Maine’s continual increase in drug overdose deaths, especially from heroin, is alarming and rightly prompts concern and calls for quick action. But prescribing how doctors treat patients with pain is the wrong approach.
We understand Gov. Paul LePage’s motivation for pursuing legislation to limit how much pain medication doctors can prescribe. Four of five new heroin users, after all, began their addiction with opioid pain medication, according to the American Society of Addiction Medicine.
However, strictly limiting what medical providers can prescribe risks leaving some patients with unbearable, untreated pain. Focusing instead on doctors who fall outside the mainstream of opioid prescribing practices is a more prudent solution.
Pain management is a serious problem. Many Mainers suffer daily from the consequences of physically demanding labor, accidents and diseases such as cancer and shouldn’t be denied relief. But there are warning signs that opioid pain medication often is prescribed in larger doses than necessary or prudent.
In 2012, Maine had the highest rate in the country of prescriptions for long-acting opioid pain relievers. The state’s overall opioid pain reliever prescription rate was 85 prescriptions per 100 people, placing the state in the middle of the country but well above the New England average of 70.
Nationally, prescription opioid sales have tripled since 1999, but Americans are reporting no less pain, according to the Centers for Disease Control and Prevention.
Exploring alternatives to medication is part of the solution but so is improved monitoring of painkiller prescribing through the state’s Controlled Substances Prescription Monitoring Program and the Maine Board of Licensure in Medicine.
Two bills lawmakers will consider this week take different approaches to reducing opioid prescriptions.
LD 1646, from the governor, would set strict limits on the amount of pain medication physicians and other medical providers can prescribe. Prescribers would face financial penalties for violating these limits. It would also require use of the state’s prescription monitoring service and electronic filing of all opioid prescriptions.
LD 1648, introduced at the behest of the Maine Medical Association, would direct the state’s Board of Medicine to develop such limits that would be written into rules governing prescribers and dispensers of controlled substances. Given the rise in overdose deaths in Maine and the governor’s insistence on tough standards and quick action, Gordon Smith, executive vice president of the MMA, said his group’s go-slow approach is unlikely to gain support in State House.
In other words, expect a compromise between the two bills.
While the MMA considers LePage’s limits too strict, they mirror prescribing guidelines from the CDC that were released this week. For example, LD 1646 would limit opioid painkiller prescriptions for acute pain to only three days. This is the same as the CDC recommendations, which have also been criticized by doctors and patients. Massachusetts Gov. Charlie Baker signed a new law Monday to limit first-time opioid prescriptions to a seven-day supply.
LePage’s bill also would restrict opioid pain medication prescription strength to no more than 100 morphine milligram equivalents per day. The CDC suggests limiting opioid prescriptions for chronic pain to less than 50 morphine milligram equivalents per day.
The CDC guidelines are voluntary.
In Maine, a set of guidelines coupled with an effort to identify and educate medical providers with high rates of opioid prescriptions is a solid, middle-ground approach. Medical providers who prescribe painkillers at above-average rates would be identified for training and counseling. If necessary, the licensure board could tie specific improvements in prescribing practices to medical licenses. This approach focuses on improvement, not punishment.
The Bangor Area Controlled Substance Group, which includes medical providers, municipal officials and concerned citizens, has developed medical practice standards for opioid prescribing and a patient provider agreement that details the patient’s responsibility when prescribed opioid painkillers. The patient agrees to use just one pharmacy, to be available for pill counts and urine tests and to not request early refills. These standards and documents are in use at all the major health care providers in the Bangor area, including Eastern Maine Medical Center, St. Joseph Healthcare, Acadia Hospital and Penobscot Community Health Care.
This work lays the foundation for better monitoring of patients and providers to ensure more responsible opioid prescribing and use. Expanded statewide, it could serve as the foundation for identifying providers who need guidance and support to improve prescribing practices. This is a more constructive approach than restricting how all medical providers can treat their patients.
