Patty Wight stated that a year ago that, Maine was one of the first states to set limits on opioid prescriptions. The goal in capping the dose of prescription painkillers a patient could get was to stem the flow of opioids that are fueling a nationwide epidemic of abuse.
Maine’s law considered the toughest in the U.S., is largely viewed as a success. But it has also been controversial — particularly among chronic pain patients who are reluctant to lose the medicine they say helps them function.
Ed Hodgdon, who is retired and lives in southern Maine, was just that sort of patient — at least initially. Name a surgery, and there’s a decent chance Hodgdon has had it.
“Knee replacement. Hip replacement. Elbows. I’ve got screws in my feet,” he says. Hodgdon has rheumatoid arthritis. And along with each surgery came an opioid prescription for pain. At first, he got some relief from the drugs, but it didn’t last. “It just numbed it for a while,” he says, “and then I needed more.”
Though Hogdon kept increasing the dose, the pain never went away. “And then I found Dr. Medd. That’s my angel right there,” Hodgdon says, nodding toward Dr. Donald Medd, a general internist in Westbrook.
Medd had already started to taper high doses among patients like Hodgdon before Maine put a cap on new prescriptions for opioids last July. The new limit allows a maximum of 100 morphine milligram equivalents (the standard used to measure potency for all prescription opioids) for most patients per day — with certain exemptions for some cancer patients, those in hospice care, and some others. Patients with existing prescriptions were, by and large, given a year to meet the new restriction.
Medd was ahead of the game because he’d noticed that many of his patients on high doses of opioids grew increasingly angry about their pain as time wore on, and tended to demand ever more medication. At the same time, they were struggling to function in daily life because of the drugs’ side effects.
“You know, at some point, the medications get in the way of some sort of recovery,” Medd says.
Opioids were affecting Hodgdon’s mood and his memory. Medd worked with him to cut the dose he was taking every day by two-thirds and helped him get in touch with a psychologist for further help. Though Hodgdon still lives with some pain, he says his life is infinitely better. “I can remember things,” he says. “I get along better with people.”
Despite success stories like Hodgdon’s, Medd says he initially opposed Maine’s law. He didn’t want the legislature to interfere with medicine.
But now he thinks the law gave a necessary nudge too many doctors. Compared to a few years ago, Medd says, he and colleagues in his medical practice have cut the number of their chronic pain patients who are on opioids by almost half — from about 1,500 to 800.
In nearly all counties in the state, the number of prescriptions for painkillers is dropping. It’s a trend that Gordon Smith, executive vice president of the Maine Medical Association, says was underway even before the law took effect.
“We had the fourth largest drop in the country,” he says, citing a 21.5 percent reduction in opioid prescriptions from 2013 through 2016.
The data only include the first few months after Maine’s prescribing cap went into effect, Smith says; he expects the law will accelerate further reductions.
“Now having said that, it’s not been easy,” he says. “It’s been particularly difficult for patients,” he says — specifically for the 16,000 patients on high-dose opioids who were expected to taper to the 100 morphine milligram limit by July of this year.
“I was about four times above that,” says Brian Rockett. He operates a wholesale business buying lobsters on the Maine coast. Rockett started taking opioids years ago to ease the pain of injuries from racing motorcycles and boats. When he tried to taper the dose, he says, he had unbearable pain. So, he filed a notice of intent to sue the state over its restrictions on how much he could be prescribed.
“I just knew that I was facing possibly losing my business,” he says.
Rockett wasn’t alone in his inability to taper his use of the drug, and Maine lawmakers — like Dr. Geoffrey Gratwick, a state senator who is also a rheumatologist — took notice.
“A certain group of people simply cannot come off [opioids],” Gratwick says.
He recently pushed through a change to Maine’s law that allows broader exemptions, so that people with incurable, chronic conditions can continue to take high doses.
It put the decision about that back in the hands of the doctor and patient, Gratwick says, “where it should be.”
Under the revised law, Rockett was able to increase his dose and dropped his lawsuit.
