As I write this, a bill aimed at addressing the over-prescribing of opioid pain medications is making its way toward almost certain passage in the Maine Legislature. While we all should be very wary of any attempt to legislate the clinical practice of medicine, it is important to understand the genesis of these efforts.
We have known since 2010 that the dramatic increase in opioid prescribing in the last 25 years has been accompanied by:
- equally dramatic increases in the rates of overdose from these medicines (85 percent of which are accidental),
- death from prescription opioid overdose (a 265-percent increase in men and a 400-percent increase in women), and
- addiction to opioids.
We have known since 2006 that rates of heroin use and addiction have been increasing and that:
- Four out of five people who become addicted to heroin start their misuse of opioids with prescription drugs.
- Prescribing benzodiazepine drugs like lorazepam and alprazolam along with the opioid quadruples the risk of overdose.
- Higher doses of opioids lead to higher risks of overdose (nine times the risk if a person takes 60 milligrams of oxycodone a day).
- For the highest-risk users of prescription opioids, two-thirds of the pills that they use come from family and friends and not from drug dealers (meaning that they abuse the pills that we prescribe).
- Drug use and addiction account for more than 40 percent of the crime in Maine, and last year 272 Mainers died from overdose, a 31-percent increase in that grim statistic compared with 2014.
And, most critically, we know that there is no evidence that opioids help people with chronic pain and that there is very significant evidence of harm.
What the legislature knows is that, despite all of this, Maine’s doctors, nurse practitioners and physician assistants have not changed their prescribing patterns.
- Maine still leads the nation in the prescribing of long-acting opioids.
- We prescribe a volume that would provide 60 opioid pain pills for every man, woman and child in Maine every year.
Although the MaineCare limits and prior authorizations enacted in 2013 resulted in decreased opioid prescriptions for MaineCare members:
- We have increased our prescriptions for all other payers in the state.
- We continue to prescribe to people even after arrests on drug charges.
- We even prescribe to people with opioid addiction.
They have correctly expected us to reduce the prescribing of opioids and the dangerous combinations of opioids and benzodiazepines; they have explicitly asked that we help solve the challenge of opioid addiction by recognizing it, diagnosing it and treating it; and they passed a law that allows us to prescribe naloxone, a life-saving antidote for opioid overdose with the expectation that we would help to make it widely available.
And, as a population of prescribers in Maine, we have simply failed in all of these areas. It should not surprise us that the legislature feels compelled to act.
Here in the greater Bangor region, we have worked hard to address prescribing patterns. Since 2013, PCHC has decreased the number of its patients on chronic opioids by 25 percent and the number of people on chronic benzodiazepines by even more.
The Community Health Leadership Board has convened a work group of clinical leaders, which includes representatives from Acadia Hospital, Bucksport Regional Health Center, Community Health and Counseling Services, Eastern Maine Medical Center, Health Access Network, PCHC and St. Joseph Healthcare. Together we have developed standards for the prescribing of controlled substances, and patient contracts and consent forms that will be used by all organizations listed.
The group is also working on emergency department prescribing, medical specialty and dental prescribing, and will also be focusing on expanding substance use treatment services in primary care.
The Health Access Network and PCHC are recipients of federal grants to expand their existing Suboxone treatment services. Eastern Maine Medical Center’s Center for Family Medicine has been a statewide leader in offering these services, and Eastern Maine Medical Center and St. Joseph Healthcare are also examining how more can be done. We are also working toward a protocol that will make naloxone much more readily available for our patients at risk for overdose, including those receiving opioid prescriptions.
Together, we have taken these critical issues and our responsibilities in addressing them seriously, and we are developing standards that are being embraced across the state. We have a lot more work to do, and we need everyone’s help in carrying this out while maintaining a compassionate and caring environment for all of our patients. In doing all of these things, and in our collaborations with health care organizations in our region and across the state, we can meet this most important public health challenge of our time.
Noah Nesin is vice president of medical affairs at Penobscot Community Health Care. He practiced as a family physician for 27 years in the greater Lincoln area, first in private practice and then as medical director at Health Access Network, a federally qualified health center. He served in leadership positions at the local hospital and as a teacher of medical students, family practice residents and other students. In 2013 Dr. Nesin joined PCHC as chief quality officer and became chief medical officer in March 2014. Dr. Nesin is involved in a number of statewide initiatives, including the State Innovation Model grant, the Maine Independent Clinical Information Service, Maine Quality Counts, the Lunder Dineen Foundation, and Hanley Center.