May 20, 2018
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A path to better opioid prescribing for Maine?

By Dr. Erik Steele

I would rather incise large boils for oodles of yucky pus or drive a car full of bad-ass bees than prescribe narcotic pills to patients on a chronic basis. That’s why I was hoping the Maine Legislature would pass a bill it was considering to make prescribing narcotics so burdensome I would have had a good excuse to punt the patients and the problem to someone else.

No such luck; the Legislature ordered the establishment of an ad hoc work group to study narcotic prescribing in Maine and its relationship to Maine’s narcotic pill addiction epidemic, and report back to the Legislature with recommendations by year end. That left me to continue wriggling on the hook of narcotic prescribing for chronic pain, the singular most difficult, stressful thing I do in the practice of medicine.

I wish this work group luck, because I need all the help I can get on the issue, and so will they. For that group and others seeking to assure adequate pain treatment here while stemming the flow of narcotic pills to Maine people (who currently have the highest rate of residents seeking treatment for narcotic addiction in America), here are a few ideas.

First, don’t put the burden of all of the solutions on the shoulders of the providers (physicians, nurse practitioners, and physician assistants). We cannot fix this problem alone, especially when society wants complete control of its pain on the one hand, but no spillover of the narcotics used in the treatment of that pain into the realm of narcotic addiction and abuse on the other.

I need help with this dilemma. For example, my employer measures the satisfaction of patients with my treatment of their pain, and the state medical board can take my license away if I am felt to be too liberal in my treatment of pain with narcotics.

We need more and better treatment programs for addicts, not just more jail cells. We need education of the public about the treatment of pain, the risk of narcotics, and the trade-off between narcotic abuse and narcotic pain  treatment, and much more. So don’t leave me and my medical colleagues alone at the dike holding back an ocean of addiction and pain when the report is done; this is a societal problem too.

I am personally tired of being told by people who know almost nothing about this subject and who bear no responsibility for caring for patients whose lives are being run and ruined by pain, that the answer is for me to simply prescribe fewer pain pills and this is just my problem to fix.

We also need better help treating some of these patients. Most of Maine’s pain specialists do not provide ongoing assistance to primary care providers in the management of patients with severe, chronic, nonoperable pain who are getting by only with the help of large daily doses of narcotics.

So second, the work group should make recommendations for the development of regional multidisciplinary pain centers in Maine to which all of us can refer challenging chronic patients for pain expert management advice and co-management. Such centers must have pain specialists, mental health and addiction experts, physical therapists, etc., work with patients and their primary care providers over the long haul. The centers must be able to take all patients regardless of ability to pay. Such centers will not be economically viable without state government help; that’s probably why there isn’t a center like this that I know of in all of Maine.

Third, charge the state’s medical and hospital associations, and its professional associations of emergency and primary care physicians, to work collaboratively on the problem on a sustained basis. Despite the magnitude of the problems with narcotic pill prescribing and addiction in Maine, there is no ongoing, organized effort among hospitals and physicians to address them. Responsibility for ongoing work after the ad hoc group is done must be housed in those physician and hospital organizations, with other stakeholder support, or the effort to rein in narcotic prescribing and addiction will die faster than the Oxycodone I prescribe can be snorted.

Fourth, hurry. Boils and bees seem more appealing all the time.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems.

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