The ATTC/NIATx Service Improvement Blog: Shared Decision Making: Helping prescribers taper opioid prescriptions in Maine

January 12, 2017

Maureen Fitzgerald
Editor, NIATx and ATTC Network Coordinating Office

Image: CDC Injury Prevention & Control

States across the country are taking a variety of actions to respond to the opioid crisis. Forty-nine states have established Prescription Drug Monitoring Programs that track prescription and dispensing data as a way to reduce misuse and diversion, particularly of prescription pain medication.

Three states, Maine, Washington, and Massachusetts, have added additional regulations that limit the daily amount of opioid pain medications doctors can prescribe. Maine’s law, the most restrictive of the three states’, went into effect this month. It sets a 100 morphine milligram equivalent (MME) for new patients, and 300 MME for current patients.

The law does not place daily MME limits on medications prescribed for treating substance use disorders. It’s intended to keep people with chronic pain from the taking higher doses of opioid pain medication that increase the risk of overdose and death.

The opioid epidemic in Maine

The opioid epidemic has hit Maine particularly hard. It’s had one of the highest drug overdose death rates in the country, with the CDC reporting a 26.2 percent increase in drug overdose deaths from 2014-2015.

Higher Dosage, Higher Risk. "Higher dosages of opioids are associated with higher risk of overdose and death--even relatively low dosages (20-50 morphine milligram equivalents (MME) per day) can increase risk." CDC Fact Sheet: Calculating total Daily Dose of Opioids for Safer Dosage

An August 2016 press release from Maine’s Department of Health and Human Services links the overdose death rate to the overprescribing of opioid pain medications:

“With more than 70% of those addicted to heroin having started with a legally prescribed pain pill, these new prescription limits on pain pills will both change the way our physicians treat pain and prevent others from becoming addiction to prescription pain pills and heroin.”
Maine’s Department of Health and Human Services Commissioner Mary Mayhew

The new prescription limit affects as many as 16,000 Maine residents who will have to reduce their daily dosage significantly. Maine’s PDMP will be tracking their prescriptions. Providers are under pressure to act quickly. All current patients must be tapered to the lower dosage by July 2017, and doctors who don’t meet this deadline may face a hefty fine.

All this means that difficult conversations are now taking place between Maine primary care doctors and their chronic pain patients.

Shared Decision Making (SDM): A way to change the conversation

Primary care doctors with little formal training in substance use disorders face a challenge in tapering medication for patients who have become opioid dependent. And finding the time and a structure for tapering patients is also a challenge. One approach that's proving effective in Maine is Shared Decision Making.

See related story in the January 2017 ATTC Messenger: Shared Decision Making and Medication-assisted Treatment

“Shared Decision Making is a way of including the patient in the process so that everyone has a stake in the results, and everyone can take some credit for the successes,” says Jesse M. Higgins, RN, MSN, PMHNP.

Higgins is Director of Behavioral Health Integration at Acadia Hospital in Bangor, Maine. In August 2016, she did a presentation on Shared Decision Making with Neil Korsen, MD, of Maine Medical Center, as part of SAMHSA’s Recovery to Practice webinar series on Shared Decision Making.

Click here to access the Recovery to Practice recorded webinar and presentation slides for Shared Decision Making: Changing the conversation

Higgins is leading a pilot project that teaches primary care providers how to use Shared Decision Making in talking about tapering with patients with opioid dependence.

“We’ve found that many chronic pain patients also have a pretty extensive trauma history,” explains Higgins. “They also have a lot of shame about misuse or dependence on prescribed substances that’s compounded by feeling that providers will be judgmental or dismissive. At the same time, primary care providers and patients can often come into the office anticipating that the conversations about tapering are going to go badly. It’s difficult to have a positive conversation in that environment.”

The SDM approach to the opioid epidemic depends on the integration of nine psychiatric mental health nurse practitioners and nine licensed clinical social workers who practice in 21 primary care and medical practices in Maine; 12 of these use telemedicine providers for at least part of their team. These behavioral health experts are employed by or supervised by Acadia Hospital's Behavioral Health Integration program.

"We integrated scripting about reducing pain medication into the EMR so it fit into the primary care workflow and allowed them to cover certain points about the rationale behind tapering."

The providers give patients brief education about the risks and benefits of various treatment options. This brief education often leads to a discussion about next steps for patients who may also meet criteria for a mental health or substance use disorder, and typically involves primary care providers collaborating with integrated psychiatric mental health nurse practitioners and licensed clinical social workers. Integrated providers are available to provide support to all providers and patients in the practices.

Pilot test results

The pilot began in April 2015, when EMMC Family Medicine Husson Avenue joined Maine Quality Counts’ Chronic Pain Collaborative 2. The practice recommends that all patients on opioids for longer than 90 days should be screened for depression, substance use disorders, anxiety, and history of trauma. These screenings help inform a comprehensive health approach to patient care.

In her own integrated practice, Higgins also meets with primary care providers at monthly meetings, where the providers report on their progress in reducing patients’ MME doses. A population health nurse, a behavioral health case manager and a therapist also attend these meetings.

"Because primary care providers don't have clinical supervision, it's really helpful to provide space to talk about the issues that arise through shared decision making with patients who struggle with chronic pain or substance use disorders," says Higgins. "We've found that SDM is providing a structure and strategy that builds providers’ confidence that appointments with chronic pain patients will go well.”

“The CDC recommendations and state legislation set clear standards for responsible opioid prescribing, and systematic medication monitoring revealed previously undisclosed patterns of prescription opioid misuse,” says Higgins. “Subsequent tapers have often unmasked underlying psychiatric symptoms. The opioid epidemic presents the medical community with an opportunity to bridge patients to safer, more effective treatment.

Shared decision-making provides infrastructure to shape positive, patient-centered conversations in which patients bring their values and treatment goals to the table, and providers bring their clinical judgment and unconditional positive regard for all patients. Only by providing integrated, comprehensive health care can patients and providers weather this storm intact. Everyone needs support sometimes, even doctors.”

Questions about the SDM pilot in Maine? Submit your question in the comment section below, or Contact Jesse M. Higgins directly at jmhiggins@emhs.org