Maine Mandates e-Prescribing of Controlled Substances

Ken Terry

April 22, 2016

Maine has become the second state to mandate the electronic prescribing of controlled substances (EPCS), after New York, and the third state to require electronic prescribing. Minnesota has had mandatory e-prescribing since 2011.

Maine's new statute, "An Act to Prevent Opiate Abuse by Strengthening the Controlled Substances Prescription Monitoring Program," includes a number of provisions designed to reduce overprescribing of opioids. In addition to the EPCS requirement, which goes into effect July 1, 2017, the legislation also has provisions that limit the durations and doses of opioid prescriptions. It also requires that prescribers receive continuing medical education on addiction, according to a bulletin from the Maine Medical Association (MMA).

Specifically, the legislation mandates a limit on opioid scripts to 7 days for acute pain and 30 days for chronic pain, with no limits on renewals. In the original bill, the MMA notes, the limits were 3 days for acute pain and 15 days for chronic pain. The effective date of that provision was also pushed back to January 1, 2017, from August 1 of this year, Gordon Smith, JD, the MMA's executive vice president, told Medscape Medical News.

There is a 100-mg limit (morphine milligram equivalent) on the average daily dose of opioids, effective 90 days after the law's passage for new prescriptions. But patients who are already receiving drugs in excess of that limit can take up to 300 mg until July 1, 2017. By then, the MMA said, the state's Department of Health and Human Services (DHHS) is expected to add a number of exceptions to this rule.

The MMA sought and received exceptions from all the law's provisions for patients with cancer; patients receiving hospice care, end-of-life care, or palliative care; patients receiving medication-assisted therapy; and patients receiving medications in hospitals and nursing homes. Smith said DHHS is writing regulations on the exceptions and that MMA is seeking additional ones, such as for burn victims.

Learning Curve

Another provision of the new law requires physicians to check with the database of the prescription monitoring program before prescribing opioids. This requirement has actually been in place since 2005, when the original prescription monitoring program statute was adopted, Smith noted. However, surveys show that "between 7% and 20% of prescribers are using [the prescription monitoring program database], even on an occasional basis," he said.

The e-prescribing mandate in the bill did not elicit opposition from physicians, he said. "Polling data from our members showed they accepted the [prescription monitoring program] mandate, they supported e-prescribing, and supported mandatory CME," he observed. "But they opposed limits on the length and dosage of prescriptions, because they viewed it as interfering with their medical decisions."

Although most prescribing Maine physicians use electronic prescribing for routine medications such as antibiotics, fewer than 1% of them electronically prescribe controlled substances, Smith said. A lot of physicians do not know anything about the details of the Drug Enforcement Agency's requirements for EPCS, and there are some other challenges for Maine physicians to overcome, he said.

"But New York has shown that you can do it," he pointed out. "All the chain pharmacies are equipped to accept [EPCS]. There are somewhere between 80 and 130 [e-prescribing software] vendors who are certified by the [Drug Enforcement Agency] and who can work with practices to get them there. I don't know that we're going to make it happen by July 1, 2017, although there is a waiver provision."

The deadline for mandatory EPCS was January 1, 2018, in the original bill, Smith noted. DHHS Commissioner Mary Mayhew suggested the deadline be pushed up 6 months, and the MMA agreed on the condition that physicians could obtain waivers for reasons such as not having the proper technology or access to broadband Internet connections. There are other statutory exceptions in the New York law that Smith hopes the legislature will add in its next session.

The New York e-prescribing law, which is also aimed at curbing opioid addiction, went into effect March 27. The state legislature postponed the deadline for a year before that to give physicians and electronic health record vendors more time to prepare for the change.

Real Crisis

Smith said the MMA decided to negotiate compromises and support the bill because there is a real crisis of opioid abuse in Maine. The association knew that the legislature and the governor, who proposed the bill, were determined to pass it. The public was demanding action because of the grim statistics about this epidemic.

Among all of the states, Smith noted, Maine has the highest number of prescriptions for long-acting opioids per capita. Five people die each week in Maine from overdoses of opiates and heroin, and most addicts say they started on prescription drugs. In addition, 1000 babies were born in Maine last year with neonatal abstinence syndrome, which can affect their health for many years.

Partly because of all the publicity about the opioid deaths, Smith said, the MMA did not receive much pushback from its members about its support for the legislation in its final form. "We're satisfied that we found a balance between the needs of patients who are on pain medications and are in pain and the vast majority of prescribers, who try to prescribe responsibility."

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