Maine law places restrictions on opioid prescriptions

Echoing a nation-wide problem, Maine is working to stem the rise of opioid use and overdose.

Maine reported more than 270 drug overdose deaths in 2015 – a 31 percent increase over 2014 – and had already recorded 189 drug overdose deaths for the first half of 2016. A majority have been linked to opioids – which include heroin, fentanyl and prescription painkillers.

A new state law enacted in July aims to prevent the overuse of opioids at the initiation of treatment. The law requires doctors to use the state’s prescription monitoring program (PMP) and sets a dosage cap on opioids.

“One of the goals of the law is to have prescribers checking the PMP to ensure patients don’t seem to be getting prescriptions from more than one provider or are filling scripts at more than one pharmacy,” said Christopher Pezzullo, M.D., Maine’s state health officer, Department of Health and Human Services.

The law also requires dispensers – such as pharmacists – to check the PMP when dispensing to new customers, out-of-state customers or customers paying in cash rather than with insurance.

The law places limitations on the duration and dosage of opioid medication that can be prescribed. While the law is in effect for new patients, that part of the law goes into effect in 2017 for existing patients on higher doses than the law allows, to give them time to come up with a more functional plan with their prescribers. Pezzullo added that there will be some exemptions, such as for patients under hospice care or cancer care.

Also, starting next July all prescribers must submit prescriptions for benzodiazepine and opioid medication electronically to try and prevent diversion and all prescribers must undergo continuing education as a condition of prescribing opioid medication.

Pezzullo says the rise in opioid use is “sort of the culmination of 20 years of policies that have really created very easy access to prescription opioids.”

“The pharmaceutical industry, especially in the 90s and early 2000s, had led us to believe that opioids were not addictive,” Pezzullo said. “The cost for prescribing opioids is fairly low. Prescribers were led to believe the choice was a good option.”

However, “If you have a box full of tools to treat chronic pain – probably opioids are the most dangerous tool in the toolbox,” Pezzullo said.

Stephen Cotreau, LADC, program manager, Portland Recovery Community Center, said that historically, while “addiction” hasn’t changed – the drugs that are prevalent and their potency has changed. He said the fluctuating potency of opiates on the street is one reason for increasing overdoses. For example, if someone addicted to prescription opioids switches to heroin when that opioid prescription is no longer available, the different drug will have a different potency level.

“And now, we’re seeing dramatic shifts from heroin to fentanyl,” Cotreau said. “So it’s a Russian roulette as far as potency levels go.”

“The age of so many people who are struggling now with a very severe addiction – they are so young,” Cotreau said. “Not that we didn’t see that 30 years ago, there were young people that were addicted, but the things that they were using – the acuity wasn’t so high. So if you take alcohol – yes, alcohol can mess up your life, but it takes a lot longer.

“With opiates we’re seeing really high acuity in late teens/early 20s,” he said.

Cotreau commended the legislation to strengthen the prescription monitoring program. “I think there is a huge amount of overprescribing,” Cotreau said. “Anecdotally, I hear all the time of people going to the doctor and explaining they are in recovery and still getting pushed into prescriptions. I think it’s built into the medical system with addressing pain.”

Cotreau is, however, concerned about the people who are currently being prescribed over the limits, who will have to reduce their dosage to comply with the new law. “I think that we have a huge population, at least in the thousands, that are right now being prescribed over the limits that are going to go into place, and there’s no treatment available,” Cotreau said. “So what’s going to happen to those people? My concern is how we are going to handle the transition.”

Cotreau said his center helps people find help with addiction and often that means referring them out of state, because a lack of availability in Maine. Cotreau said in addition to medication-assisted treatment, people need more access to detox programs and residential care. “We have 16 detox beds in the entire state of Maine,” Cotreau said. “There’s a lot of focus federally on medication-assisted treatment and I am definitely supportive of anybody’s pathway to recovery, but I think we need to let people choose what that is.”

Among medication-assisted treatments, Pezzullo said the state is launching a pilot program to expand Vivitrol treatment. Also, Pezzullo said the state is working to ensure that methadone treatment facilities are also providing the right level of behavioral intervention. “From my perspective, methadone treatment only works if behavioral therapies are robust and are part of the treatment,” Pezzullo said.

Additionally, the state launched a hotline to help pregnant women with substance use disorder connect with appropriate treatment.