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Part I: Maine's Prescription Monitoring Program
04/16/2012   Reported By: Jay Field

Maine has a drug problem. More specifically, a pill problem. As part of the effort to combat this growing type of substance abuse, Maine began operating a prescription drug monitoring program. Forty-one states now run these electronic databases. Pharmacies feed them regular updates on what controlled substances are being dispensed week-to-week or month-to-month. Roughly half of Maine's physicians are registered to use the database, the highest level of participation in the nation. But in the eight years since the system launched, abuse and diversion of pills has become more widespread and consistently high numbers of people are dying from overdoses. This week, we begin a series of reports on the so-called PMP in Maine. We'll look at where Maine's approach to prescription drug monitoring is working and where it's falling short. Part 1 begins with a look at how we got to where we are today.

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Part I: Maine's Prescription Monitoring Program Listen

In 1997, thirty-four people died of drug overdoses in Maine. That same year, a new chief medical examiner arrived in Augusta, the state capitol.

"I thought I'd come to some kind of paradise at that point," said Dr. Peggy Greenwald.

She spoke about her early years on the job at a statewide summit on prescription drugs last fall.

"Having come from California and Boston, where there was huge epidemics of cocaine and methamphetamine, it kind of looked like the drug problem had passed us by," Greenwald said.

But by 2001, the number of drug-related fatalities in Maine had tripled.

They jumped again in 2002 to 165 deaths, a number that's held steady ever since.

And with each passing year, it turns out, the deceased have increasingly shared one thing in common: the presence of at least one prescription drug in their systems when they died.

Greenwald said overdoses from these powerful narcotics now kill more people in Maine each year than car accidents.

"Clearly, we still have a core problem there that we need to deal with," she said. "Prescription monitoring, narcotic contracts, drug screening, they help us identify when people do abuse, but they really are not helping us to prevent it."

In the spring of 2003, after two unsuccessful tries, Maine lawmakers finally created a prescription drug monitoring program. Anne Perry, a nurse practitioner and former state representative from Washington County, spoke with reporters, shortly before the bill's final passage.

"Essentially there will be identification numbers set up for clients who come in to have a prescription filled," said Perry. "And it will go onto a central system. It'll allow the pharmacist to know whether there has been other prescriptions for that person throughout the state."

And hopefully, the thinking went, their doctor too. The PMP would teach physicians and pharmacists to recognize the signs that a patient might be doctor shopping: going from practice to practice, feigning pain, in an effort to score drugs.

"So if a patient crossed a threshold or a high number of prescribers or a high number of pharmacies within a given quarter, that patient would trigger what's called a patient threshold report," said Dan Eccher. He used to manage Maine's PMP.

He said these red flag reports get worked up and sent out to doctors at the Office of Substance Abuse in Augusta, where the database is housed and managed. Eccher ran the PMP for four years. He has a Masters in Public Health from Boston University, specializing in epidemiology and biostatistics. Eccher said after few months on the job he began to realize that managing the drug database was unlike any other job in the state.

"I started to feel uncomfortable with the fact that I had access to information that no one else in the state had access to," Eccher said.

Like exactly how much pain medication doctors, nurse practitioners and physicians assistants in Maine were prescribing on a daily basis.

"I was basically the only one in the state who was able to see what prescribers were doing," said Eccher.

And in many cases, prescribers themselves didn't realize what was happening.

"The first three weeks that I was on the job I felt like I was a patient magnet. I was the new provider on the block. I didn't know them," said Ann Gahagan. She who became a nurse practitioner in Presque Isle in 2004. She said that after she prescribed pain medication to one patient, she'd almost immediately get calls from pharmacists in the area. The prescription had been altered.

"They didn't know what to do about that. They said, 'Did you prescribe such and such to such and such?' And I said, 'NO!' And they would give the prescription back to the patient, and the patient would take it from one pharmacy to the other, from Houlton to Fort Kent."

The police finally arrested the patient and Gahagan had to give a deposition. At the time, Gahagan said she'd never even heard the words diversion and oxycontin or hydrocodone used in the same sentence.

"It was quite an eye opener for me. And I realized that there were multiple patients in the same situation and we weren't really doing a very good job kind of policing ourselves," Gahagan said. "I don't think we realized how much we were prescribing and I don't think we had the research to back up how addictive these meds were."

Their addictiveness, of course, is now well documented. But only recently, have researchers begun to figure out how big a role prescribing practices may be playing in unintentionally fueling Maine's prescription drug abuse problem. Dr. Christina Holt is a family physician and researcher at Maine Medical Center in Portland. Two years ago, Holt got some funding to study prescribing trends in Maine, using five years worth of data from the prescription monitoring program.

"In 2006, we had about two million prescriptions dispensed. And in 2010, there were two and half million," Holt said. "So over five years, there was 22% more prescriptions that were dispensed from pharmacies in Maine."

During the same time period, the number of oxycodone prescriptions filled in Maine went up by nearly 50%.

"What this type of data set does not tell us is, 'Are the purposes for which these prescriptions are being written, are those legitimate or not?'" said Hold.

Part II of this series will look at the role the Prescription Monitoring Program plays in trying to answer this question and whether Maine's approach is working as well as it could be.


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