting to prevent or intervene early in misuse, addiction and overdose, states have enacted numerous laws related to prescription drug monitoring programs, access to naloxone, pain clinic regulation, provider education and training, and other topics. NCSL tracks these bills in the Injury Prevention Database, which follows six categories of legislation aimed at preventing prescription opioid misuse. The database cataloged more than 1,300 bills on these topics from 2015 to 2017.
Prescription drug monitoring programs (PDMPs) are one of the strategies with the most evidence backing their effectiveness to improve opioid prescribing and protect patients. In recent years, states have enacted bills to mandate PDMP registration for providers, determine who can access the PDMP on behalf of prescribers, set the length of time within which to report dispensing of prescriptions, establish requirements for checking the PDMP before prescribing, and more.
Naloxone is a medication that can reverse an opioid overdose. In addition to laws providing immunity for carrying, dispensing and/or administering naloxone, lawmakers have been increasing access to naloxone. For example, states have allowed third-party prescriptions, naloxone standing orders and pharmacists to dispense naloxone without a prescription. Other laws have expanded who is allowed to carry and use naloxone, such as family and friends, school personnel, law enforcement and emergency/first responders.
State legislators have also considered legislation related to pain clinics—facilities that specialize in treating chronic pain. Pain clinic laws often focus on licensing, regulation or other requirements. If pain clinics prescribe pharmaceuticals based primarily on finan- cial gain rather than medical need, it can lead to over-prescribing and misuse of prescription drugs. These laws have been shown to be effective in states that identified an issue with certain pain clinics.
States have also created requirements for training or education for providers related to opioids, such as training in prescribing controlled substances, pain management and identifying substance use disorders.
Conclusion
State legislators, health care providers, patients and families continue to confront the opioid epidemic with various strategies. It remains a challenge to treat pain and ensure access to effective treatments, while also preventing misuse, addiction and death. In the past few years, state leaders in at least 33 states have adopted guidelines, limits or other requirements for prescribing opioids. These new policies are among the numerous strategies that are being tested as leaders search for solutions to the epidemic.
State Prescribing Legislation
This table summarizes the limitations for opioid prescriptions recently made in state legislation, as of April 4, 2018. It does not include the laws in New Hampshire, Ohio, Oregon, Rhode Island, Utah, Vermont, Virginia, Washington and Wisconsin that authorize other entities to set prescribing limits or guidelines.
State Prescribing Legislation
State and Bill Number (Year Enacted) |
Number of Days or MME* |
Limitations/
Requirements |
Exceptions to Number of Days/MME |
Chronic
Pain |
Cancer |
Palliative Care |
Hospice Care |
Provider Judgment |
SUD /
MAT** |
Other |
Alaska
HB 159 (2017) |
7 days
|
Initial prescription for adult
Any prescription for minor
|
x
|
x
|
x |
|
x |
x |
Patient travel or logistical barrier |
4 days
|
Initial prescription for adult when prescribed by an optometrist
Any prescription for minor when prescribed by an optometrist
|
Arizona
SB 1001a (2018)
|
5 days
14 days
90 MME/day
|
Initial prescription
Following surgical procedure
New prescription
|
|
x |
x |
x |
x
|
x |
Traumatic injury
Skilled nursing facility care
Burn treatment
Infant being weaned off opioids at time of discharge (day exception only)
Hospitalization (MME exception only)
|
Connecticut
HB 5053 (2016)
HB 7052 (2017) |
7 days
5 days |
Initial prescription for adult
