Intent On Reversing Its Opioid Epidemic, A State Limits Prescriptions

Aug 24, 2017
Originally published on August 23, 2017 9:34 am

A year ago, Maine was one of the first states to set limits on opioid prescriptions. The goal in capping the dose of prescription painkillers a patient could get was to stem the flow of opioids that are fueling a nationwide epidemic of abuse.

Maine's law, considered the toughest in the U.S., is largely viewed as a success. But it has also been controversial — particularly among chronic pain patients who are reluctant to lose the medicine they say helps them function.

Ed Hodgdon, who is retired and lives in southern Maine, was just that sort of patient — at least initially.

Name a surgery, and there's a decent chance Hodgdon has had it.

"Knee replacement. Hip replacement. Elbows. I've got screws in my feet," he says.

Hodgdon has rheumatoid arthritis. And along with each surgery came an opioid prescription for pain. At first he got some relief from the drugs, but it didn't last.

"It just numbed it for a while," he says, "and then I needed more."

Though Hogdon kept increasing the dose, the pain never went away.

"And then I found Dr. Medd. That's my angel right there," Hodgdon says, nodding toward Dr. Donald Medd, a general internist in Westbrook.

Medd had already started to taper high doses among patients like Hodgdon before Maine put a cap on new prescriptions for opioids last July. The new limit allows a maximum of 100 morphine milligram equivalents (the standard used to measure potency for all prescription opioids) for most patients per day — with certain exemptions for some cancer patients, those in hospice care, and some others. Patients with existing prescriptions were, by and large, given a year to meet the new restriction.

Medd was ahead of the game because he'd noticed that many of his patients on high doses of opioids grew increasingly angry about their pain as time wore on, and tended to demand ever more medication. At the same time, they were struggling to function in daily life because of the drugs' side effects.

"You know, at some point the medications get in the way of some sort of recovery," Medd says.

Opioids were affecting Hodgdon's mood and his memory. Medd worked with him to cut the dose he was taking every day by two-thirds and helped him get in touch with a psychologist for further help. Though Hodgdon still lives with some pain, he says his life is infinitely better.

"I can remember things," he says. "I get along better with people."

Despite success stories like Hodgdon's, Medd says he initially opposed Maine's law. He didn't want the legislature to interfere with medicine.

But now he thinks the law gave a necessary nudge to many doctors. Compared to a few years ago, Medd says, he and colleagues in his medical practice have cut the number of their chronic pain patients who are on opioids by almost half — from about 1,500 to 800.

In nearly all counties in the state, the number of prescriptions for painkillers is dropping. It's a trend that Gordon Smith, executive vice president of the Maine Medical Association, says was underway even before the law took effect.

"We had the fourth largest drop in the country," he says, citing a 21.5 percent reduction in opioid prescriptions from 2013 through 2016.

The data only include the first few months after Maine's prescribing cap went into effect, Smith says; he expects the law will accelerate further reductions.

"Now having said that, it's not been easy," he says. "It's been particularly difficult for patients," he says — specifically for the 16,000 patients on high-dose opioids who were expected to taper to the 100 morphine milligram limit by July of this year.

"I was about four times above that," says Brian Rockett. He operates a wholesale business buying lobsters on the Maine coast. Rockett started taking opioids years ago to ease the pain of injuries from racing motorcycles and boats. When he tried to taper the dose, he says, he had unbearable pain. So, he filed a notice of intent to sue the state over its restrictions on how much he could be prescribed.

"I just knew that I was facing possibly losing my business," he says.

Rockett wasn't alone in his inability to taper his use of the drug, and Maine lawmakers — like Dr. Geoffrey Gratwick, a state senator who is also a rheumatologist — took notice.

"A certain group of people simply cannot come off [opioids]," Gratwick says.

He recently pushed through a change to Maine's law that allows broader exemptions, so that people with incurable, chronic conditions can continue to take high doses.

It put the decision about that back in the hands of the doctor and patient, Gratwick says, "where it should be."

Under the revised law, Rockett was able to increase his dose, and dropped his lawsuit.

