Prescription tracking at 10: Maine police, doctors, lawmakers disagree on more stringent monitoring, even as drug abuse picture improves
Part 2 of a 2-part series
Brent Gallant will never forget the moment that launched his 15 years of prescription drug addiction.
“I remember the first day I took a Vicodin, to a tee,” says the 44-year-old lobsterman from Brunswick.
It was nearly two decades ago. Gallant worked for a paving business, and the owner’s son offered him a painkiller for an easy high. He offered again the next day. Gallant soon began paying for the drugs — just $3 per pill, much cheaper than the drinking habit he dropped in favor of medication intoxication.
A co-worker at the paving business, an older Vietnam veteran with lingering pain from the war, also had pills to share. He doctor-shopped for his drugs.
“He lived two hours north of where we worked,” Gallant says. “I would drive up there three or four times a week just to go get a couple pills to feel better.”
Gallant worked his way up from the Vicodin, gradually slipping into a hardcore drug habit and spending up to $400 per day for OxyContin and other pills. His 5-foot-11 frame wasted away to 121 pounds.
“It cost me my wife, my kids, my job,” he says. “It’s just a horrible, horrible thing to get caught up in.”
In Maine, drug investigators are familiar with the doctor-shopping circuit, and the addiction and destruction it leaves in its wake. It’s a chief reason Maine started its prescription monitoring system 10 years ago this month.
“We’ve had some cases where a person is literally traveling half the state to fill a prescription,” says Roy McKinney, director of the Maine Drug Enforcement Agency. “They’ve got a circuit, they’re visiting different doctors and then going to different pharmacies and paying cash.”
An extreme example culminated in northern Maine recently.
Authorities are still trying to determine the identity of man who visited a Fort Kent hospital on July 17, while allegedly crisscrossing the country in a desperate search for prescription drugs, injuring himself and using at least 10 different aliases while trying to obtain painkillers at hundreds of hospitals.
Although more Maine prescribers than ever before are registered for the drug-tracking program, McKinney says it’s overdue and not enough.
“That’s only half the battle,” he says. “The other side of that battle is not only are they registered, but are they actively looking at that database when an individual presents themselves with chronic pain or whatever the malady may be, and they’re going to write a prescription for these powerful opioids?”
Other states are fighting that battle. In Kentucky, New York and Tennessee, prescribers not only must enroll but are mandated to consult the program before issuing the first opioid prescription to a patient. Doctor shopping in New York dropped a remarkable 75 percent after the requirement, according to the Prescription Drug Monitoring Program Center of Excellence at Brandeis University. In Kentucky, it dropped 36 percent.
“That’s something that a state like Maine and others should consider,” says John Eadie, the center’s director.
So far, Maine appears reluctant to follow in those footsteps. In other states, requiring prescribers to use the program has led to complaints that such mandates intrude on the practice of medicine and burden time-strapped physicians.
Maine doctors would oppose such a move, according to Gordon Smith of the Maine Medical Association.
Others think mandating the program would be a tough sell here, too.
“I’m not sure if the Legislature is ready to go there yet,” says Maine Attorney General Janet Mills, citing the recent changes and legislators’ concerns about patient privacy.
Signs of progress
Nevertheless, there are hopeful, if conflicting, signs for the future of Maine’s prescription drug problem and the effectiveness of the monitoring program.
The number of Maine residents who filled prescriptions for controlled drugs is largely on the decline. In 2013, the state’s pharmacies filled 1.1 million prescriptions for narcotics, a nearly 18 percent drop from 2009.
While the amount of narcotic pills per capita has fallen overall, Maine prescribers still doled out one type of narcotic painkiller, extended-release opioids, at the highest rate in the nation in 2012, according to a July study by the U.S. Centers for Disease Control and Prevention. Researchers speculate as to why, suspecting aggressive marketing of the drugs and chronic pain problems in Maine’s older population.
Prescriptions for stimulants, including ADHD medications, are also on the increase, according to a May report conducted on behalf of Maine’s Department of Health and Human Services.
On the brighter side, an indicator of doctor shopping — the rate of patients who obtain prescriptions from five or more prescribers and fill them at five or more pharmacies over three months — dropped in Maine by a notable 24 percent from 2011 to 2012, followed by an 11 percent drop the next year, according to Peter Kreiner, principal investigator at the Brandeis research center.
The average daily dose, another measure that can point to problematic prescribing, has dipped 2 percent each year in Maine since 2011.
In the coming year, prescription information from Maine pharmacies also will be updated in the monitoring program daily rather than weekly, says Guy Cousins, director of the Office of Substance Abuse at Maine DHHS, which oversees the program.
A lack of real-time data was a chronic complaint about Maine’s system, according to prescribers and pharmacists surveyed last year.
In January 2013, MaineCare adopted new policies for pain management, including requiring chronic pain patients to try alternative therapies and limiting their daily painkiller dosing. The reforms are expected to influence prescribing behavior across the state, and they have caught the attention of private insurers.
Cousins views the monitoring program not just as a way to nab doctor-shopping criminals, but as part of this wider, systemic effort to rethink the treatment of pain.
“It’s not just the [prescription monitoring program]. … It’s information to be able to have a conversation with the client you’re trying to provide care to in a coordinated way,” Cousins says.
Experts also say Maine’s prescription monitoring program has emerged as a leader for its use as a data-driven public health tool.
“Maine has gone out of its way to make its data available to doctors, to other prescribers, to pharmacists and to the people involved in substance abuse treatment and elsewhere as a way to effectively try to combat the opioid epidemic,” Eadie says.
Unlike many other states, Maine’s program analyzes data and alerts prescribers when patients meet doctor-shopping thresholds, whether they’ve asked for the information or not.
As of May, Maine health care licensing boards began automatically enrolling prescribers when they apply for or renew their license.
The program is also linked with the state’s Health Information Exchange, a network for electronic sharing of health care data. Prescribers can access the exchange and the monitoring program with one account, saving precious minutes during office visits with their patients.
Maine hopes to connect to New Hampshire’s fledgling prescription monitoring program. In 2012, New Hampshire became the 49th state to adopt one, and it expects it to launch this fall after funding delays.
All of this, says Smith of the Maine Medical Association, is why monitoring remains the most important tool prescribers have to prevent diversion and abuse of prescription drugs.
“There were way too many anecdotes that people went to the dentist and had an extraction and needed two Vicodin and got 30,” he said. “Over time, that’s gotten a lot better. A lot of the overprescribing has been squeezed out of the system.”
Recently, Maine and New England have seen another opiate threat re-emerge: heroin, which killed 34 in Maine by overdose last year.
Yet overdose deaths from opioids concocted in pharmaceutical companies’ labs still outnumber heroin 3-to-1 in Maine, underscoring the critical need for prescription monitoring going forward.
Gallant, in Brunswick, says he’s now clean. He descended into heroin addiction when painkillers got expensive and harder to score, partly because of better tracking by the prescription monitoring program.
On Oct. 23, Gallant will mark three years of sobriety, with the help of a recovery program through the Addiction Resource Center at Mid Coast Hospital in Brunswick.
He was addicted for five times as long.
“I don’t know if that will ever go away, thinking about it,” he says of the drugs. “Doing it for so long like I did, it’s always in the back of your mind. … I keep going to my pillow every night and waiting to see what the next day brings.”