Consortium begins dialogue to tackle prescription abuse

Calling the misuse of prescription pain medication "an epidemic across the country," Maine Medical Association Executive Vice President Gordon Smith introduced a roster of speakers prepared to address the problem. The audience of about 50, including medical professionals, law enforcement personnel, lawmakers and other stakeholders, met at the Regional Medical Center at Lubec on February 6.
Maine Senate President Kevin Raye of Perry started out by describing the formation, announced earlier the same day, of a 17‑person task force charged with implementing the recommendations developed at the Prescription Drug Abuse Summit held last October. The task force will be chaired by pharmacist Joe Bruno, president and CEO of Community Pharmacies, and includes an array of medical, legal, administrative and law enforcement specialists. The executive order, signed by Governor Paul LePage, recognizes "the challenge of balancing prevention, education and enforcement with the need for legitimate access."
Raye, describing past efforts as "fragmented," stated that this was the first time such a multi‑disciplinary effort had been mounted in Maine. The group will work to address issues that include: the disposal of no‑longer‑needed medications; implementation of a statewide "Diversion Alert Program" to help identify individuals who may be misusing medications; development of an "evidence-based" public education program; and the establishment of specific recommendations to optimize the Prescription Monitoring Program.
Maine Attorney General William Schneider spoke about the widespread nature of the problem of prescription drug misuse. He noted that, in 2009, 169 people died in Maine from drug overdoses and that prescription drugs counted for 97% of those cases, mostly methadone and oxycodone. He added that he couldn't speak of the babies born with addiction "without choking up."
Schneider described how, in his earlier days as a prosecutor, most convictions involved "heroin, crack and cocaine," but nowadays "80% involve prescription painkillers." He pointed out that the presence of large cities facilitates the movement of the "hard drugs," but that in Maine the lack of major cities and the diverse nature of the population make distribution of those more difficult. Prescription medications, however, are "available everywhere" and are often obtained, knowingly or not, from family members. He added that attempts to obtain these medications are often found to be the cause of major crimes, including murder.
Several medical professionals in the audience expressed concerns about being held liable for reporting individuals -- including other doctors -- for what they believe to be misuse, observing that their reports were "discoverable" by defense attorneys. Schneider replied that although there were "due process" issues involved and that patient confidentiality rules were complex, medical personnel who feel that filing a report would leave them open to recrimination should "talk to us," suggesting there were ways to deal with this problem.
Referring to the October meeting, Schneider noted that members of that group had referred to the "culture of hopelessness, culture of poverty" as being a key component of the drug diversion problem. Smith added, "This is the most difficult one to work with."
Chris Gardner of the Maine Drug Enforcement Agency spoke of some of the enforcement challenges. According to Gardner, most of the improperly utilized prescription drugs were obtained by "doctor shopping," illegal Internet pharmacies, theft of drugs, prescription forgery and by illicit prescriptions from doctors. He referenced several Maine statutes that are already on the books that cover these offenses. Gardner got a chuckle from the doctors in the room when he said that, during the execution of a search warrant, it is quite common to "find the Physician's Desk Reference on the kitchen table," adding that most of those prosecuted are quite familiar with the properties of the medications. "These people know exactly what they're doing," he said.
Gardner pointed out that a single bottle of 150 30-milligram oxycodone tablets commands a street price of $6,000, making it profitable to travel great distances to obtain medications for resale.
Patricia Lapera of the Office of Substance Abuse described the Prescription Monitoring Program (PMP), which tracks, among other things, usage patterns and number of different physicians prescribing to each patient. She cited numbers that showed that, while most people obtain prescriptions from only one physician, many visit more than one. In fact, according to Lapera's data, in both 2006 and 2007, 83 different physicians wrote prescriptions for a single individual, although possibly not the same individual in both years. This "doctor shopping" behavior is the issue that the PMP is designed to address; according to Lapera almost all states have implemented similar systems and interstate data‑sharing has started.
Rebecca Morin from the Maine Primary Care Association (MPCA) spoke of efforts to persuade more physicians to make use of the PMP before issuing prescriptions for classified medications. The association is also working towards "utilizing an equitable discontinuation process in primary care," which includes increased use of "patient contracts" where patients agree in advance to procedures to end the use of potentially addictive painkillers. Morin provided a white paper prepared by the MPCA that states that "with a rate of 87‑200 defined daily doses [of opoid‑based medications] prescribed per 1,000 Medicaid [MaineCare] beneficiaries, Maine ranks among the nine states with the highest rates of opoid prescribing."
Smith of the Maine Medical Association closed the meeting by talking about efforts to educate physicians about dealing with pain without the use of medicine, such as yoga. He cited personal experience where he was provided a series of stretching exercises that allowed him to overcome pain and resume running without any medications. He also emphasized the use of patient contracts. When Smith said, "Most of the people started out with a legitimate need. Then they got in trouble," the MDEA's Gardner nodded vigorously in agreement.
Smith concluded the meeting by saying, "We don't want physicians to be part of law enforcement," and then added, "We also don't want physicians to be complicit in the deaths of 170 of our neighbors each year."
(This article is part one of a two-part series.)