Any prescription for minor
|
x |
x |
x |
|
x |
x |
|
Florida
HB 21 (2018)
|
3 days |
Prescription for acute pain
|
|
|
|
|
|
|
7-day supply permitted if medically necessary based on provider professional judgment
Definition of acute pain excludes: cancer, terminal conditions, traumatic injury, and palliative care
Exceptions in dispensing provisions allow for MAT
|
Hawaii
SB 505 (2017) |
7 days |
Initial concurrent prescriptions of opioids and benzodiazepines
|
x |
x |
x |
x |
|
x |
Post-operative
care |
Indiana
SB 226 (2017) |
7 days |
Initial prescription for adult
Any prescription for minor
|
|
x |
x |
|
x |
x |
Adopted by medical licensing board rule |
Kentucky
HB 333 (2017) |
3 days |
Initial prescription of Schedule II controlled substance for acute pain
|
x |
x |
|
x |
x |
x |
Inpatient setting
Major surgery or trauma
Determined by licensing board in consultation with state Office of Drug Control Policy
|
Louisiana
HB 192 (2017) |
7 days |
Initial prescription for adult for acute pain
Any prescription for minor
|
x |
x |
x |
|
x |
x |
|
Maine
SB 671 (2016)
SB 338 (2017) |
100 MME/day
7 within
7 days
OR
30 within
30 days |
Acute pain
Chronic pain
|
|
x |
x |
x |
|
x |
Determined by dept. of
health
ER, inpatient hospitalsetting,
long-termcare facility
or residential
care facility
Surgical procedures
|
Maryland
HB 1432 (2017) |
Requires providers to prescribe lowest effective dose of an opioid and a quantity that is not greater than needed for the expected duration of pain
|
x |
x |
x |
x |
|
x |
|
Massachusetts
HB 4056 (2016) |
7 days |
Initial prescription for adult
Any prescription for minor
|
x |
x |
x |
|
x |
x |
|
Minnesota
SF 2a (2017) |
4 days |
Schedule II through IV controlled substances when used for acute dental or ophthalmic pain
|
x |
x |
x |
x |
x |
|
|
Nebraska
LB 931 (2018)
|
7 days |
Prescription for minor for acute pain
|
|
x |
x |
|
x |
|
|
Nevada
AB 474 (2017) |
14 days
90 MME/
day |
Initial prescription of Schedule II through IV
controlled substancesfor acute pain
MME limit for opioid that has never been
issued to patient before or has been issued morethan 19 days prior
|
|
|
|
|
|
|
|
New Jersey
SB 3 (2017) |
5 days |
Initial prescription for acute pain
Requires “lowest effective dose” of opioid for any prescription for acute pain
|
|
x |
x |
x |
|
x |
Long-term
care facility |
New York
SB 8139 (2016) |
7 days |
Initial prescription for adult
|
x |
x |
x |
x |
|
|
|
North Carolina HB 243 (2017) |
5 days
7 days |
Initial prescription for certain Schedule II and III controlled substancesfor acute pain
Prescription for certain Schedule II and III controlled substancesfor post-operative relief
|
x |
x |
x |
x |
|
x |
Administered in hospital,
nursing home or residential
care facility |
Pennsylvania
SB 1367 (2016)
HB 1699 (2016) |
7 days |
Prescription in ER, urgent care, hospital
observation
Any prescription for a minor
|
x |
x |
x |
x |
x |
|
|
Rhode Island
SB 2823 (2016)
HB 8224 (2016) |
30 MME/day |
Up to 20 doses for initial prescriptions for
adults for acute pain
|
x |
x |
x |
|
|
x |
Dept. of health regulations |
Utah
HB 50 (2017) |
7 days |
Prescription for Schedule II and III opioids for acute pain
|
x |
|
|
|
|
|
Surgery (permits up
to 30 days)
Complex or chronicconditions
|
West Virginia
SB 273 (2018)
|
7 days
3 days
|
Initial prescription for “lowest effective dose”
Prescription for minor
Also:
3-day supply written by a dentist or optometrist
4-day supply of an opioid for outpatient use for an adult seeking care in an emergency room or urgent care
|
|
x |
x |
x |
|
x |
Long-term care facility
7-day supply permitted in urgent care if medical rational is documented
|
*Morphine milligram equivalents (MME)
**SUD/MAT denotes exceptions for treatment of substance use disorder (SUD) or medication-assisted treatment (MAT).
Note: The table summarizes the enacted legislation and the changes made to existing law. For a more comprehensive look at how states handle prescription drug limits, view the full statutory language.