A New Era of Opioid Prescribing in Maine
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Rudd et al. MMWR. 12/30/16. Vol. 65, Nos. 50 & 51.
Opioid overdose deaths have continued to climb over the past few years. This national trend is also being seen in Maine where it ranked #13 in terms of overdose deaths per 100,000 population (MMWR: Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015). In response to this trend, Maine has recently passed legislation that creates a series of provisions for prescribers of opioids and benzodiazepines. While there are specific requirements that apply to the management of chronic pain, this post will focus on the management of acute pain for prescribers in the emergency department and urgent care setting. Additional requirements that pertain to pharmacies and health systems are not addressed here (chronic pain, cancer treatment, palliative care, acute management for chronic pain patient). When prescribing opioid or benzodiazepine medications in the acute setting, here are six provisions every prescribing physician should know.
1. The Maine Prescription Monitoring Program (PMP) must be checked before every new prescription and every 90 days.
Prior to writing any new prescription and again every 90 days the prescriber or a designee must access the PMP and review the record for the patient.
You can access the Maine PMP login here.
Non-physicians may be approved to access the PMP and provide this information to the prescriber with the approval of your hospital chief medical officer.
You should document in the medical record that the PMP has been reviewed. This is accomplished at Maine Health via an attestation during the EPIC prescription navigator.
2. 100 Morphine Milligram Equivalents per day (MME) is the maximum presciption that can be written for acute pain.
Prescriptions for the management of acute pain are limited to a total daily dose of 100 MME. This is equal to 67 mg of oxycodone or 100 mg of hydrocodone.
When the patient is taking concurrent opioid pain medications there is a cumulative limit of 100 MME per day. If a patient has chronic pain and has new post-operative pain or a new acute pain, Exemption F may be used on the prescription to exempt the daily limit.
Calculators are available for free download. Click here for an opiate calculator app for your smartphone.
Please consider the total daily dose of PNR medications. This will be calculated based on the maximum number of PRN doses that could be taken over a 24-hour period.
Click here for the CDC daily dose tool and information sheet
3. A seven day supply is the maximum duration of opiates that can be prescribed for acute pain.
When prescribing medication for the management of acute pain, prescriptions are limited to a 7-day supply
Please consider the total number of days that you are prescribing when writing a PRN prescription. A medication prescribed 1 tab BID PRN would be limited to 14 tablets as this will be calculated as a 7-day supply.
Prescriptions should include reference to the management of “Acute Pain” as this will clarify to pharmacies the appropriate set of prescribing and dispensing requirements.
5. As of July 1st, 2017, all prescriptions for opioids and benzodiazepine medications must be transmitted electronically to the pharmacy.
Individual practice settings will establish protocols which are consistent with this requirement.
6. Providers are required to complete 3 hours of CME relevant to the prescribing of opioid and benzodiazepine medications every 2 years.
Although many providers have recently received mailings selling courses that will meet this requirement, the state has clarified that they do not require a specific program or curriculum.
Maine Health providers should pay attention as a series of educational opportunities have been offered which will fulfill this obligation.
REFERENCES
1. Rudd RA et al. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. Morbidity and Mortality World Report. December 30, 2016. Vol. 65, Nos. 50 & 51.
Written by Timothy Fallon, MD
Edited and Posted by Jeffrey A. Holmes, MD
