County spurred to shift view toward prescription drugs

Abuse of prescription drugs is becoming a national concern, with the U.S. Centers for Disease Control and Prevention reporting that overdose deaths now outnumber deaths from motor vehicle accidents. In 2009 at least 37,485 people died from overdoses, a number that has doubled since 1999.
Maine is no exception. According to the Maine Department of Health and Human Services' Office of Substance Abuse, 544,641 different Maine individuals filled at least one prescription for a Schedule II, III or IV drug in 2008. One year later Washington County is noted by the Maine Center for Disease Control as having the highest rate of a prescribed controlled substance use in the state, at a rate of 2.15 prescriptions per person versus the state average of 1.88 per person.
In Washington County, professionals in healthcare, public safety and governance and policy have begun meeting to discuss what can be done about prescription drug overprescribing or abuse and pain management. Eleody Libby, executive director of Washington County: One Community (WC:OC), says, "As a society do we need to back up and ask ourselves how we feel about pain and how we manage it. Do we really need a pill?" She adds, "How do we make changes that help our community? It's not like a person as a child says, 'I want to grow up to be a drug addict.'"
Libby's organization is receiving a five‑year federal Drug Free Community grant. A part of that grant will be used to coordinate efforts of different groups who have particular knowledge areas, such as healthcare and public safety, to begin addressing the problem through prevention. Eastport Health Care CEO Holly Gartmayer‑DeYoung says, "We're embarking on a county‑wide strategy with WC:OC as the hub."

Using the Prescription Monitoring Program
Late October Gartmayer‑DeYoung brought many of her colleagues together to the first of a series of round‑table discussions. She says the meeting, "Demonstrated a common commitment and a yearning to be a better system." Part of that system is the Prescription Monitoring Program. The PMP is a registry of all prescriptions dispensed by commercial pharmacies, legal Internet and mail order sources for Schedule II through IV drugs. The state's prescribers may register to use the site to check to see if a patient is being overprescribed and is possibly "doctor shopping" or "pharmacy hopping." Recent state legislation has opened PMP use to certain healthcare support staff, not just doctors and pharmacists.
Gartmayer‑DeYoung notes that through the round‑table discussion the PMP enrollment process was identified as an area of concern. "I see an opportunity," she says and explains that rather than the PMP enrollment being a paper process requiring a notary and then a two‑week or longer wait for a password, an online process like those used for federal healthcare registries would allow for confidential, secure and timely registration.
PMPs are used in a majority of the country's states. According to the Alliance of States with PMPs, only New Hampshire and Missouri are without one. About 13 other states have passed legislation but have not yet enacted programs.
According to figures provided by the Maine DHHS Office of Substance Abuse, which maintains the state's PMP, as of 2009 31%, or 1,375 out of 4,400, of Maine's prescribers were using the registry. In 2007 only 1.9% or 19 Washington County's prescribers had signed up to use the registry. By the end of 2009 that number had tripled to 63 registered requesters. Calais Regional Hospital, Down East Community Hospital (DECH), Eastport Health Care and the Regional Medical Center at Lubec all utilize the PMP. Use is not mandatory, but the CEOs of all four organizations stress that their medical staff are using it and that educational efforts about the PMP's importance are ongoing.
Sheriff Donnie Smith has been a vocal supporter of the PMP and has been critical of the less than 100% use of the PMP by the county's medical community. There is no mandatory mechanism in place for PMP registration at the local or state level. Gartmayer‑DeYoung supports the idea that physician and pharmacist enrollment should be mandatory at the state licensing level. Marilyn Hughes, CEO of the Regional Medical Center at Lubec, says, "There is a need for legislative intervention at this point. We're at a point where providers need support." She notes that at times providers have tried diligently to get patients off narcotics and for their efforts were reported to the board. "I don't think a mandatory registry is a bad thing."
DECH CEO Doug Jones is not as sure about having the PMP be mandatory at the state licensing level. "If the state were to do anything it would be better education about the seductive nature of these medications. Patients start out thinking it's like aspirin C they can just walk away from it, and that's not true." For education and outreach efforts, Jones says, "I like to put doctors in the lead. If a legislator reached out to the MMA [Maine Medical Association], they'd find a receptive ear."
However, Sheriff Smith questions the effectiveness of having a non‑mandatory registry. "I don't understand why it isn't mandated by the board [of hospitals]. I think they're having trouble keeping physicians, so they don't want to."

Collaborative approach to the big picture
Calais Regional Hospital CEO Michael Lally says of the round‑table's efforts, "The real theme of the round‑table was the collaborative approach. As a subject matter it's going to take a while." The sheriff notes that CRH has received consistently high marks by the PMP office in Augusta not only for its use of the registry but also for its use of other pain management options. Lally explains that the hospital provides ongoing education about the registry to its staff. It may also help that former Rep. Anne Perry, who helped introduce legislation to start the state's PMP, works at CRH as a family nurse practitioner, he says, so the hospital's culture understood the concept long before it was put into effect.
A critical aspect of monitoring prescriptions, Lally and Jones note, is the work by the medical staff in emergency rooms with rural and family healthcare providers and the use of patient contracts when narcotics are involved. "All our ER doctors use it C that's one of the more challenging environments," Jones says of the ER. The patient contracts specify that random drug tests and pill counts may take place, or if pills are lost or missing, they will not be replaced. Hughes' organization also uses contracts, but she says, "There's enough chronic pain in this county to warrant more resources." The closest pain management services are available in the Lewiston area, with more limited service in Bangor.
Identifying and managing a patient's pain needs to involve more than medication, says Libby. Hughes agrees. "We need to reassure patients that we're going to help them manage their pain with a number of options."
"There's a big picture that needs to be looked at," comments Sheriff Smith. Both he and Libby believe the county's community needs to shift how it views substances through education, prevention and treatment. WC:OC will be working to address that big picture. Libby envisions that the round‑table group will be a subset of a task force that will provide recommendations on actions to take. There are two tiers the task force will address: underage drinking and tobacco use, which often act as a precursor to drug use, and cultural norms revolving around substance use and abuse.
A subcontractor will be working with hospitals and medical centers to set up procedures to use the PMP more efficiently, and information will be made more widely available about disposing of drugs in a responsible manner. Pain management resources need to be examined partially as a wish list, but also to determine what is available in the county that could be used more effectively, whether it's a walking track to combat depression, a massage therapist to help with pain or a nutritionist to help with overall health.
"What are we promoting and what are we supporting?" Libby asks. "We have some resources, but are we supporting them as a culture?" She adds, "How do we make it all fit together? Drug use is a huge issue; it's a phenomenon."