At Acadia Hospital in Bangor, individuals suffering from chronic pain, many of them for years, gather once a week to find relief in their thoughts, rather than a pill bottle.
Some injured themselves at work, others struggle with debilitating headaches and neck pain. A few don’t know why they hurt.
While some take prescription narcotics, all of them are learning to ease their pain by thinking about it differently as part of the hospital’s cognitive behavioral therapy pain treatment program.
“Many people don’t want to take these medicines,” said Brent Scobie, who oversees the program. “They want to reduce, if not eliminate, them.”
Launched in September 2012, the program served 54 patients from across the state in its first year, Scobie said. Many of the patients saw improvements in the severity of their pain, their ability to handle day-to-day life in spite of it, and their level of psychological distress, he said. Attending once a week for eight sessions, patients learn to understand the relationship between pain and stress and how to monitor their thoughts and behaviors to better manage symptoms.
Chronic pain patients in Maine are increasingly turning to such approaches, due in no small part to changes in the state’s Medicaid program. In response to legislation targeting the state’s opiate addiction problem, MaineCare, the state’s version of Medicaid, in January 2013 began requiring chronic pain patients to try alternative therapies and limiting their daily painkiller dosing. The program also restricts patients to two weeks of opioid painkillers during a year, unless a doctor justifies a longer treatment period.
As a result, MaineCare recorded a remarkable 30 percent drop since 2011 in the number of recipients receiving prescriptions for opiate medications. The reduction, for drugs such as OxyContin, Vicodin and hydrocodone, led to savings of more than $1 million last year, according to Dr. Kevin Flanigan, MaineCare’s medical director.
“I’m very pleased that MaineCare’s been able to take the lead and shift its policy toward one that embraces what the evidence and the literature shows to be more effective treatment of pain,” Flanigan said. “We’ve been able to do that so far without negatively impacting those people who truly require opioids for pain management. In short, I think our members are getting a higher level of care today because those options are available to them.”
The state has witnessed a corresponding uptick in the number of visits to physical and occupational therapists, cognitive behavioral therapists, chiropractors and other alternative pain treatment providers.
While opioid painkillers can prove helpful in the short term, as part of recovery from an injury or surgery, the drugs fall short for patients who experience lingering pain for months or years, Scobie said.
“They’re really not indicated for the treatment of chronic pain, although they’ve been the most commonly used treatment for chronic pain within the U.S. health care system … They don’t work well and they cause tremendous side effects and carry tremendous risks, as we know here in the state.”
Flanigan said he hadn’t expected the policy changes to result in such a large downturn in the number of MaineCare patients receiving opiate medications.
“[The change] wasn’t designed to impact the number of members getting opioid prescriptions, it wasn’t designed to impact the total amount of opioids,” he said. “It was designed to improve pain management. In doing so, you have providers better assessing which treatment to pursue.”
The changes also included shifting the definition of what treating pain should accomplish, Flanigan said. Rather than expecting to live a life without pain, patients should measure success in terms of how well they function in their daily lives, he said.
“You might not be pain-free and yet your pain is reduced to the point that you can do everything you need or want to do,” Flanigan said.
Police have linked the MaineCare changes to a resurgence of heroin use in Maine over the last year. Opiate medications have become harder to obtain and more expensive, and provide a less potent high than heroin, Brunswick police Detective Rich Cutliffe, an MDEA agent with the Portland Task Force, said in May.
During debate last year, the changes also sparked concerns that patients with a legitimate need for opiate painkillers would face hurdles accessing the medications. But Flanigan said those worries haven’t panned out. The impact on cancer patients and those in palliative or hospice care, who often need high doses of opiate medications for longer periods, has been minimal, he said.
No patients have filed appeals after being denied an opiate medication based on the new rules, according to Flanigan.
The program also has seen a five percent drop in ER visits for MaineCare patients with a diagnosis of drug overdose.
While the state’s physicians organization has pushed back against other new MaineCare rules — particularly those restricting methadone treatment for substance abuse — the group supports the changes to opiate prescription practices.
“I think it’s gone remarkably well,” said Gordon Smith of the Maine Medical Association, which was part of a work group involved in drafting the changes.
While MaineCare has seen the number of recipients receiving prescriptions for opiates decline, other insurers appear to be lagging behind the program, Smith said. There’s been no similar drop among commercially insured patients and even an uptick in Medicare patients on the medications, he said.
On a related front in the battle against opiate addiction in Maine, thousands of physicians are flooding the Maine Department of Health and Human Services with registration applications for the state’s prescription monitoring program, Smith said. The program, which operates a database that records patients’ prescriptions for restricted drugs in an effort to prevent “doctor shopping,” was hit with 2,000 applications over three days ahead of a looming March 1 registration deadline, he said.
Smith estimated about 75 percent of Maine doctors have now registered for the monitoring program. His association is backing legislation that would instead allow doctors to automatically register upon seeking a Maine medical license.
So far, Maine appears to have enough therapists to accommodate the rise in MaineCare patients seeking alternative treatments, Smith said. New clinics have opened to meet the demand and more providers are accepting chronic pain patients, according to Flanigan.
At Acadia Hospital, the cognitive behavioral therapy program for chronic pain operates right alongside the facility’s methadone clinic for substance abusers. While partly a response to the MaineCare changes, the therapy program also was designed to prevent patients from ever needing methadone to recover from addiction, Scobie said.
A survey of Acadia’s methadone patients in 2008 showed that 66 percent were first exposed to opioids as part of treatment of chronic pain, he said.
Even for a patient taking narcotics, dropping from four pills a day to two could mean better control over their pain, Scobie said. The average patient in the cognitive therapy program has been in pain for more than 11 years, he said.
“In the context of chronic pain … there’s no silver bullet,” Scobie said. “What the research tells us is that the best treatment for chronic pain is a mix of multiple kinds of treatments that match the particular needs of each patient.”