Tuesday, January 10, 2017

Maine Makes Opioid Changes

Last March, the Maine legislature passed S.P. 671. It became effective January 1, 2017 and illustrates an effort to recognize the dangers of medication. Maine is not one of the most populous states according the wikis. But, it has done some innovative things with workers' compensation. This recent legislative action is not specific to workers' compensation, but it is likely to have an impact. Maine's largest workers' compensation carrier, MEMIC, apparently thought so and reached out to injured workers recently regarding the changes. 

There are many states with prescription drug monitoring programs, "PDMP." E-FORCSE and KASPER are two I have discussed. One of the questions I have posed regarding PDMPs is the sentiment that leaves many voluntary. In 2015 I asked If it's Worth Having, is it Worth Checking? Florida's PDMP is a database into which information must be contributed, but whether to consult that data in making prescription decisions is up to the physician. We insist that the data is compiled, which suggests it is deemed relevant, but we curiously do not insist that it is used.

Maine's PDMP was also discretionary until S.P. 671. Now, the PDMP must be checked "upon initial prescription of a benzodiazepine or an opioid." Benzodiazepines include a long list, but some likely familiar examples are Xanax, Librium, Diazepam, Valium and Klonipin. Opioids include a similarly long list, including methadone, fentanyl, tramadol, oxycodone and name brands like Oxycontin, Zohydro, Duragesic and Dilaudid. 

When a Main physician prescribes a benzodiazepine or an opioid now, the PDMP must be consulted. And, if the prescription is renewed, the PDMP must be consulted every 90 days. Any physician that fails to do so is subject to a fine of "$250 per incident, "not to exceed $5,000 per calendar year." That math is pretty easy, the fines stop each year after twenty violations. Logically, there are perhaps other appropriate steps for providers who have more than twenty violations in  a year?

There are provisions of S.P. 671 that will change practices for "dispensers" also. There are instances in which prescriptions might be forged or altered. This is a possible methodology to obtain medication that was not prescribed, or to obtain more medication than was prescribed. If a dispenser "has reason to believe that that prescription is fraudulent or duplicative," then the "dispenser must notify the program." The dispenser is also obligated to delay filling the prescription "until the dispenser is able to contact the prescriber." Dispensers are subject to parallel penalties: $250 per violation with a cap of $5,000 per year. 

Fraud is a serious concern with prescriptions. Papers can be forged or modified. The verification requirement for dispensers above begins to address this concern. But, S.P. 671 will phase in another layer of security within a year. By January 1, 2018, any prescription for opioids will have to be electronic. This will make fraud and forgery more difficult. But, everyone has some doubt about the infallibility of computers, those use them, and the evil out there able to hack or manipulate them. 

In a similar step, Florida has precluded telephonic prescriptions for opioids. A great many prescriptions are not written, but are instead "called in." But, in Section 893.04, Fla. Stat. Florida has mandated that prescriptions for Schedule II Controlled Substances have to be in writing, except in emergency situations. In emergencies, a "72-hour supply" may be dispensed on an oral prescription, but may not be refilled. As technology increases, it will be interesting to see if Florida will follow Maine to a digital script requirement. 

There is also an educational component of S.P. 671. All healthcare providers that prescribe these medications will have one year to complete a medication training program. By the December 31, 2017 deadline, prescribers must "complete a training course on the prescription of opioid pain medication that has been approved by the Department of Health." Each prescriber will thereafter be required to complete a follow-up training course every five years. 

The new Maine law is unlikely to be a solution to all of the challenges opioids present. However, it appears to combine some sound contributions to controlling access to these medications. The education component makes logical sense. Remaining current on developing trends with medications may assist physicians. The electronic prescription requirement may improve communication between prescribers and dispensers, help to prevent errors, and make fraud more difficult. 

The most important provision of S.P. 671 is likely the mandate that the PDMP is checked both before a potentially dangerous prescription is filled, and periodically thereafter. This will help to assure that those prescribing medications know what other medications a patient is taking, and which other physicians may also be prescribing for their patient. Of course, this will not solve all problems and concerns. Patients may travel to avoid detection of poor behavior. And that argument is often raised when mandatory use of PDMP is discussed. This will remain a concern so long as PDMP is a patchwork of state systems, but there is belief that eventually there will be a national database for narcotic prescriptions. 

In the end, the question cannot be whether any bill or requirement is "THE" solution to the opioid crisis in America. The question has to be whether requirements are likely to be "A" solution. 




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