Even though more patients could, potentially, seek exemptions, its advocates see Maine’s law as an important step. Recent data from the federal Centers for Disease Control suggest that nationwide, despite an overall decrease in recent years, the number of opioids prescribed still triple what it was in 1999.
Interesting that we in the state of Maryland just got notification of similar restrictions for Medicaid patients and these restrictions will apply to all insurers next year. Again, I bring up the point that I stressed last blog post on the opioid crisis- is this the only root of the crisis. I think not! And more solutions, which I alluded to two weeks ago with reform homes- and what about safe places to shoot up? The question, which critics and proponents have been battling for decades-Can Safe Injection Sites Calm the Opioid Crisis? Shannon Firth of MedPage wrote that support for establishing safe injection facilities (SIFs) — places where people can use their own illicit drugs under medical supervision — is growing in the United States, but the backlash against the model has been fierce. An SIF is a facility that provides a hygienic space for people to inject, and sometimes smoke, their own illicit drugs in the presence of trained medical staff who can intervene if an emergency occurs.
Proponents of these sites also called “safe consumption spaces” argue the facilities reduce the risk of dying from an overdose, prevent needles and other drug-related litter, and, in some instances, connect the substance users with treatment. Critics charge that the facilities are a form of government-sanctioned heroin addiction that do little to improve substance users’ quality of life.
To date, there are no legally sanctioned SIFs in the United States; however, a recent study suggests the presence of at least one unsanctioned facility in an undisclosed urban area in the U.S., according to the American Journal of Preventive Medicine (AJPM).
What is the history of Safe Injection Sites?
SIFs are legal in 10 countries, including Australia, Canada, France, Germany, and the Netherlands. Roughly 98 sites are currently operating in 66 cities, according to the AJPM study.
“Implementation of supervised injection sites has been shown to improve individual health, such as overdose mortality rates, drug use and enrollment in drug treatment, HIV and viral hepatitis risk, and access to health and social services,” the authors noted.
Research also suggests these facilities may reduce health care costs.
A May 2017 study from John Hopkins Bloomberg School of Public Health, published in the Harm Reduction Journal, estimated the city could save $6 million in opioid-related costs by opening one SIF in Baltimore. The site’s total cost at $1.8 million each year was based on the model of a 1, 000 square-foot facility with 13 booths, providing 18-hour access.
Their projections were rooted in studies conducted at Insite, the first SIF in North America. Insite opened in downtown Vancouver in 2003, when the city’s HIV rate was among the highest in the industrial world, Anna Marie D’Angelo, senior media relations officer for Vancouver Coastal Health, told MedPage Today in a phone call.
Government actions, including ending funding from Health Canada for the research being conducted at Insite, led to a protracted legal battle and the publication of dueling research reports, noted CMAJ.
Ultimately, in 2011 Canada’s Supreme Court voted unanimously to order the Canadian government to exempt the clinic from any prosecution for its activities.
“During its eight years of operation, Insite has been proven to save lives with no discernible negative impact on the public safety and health objectives of Canada,” the Court said, according to The Globe and Mail. The Court further noted that its concern for denying clients services and the “correlative increase in the risk of death and disease” outweighed the symbolic benefits of Canada upholding “a uniform stance on the possession of narcotics.”
How do SIFs work? Each individual who enters the SIF undergoes a screening process in order to exclude those under the age of 19, pregnant women, and first-time users. They are given an alias or a handle as a secure means of keeping a record of each individual, said D’Angelo.
Those who pass the screening test give a staff member their alias and are assigned a booth where they can inject their own self-obtained drugs under the supervision of a nurse. Nurses will sometimes show the individual how to use a tourniquet and how to properly clean the injection site, D’Angelo noted.
Afterwards, the individual will dispose of the needle in the available biohazard and Sharps containers, and be sent to a “chill room” where juice and coffee are available. Individuals can stay for 10 -15 minutes, again under a nurse’s supervision, she explained.
“You do leave the site walking out under the influence of drugs,” D’Angelo said.
The organization’s goals are to reduce harm and connect people with care, she said. “At Insite, there have been over 3.5 million injections of illicit substances and there’s not been one death.”
