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Save the Date / July 10, 2017 a quarterly publication of the Maine Medical Association jaNUARY/FEBRUARY/MARCH 2017 Maine Medical Association Mission: SUPPORT Maine physicians, ADVANCE the quality of medicine in Maine, PROMOTE the health of all Maine citizens. PRESCRIBING FOR PAIN LIMITATIONS CONTINUING TO CHAllENGE Will you be ready to meet PATIENTS AND PRESCRIBERS Maine’s e-prescribing Maine’s landmark law limiting opioid prescriptions and rule changes as routine technical rules. Emergency mandating PMP checks and electronic prescribing routine technical rules are effective for up to 90 days. mandate by July 1, 2017? continues to present challenges to patients who are Emergency substantive rules may be effective for up to See article on page 7. over the daily dosage limits and to prescribers who are 12 months or until the Legislature has completed review trying to sort out fact from fiction relative to the law and of the rules. In its communication dated January 1, 2017 the emergency rule published by HHS on Jan. 2, 2017. to prescribers, the Department announced its intention MAINE QUALITY COUNTS Maine State Health Officer Christopher Pezzullo, D.O. to “engage in a single rule-making which will make By Dr. Erik Steele, Interim Executive Director also has communicated to prescribers stating that the permanent the emergency technical rule provisions state will not enforce the mandatory PMP checks (by and which will also provisionally adopt the emergency OVERCOMING THE OpIOID reporting violations to the appropriate licensing boards) major substantive rule provisions, which will then be EpIDEMIC IS THE WORK OF until March 1 and will not enforce dosage limitations submitted to the Maine Legislature for its review.” In All OF US prior to Oct. 1, 2017. MMA had requested a grace period other words, MMA and other advocacy organizations, in order for prescribers and patients to be educated on patients and prescribers will have at least three Peter was a patient of mine the emergency rule and also to accommodate for the opportunities to provide input into the rule and the law. to whom I prescribed opioids conversion of the PMP to a new vendor which took First is the opportunity to provide comments orally or in intermittently for several years. place on Dec. 20, 2016. The conversion to the new writing at or following the rule-making hearing February I remember to this day how platform resulted in all delegates having to re-register 13th at 9:00am at the Augusta Armory. Second is the shocked I was to finally discover that he was not only in the system, a process that also required approval by opportunity to testify at the Legislative hearing on the pathologically hooked on opioids, but was so hooked the prescriber. proposed final rules and the third is an opportunity to he was stealing money to buy them on the street. Even testify on one or more of the many bills that have been more shocking to me, was that a patient I liked and The emergency rule did provide three important submitted to this session of the legislature proposing to respected, an upstanding member of the community, additional exceptions to the law but also attempts amend Chapter 488. There will also be hearings on the had been deceiving me. to limit the exemptions previously granted by the proposed amendments to Joint Rule 21 by the licensing legislature in the original legislation (PL 2016, Chapter boards. In some cases, the proposed amendments to Well intentioned as I was, I did my part contributing to 488). The additional exemptions are: the Chapter 21 rule goes further than the statute and Peter’s opioid use disorder (OUD), and by extension the rules in mandating certain prescribing practices and my part in contributing to Maine’s opioid use disorder 1. A pregnant individual with a pre-existing universal precautions. epidemic. I was not aware enough that every patient prescription for opioids in excess of 100 Morphine I prescribed opioids to even once had a real risk of Milligram Equivalent aggregate daily limit. This Watch the MMA Weekly Update, e-mailed each developing OUD. I was too easy to convince that every exemption applies only during the duration of the Monday, for timely information on the dates of these patient’s pain needed eradication, and that opioids were pregnancy. hearings. If you are not receiving the Weekly Update the best tool for doing that. I was intent on reducing 2. Acute pain for an individual with an existing opioid and would like to do so, communicate with Lisa Martin the painful suffering of my patients, and too unaware prescription for chronic pain. In such situations the in the MMA membership office (622-3374 ext. 221 or of the suffering that might develop if my pills were acute pain must be postoperative or new onset. e-mail [email protected]). used inappropriately. I failed to see that our efforts in The seven day prescription limit applies. healthcare to be more effective in treating pain – efforts 3. Individuals pursuing an active taper of opioid MMA attorneys have provided over