Even though more patients could, potentially, seek exemptions, Maine's law is seen by its advocates as an important step. Recent data from the federal Centers for Disease Control suggest that nationwide, despite an overall decrease in recent years, the number of opioids prescribed still triple what it was in 1999.

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AILSA CHANG, HOST:

One year ago, Maine was one of the first states to set limits on opioid prescriptions. It's an attempt to slow down the flow of the pills that are fueling a nationwide epidemic. The law is considered the toughest in the nation. And it's largely viewed as a success. But it hasn't been without controversy. Maine Public Radio's Patty Wight reports.

PATTY WIGHT, BYLINE: Name a surgery and there's a decent chance Ed Hodgdon has had it.

ED HODGDON: Knee replacement, hip replacement, elbows. I've got screws in my feet.

WIGHT: Hodgdon has rheumatoid arthritis. Along with those surgeries came opioid prescriptions for pain. But he says the pain never went away.

HODGDON: It numbed it for a while. And then I needed more.

WIGHT: So gradually over time, you needed a higher dose.

HODGDON: Higher dose, yeah. And then I found Dr. Medd. And that's my angel right there.

WIGHT: Dr. Donald Medd is a general internist. Last July, Maine capped new prescriptions for opioids to a maximum of 100 morphine milligram equivalents per day. That's the standard used to measure potency for all prescription opioids. Patients with existing prescriptions were given a year to meet that limit. But Dr. Medd had already started to taper high-dose patients like Hodgdon a few years before after he noticed many grew increasingly angry about their pain and demanded more medication.

At the same time, they struggle to function in daily life.

DONALD MEDD: Yeah, at some point, the medications get in the way of some sort of recovery.

WIGHT: Hodgdon says the opioids affected his mood and his memory. Dr. Medd cut his prescription by two-thirds and connected him to a psychologist. Hodgdon still lives with some pain. But his life, he says, is infinitely better.

HODGDON: I can remember things. I get along better with people.

WIGHT: Despite success stories like Hodgdon's, Dr. Medd initially opposed Maine's law. He didn't want the legislature to interfere with medicine. But now he thinks the law gave a necessary nudge. Combined with early efforts, Medd says his medical group has cut its number of patients on opioids for chronic pain almost in half from about 1,500 to 800. Gordon Smith of the Maine Medical Association says overall, the state of Maine has seen a drop in painkiller prescriptions.

It's a trend that he says was underway even before the law took effect.

GORDON SMITH: We had the fourth-largest drop in the country, 21.5 percent reduction in opioid prescriptions from 2013 through 2016.

WIGHT: That data only includes the first few months of Maine's prescribing cap. Smith says he expects the law will accelerate further reductions.

SMITH: Now, having said that, it's not been easy. It's been particularly difficult for patients.

WIGHT: Specifically, the 16,000 patients on high-dose opioids who are expected to taper to the 100 morphine milligram limit by July of this year.

BRIAN ROCKETT: I was about four times above that.

WIGHT: Brian Rockett operates a wholesale lobster buying business on the Maine coast. He started taking opioids years ago for injuries from racing motorcycles and boats. Rockett says when he tried to taper, he had unbearable pain. He filed an intent to sue the state.

ROCKETT: I just knew that I was facing possibly losing my business.

GEOFFREY GRATWICK: A certain group of people simply can't come off it.

WIGHT: Geoffrey Gratwick is a retired rheumatologist and a state lawmaker. He recently pushed through a change to the law that allows broader exemptions so that people with incurable, chronic conditions can take high doses.

GRATWICK: It put the decision about that back into the hands where it should be, the doctor and the patient.

WIGHT: Under the revised law, Ryan Rockett was able to increase his dose and dropped the lawsuit. Even though more patients could potentially seek exemptions, Maine's law is seen as an important step. Recent data from the federal Centers for Disease Control found that nationwide, despite an overall decrease in recent years, the number of opioids prescribed is still triple what it was in 1999. For NPR News, I'm Patty Wight. Transcript provided by NPR, Copyright NPR.