Amidst all the talk of 7-day initial opioid script limits in New York, Massachusetts, and New Hampshire (with New Jersey, Connecticut and others likely not far behind), we appear to have missed a piece of legislation that, in my view, represents the single most stringent legal construct for opioid prescribing in the country. Before we get to Maine's new law, a quick aside on the new approach sweeping the northeastern US: These new limits are extremely helpful, but not the panacea some are making them out to be. A 7-day limit for new scripts (in most states, for acute pain only) will absolutely help limit black market diversion and over-utilization generally... but we'll also see more office visits (on day 8!) and not enough progress on long term chronic pain cases. A necessary step, no doubt, but insufficient to address the entirety of the problem.
Back to Maine: Guess what they did back in April that no one noticed? They put a statutory cap on morphine equivalent dosage per day. The state legislature passed it, the governor signed it, it goes into effect on January 1, 2017... and not a lot of people are talking about it.
The cap is 100 mg MED per day. Specifically, a licensed practitioner in Maine "may not prescribe... to a patient any combination of opioid medication in an aggregate amount in excess of 100 morphine milligram equivalents of opioid medication per day." But what if a patient is already on more than 100 mg MED per day? Doctors cannot prescribe to such individuals opioid pain medication in excess of 300 mg MED per day between January 1, 2017 and July 1, 2017. But starting July 1, 2017, even those individuals need to be weaned down to at or below 100 mg MED per day.
Enforcement mechanisms? They thought of that, too. "An individual who violates this section commits a civil violation for which a fine of $250 per violation, not to exceed $5,000 per calendar year, may be adjudged. The Department of Health and Human Services is responsible for the enforcement of this section."
The bill also includes several other requirements including mandatory PDMP checks, mandatory electronic prescribing, and mandatory education for prescribers (3 hours of CE) to be renewed every 2 years. There are exceptions, of course, but the exceptions are logical and do not undermine the intent and broad application of the bill (active treatment for cancer, hospice care, inpatient settings, etc. are all exempt - as they well should be).
What does all of this mean?
Some will see this as a huge step forward in fighting the most significant public health crisis of a generation. Some will see this as a vast government overreach into the practice of medicine.
It's both, really, And it's what we get when the clinical community fails to educate and police itself. "Our remedies oft in ourselves do lie..." And when they don't, we get new laws. Look for this approach in a state legislature near you...
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