forty CME promoted on a national level by healthcare regulators medications, with a maximum taper period of six presentations on Chapter 488 and the associated rules and pain experts – was ‘opioid-dependent’ itself, and months, after which time the opioid limitations will since May, 2016. If you would like a presentation at your would come back to haunt us all. apply, unless one of the additional exceptions in practice site, your medical staff or medical specialty this subsection apply. society, contact Gail Begin at [email protected] For these and other reasons, I contributed my small or EVP Gordon Smith, Esq., at 622-3374 ext. 212 or stream of unnecessary opioid pills to thousands of other The emergency rule attempts to limit the statutory e-mail to [email protected]. Many of these such streams from physician offices, hospitals, and exemptions by limiting the exception for active and presentations are supported through a contract with emergency departments across Maine. Together we aftercare cancer treatment to six months post remission. MaineCare and a grant through the Maine Health created the flood of opioids that has now engulfed us, MMA does not believe that this limitation is lawful in that Access Foundation so there is no cost to the attendees. kills more Mainers each year than car crashes, wreaks the rule-making provision authorized OUD-induced havoc in homes and communities, and the Department “to establish reasonable has made Maine a national showcase for the opioid exceptions to prescriber limits” not to tsunami. limit those exceptions already granted by the law. There are several other Having helped make this mess, I now need to help fix provisions in the emergency rule it, by starting a different small stream. As I go back into that MMA will be seeking changes to, family practice in Maine, I will take my 8 hour course and including the requirement to add the do other work to be able to prescribe suboxone therapy ICD-10 diagnosis code to each script – one part of Medically Assisted Therapy (MAT) for OUD, over 100MME, mandatory reporting and provide treatment for as many as I and my practice of unlawful scripts to the PMP can capably manage. I will begin screening for OUD coordinator and the broad definition among my patients, and treating or referring those who of “dispenser” which threatens to make need help. I will dramatically change my approach to each prescriber who also dispenses a the treatment of pain, avoiding use of opioids wherever mandatory reporter to the PMP. possible, weaning patients off opioids wherever I can, and partnering with other healthcare providers and Maine law designates the PMP state government in meticulous management of opioid regulations as major substantive rules, prescribing. That all amounts to a big, challenging pain requiring legislative approval. However, Lani Graham, M.D., a member of the prevention/harm reduction task in my practice, but I don’t think any of us who helped Chapter 488 assigned some of the force of the Maine Opiate Collaborative speaks at January 18 community get Maine and its people into this opioid mess can, in forum in Augusta. good conscience, do anything less. There is a growing help for those on the challenging SAVE THE DATE / JULY 10, 2017 front lines of MAT; health systems across Maine have geared up substantial efforts to support their physicians, MMA's 14th Annual Benefit Golf Tournament nurse practitioners, and other caregivers in this work. Augusta Country Club, Manchester, ME The Maine Medical Association, Maine Quality Counts, Contact Lisa Martin at 622-3374 ext. 221 or [email protected] Maine state government, the Maine Health Access for more details, including sponsorship opportunities. Continued on Page 3 Check out the inserts with this issue including the MMA Upcoming Happenings, Golf Flyer, and June 17, 2017 Program. A Message for Physicians and Physician Assistants of Maine President’s CORNER By Stephanie Podolski, MPH, MSPA, PA-C, President of By Charles Pattavina, M.D., President, Maine Medical Association the Maine Association of Physician Assistants RAMBLING THOughTS lost three of five people taking call in one subspecialty, so I am writing to you today as ON PROFESSIONALISM we have 22 days uncovered by that specialty in January. President of the Maine Asso- And this is a specialty we don’t call very often! ciation of Physician Assistants A couple of weeks ago I was (MEAPA), but also as your col- working in the E.D. alongside A subspecialist from the Augusta area recently wrote league and friend. As an or- my esteemed colleague, this to me: “Just saw a young kid about 10 years old ganization, MEAPA would like Scott Thomas, D.O., and from Addison because Tufts [same specialty] resident to thank our collaborating we found ourselves talking called me and I, while on call, agreed to see the patient and supervising physicians for about some rewarding col- so they would not have to go to Boston for a [non- their continued dedication to legial experiences we have operative surgical problem].
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