Opioid limits proposed for Minnesota prescribers to fight painkiller abuse

In Minnesota's latest effort to combat the abuse of prescription painkillers, a state task force has set new limits on opioid prescriptions by doctors who participate in the state's Medicaid program.

The rule, adopted Thursday by the state's Opioid Prescribing Work Group, says that doctors who exceed a new state dosage limit for more than half their patients would receive warnings and training. If they don't bring their dosage amounts down, they would eventually face removal from the Medicaid program, which covers roughly 20 percent of Minnesota's population and has broad influence on providers.

For nonsurgical physicians and dentists, the limit says that no more than half of their opioid prescriptions should exceed the dosage level of 100 morphine milligram equivalents (MMEs). That would be 20 Vicodin or Percocet pills at the common 5 milligram strength. The task force set a similar policy for surgeons, but at a threshold of 200 MMEs per outpatient prescription.

While doctors can always issue second and third prescriptions, studies have shown that many patients get over acute pain from injuries or surgeries with only small initial dosages of opioids, said Dr. Chris Johnson, an Allina Health physician who leads the task force.

"You ... don't need near as much as you think you do," he said.

The task force was formed in 2015 in response to a spike in Minnesotans dying from overdoses of prescription opioids such as oxycodone and illicit versions such as heroin. A Star Tribune review of state death records found 402 linked to opioids in 2016 — more than double the number in 2006.

The task force limits will take effect on approval by the state human services commissioner. They will apply only to prescriptions made in outpatient settings for the management of short-term, or acute, pain. And they will govern only prescriptions covered by the state Medicaid programs for the poor and disabled.

Thursday's decisions were based on an analysis of 2016 Medicaid data regarding patients who received opioids for the first time.

The analysis found that among emergency room doctors, 27 percent of outpatient prescriptions to Medicaid patients exceeded the 100 MME level.

But one in eight ER doctors exceeded that amount in at least 67 percent of their opioid prescriptions.

The data also showed the frequency with which doctors prescribed opioids.

On average, primary care doctors issued first-time opioid prescriptions to 2 percent of their Medicaid patients. But for one in eight doctors, that prescribing rate exceeded 8 percent.

The task force decided to monitor nonsurgical doctors and prescribers who exceed that 8 percent threshold.

The research basis for limiting dosage amounts is much stronger than the research for limiting the percentage of patients who receive opioids from a physician, said Dr. Jeff Schiff, medical director of the state's Medicaid program. Some doctors simply have more pain patients who would legitimately qualify for opioids, for example.

Task force members said the new targets also would need to come with exemptions for doctors whose practices require them to prescribe opioids in larger quantities.

Still to come from the task force are limits on the prescribing of opioids for chronic pain. That is controversial, because some patients have become dependent for months or years on opioids to manage pain, even though there is little medical evidence that opioids work for that purpose.

Jeremy Olson • 612-673-7744