Is this “Hospice Care” for Substance Users?
Brianne Fitzgerald, RN, a nurse practitioner in Boston, who has been working in addiction for 40 years and “cut her teeth on the AIDS epidemic” is outspoken in her opposition to these facilities.
She supports most “harm reduction” services. Fitzgerald favors needle exchanges and medication-assisted treatment (MAT) when treatment is time-limited, but she does not support safe injection facilities.
“The emperor has no clothes … There’s no more talk of recovery. There’s no more talk of improving someone’s life. This is end-stage care. It’s hospice care,” she said.
There’s one exception to her criticism of SIFs — Fitzgerald said she would endorse safe injection services if they were given in a van and not one fixed location. If services were offered from a mobile unit, communities could be engaged, she said. There could be HIV testing and clients could share coffee with people in recovery and with parents who’ve lost loved ones to addiction. “The van shows you the opioid mess is more than just the addicts,” Fitzgerald said.
Advocates responded that although some critics have noted that the overdose rate hasn’t changed much in Vancouver since Insite came along, looking at that number isn’t really “meaningful,” said Thomas Kerr, PhD, associate director of the BC Centre on Substance Use at the British Columbia Centre for Excellence in HIV/AIDS, and a professor in the Department of Medicine at the University of British Columbia in Vancouver.
The surge in the supply of fentanyl across the U.S. and Canada, a synthetic opioid roughly 100 times more potent than heroin, has hit Vancouver hard, Kerr said, which accounts for some of the rises in overdose deaths.
Also, Insite is a small facility serving only a fraction of the city’s substance users, and cannot be expected to save the lives of those 30 miles away, he continued.
The real question, according to Kerr, is “How much greater would [that rate] have been if there hadn’t been a supervised injection site?”
The opening of a SIF was linked to a 30% increase in detoxification service use, according to a study Kerr and colleagues published in Addiction in May 2007. That study also noted that “this behavior was associated with increased rates of long-term addiction treatment initiation and reduced injecting at the SIF.”
“I think there is a lot of good data out there, but people are often immune to evidence,” he concluded.
What does it matter for Drug Users? D’Angelo noted that Insite’s primary goal is to save lives.
However, just by entering the facility clients are expressing, to a small degree, concern for their well-being, she said. “They’re taking a tiny step to better their health. Somebody who’s done that is more likely to go into detox than not.”
And while it may seem counterintuitive, supporters say there is an outreach and engagement strategy focused on the path to health and recovery embedded within SIFs.
“I think people tend to react viscerally to the concept, but what they have to do is look at the results,” said Henry Dorkin, MD, director of the Pulmonary Clinical Research Program at Boston Children’s Hospital and president of the Massachusetts Medical Society, which has endorsed SIFs.
If the sites are so bad, so ineffective, he asked why have Australia and Canada and Europe done it for years? Dorkin added. “People don’t persevere in things that aren’t working.”
If we look ahead we see that in June, the American Medical Association announced its support for piloting safe injection facilities, WBUR reported.
“There are legal issues that need to be addressed, but the AMA certainly came out in support of pilot projects on these facilities so that we can collect the evidence and do a full evaluation of their effectiveness,” said Dr. Patrice Harris, who chairs the AMA’s task force on opioid abuse.
Advocates in three cities — San Francisco, Seattle, and New York — are trying to get the facilities off the ground, and state governments also are looking at the issue. For instance, members of the New York State legislature have introduced legislation to allow for safe injection sites.
Meanwhile, the California Assembly passed a bill to allow the establishment of SIFs in parts of the state. That legislation is now headed to the State Senate, according to The Bay Area Reporter.
To me, this all seems that we are all condoning the crisis of drug addiction. Maybe these will be controlled environments but to what end? The continued use of dangerous intravenous drugs! We all need to eliminate the devil, the dangerous drugs and not addicts to use the drugs safely in order to reduce overdoses and the health care costs. We might as well as legalize all of the dangerous drugs. The government can then control the quality of the drugs and make money by collecting taxes as we do with alcohol. This still doesn’t seem right, legally or ethically, it smells all wrong!