A “statistical anomaly” linked to the Togus veterans hospital fueled a spike in numbers in a recent federal report that showed Kennebec County prescribing an increasing amount of opioid painkillers even as Maine doctors wrote fewer prescriptions statewide.
While a recent report highlighted the downward trend in opioid prescribing in nearly all of Maine counties, it also drew attention to parts of the state where the number of dispensed painkillers rose or has remained elevated.
In Maine, two counties — Kennebec and Somerset — saw their overall opioid prescribing increase from 2010 to 2015, according to a July report by the U.S. Centers for Disease Control and Prevention, which relied on data collected by the consulting company QuintilesIMS.
At least one of those numbers could be lower than it seems, according to an official at the VA Maine Healthcare Systems, which is based at the Togus campus in Kennebec County.
Kurt Johnston, the system’s chief of pharmacy services, said that some of the data considered in the federal report was from prescriptions written at veterans clinics around the state, but dispensed and sent by mail from the system’s main campus in Chelsea.
Because those medications were dispensed at Togus, they were attributed to Kennebec County when the VA Maine Health Care System joined the state’s prescription monitoring program in 2013, Johnston said.
In Johnson’s view, that data made its way into the CDC study, contributing to the 24 percent increase in the total number of opioids prescribed per person between 2010 and 2015 in Kennebec County.
“That’s a statistical aberration based on the way the data (was interpreted),” Johnston said. “It’s definitely a statistical anomaly.”
For patients in the VA Maine Health Care System, he said, “All schedule 2 narcotics are dispensed from (the Kennebec County) location. … and we mail it.”
In the literature accompanying the CDC study, its authors acknowledge several of its limitations, including that it doesn’t account for where a patient lives, and health care experts say that it can be hard to pinpoint the reasons prescribing rates vary by county.
The CDC study also doesn’t reflect changes put in place by providers since 2015, as the number of deaths related to opioid addiction have continued to climb and as states like Maine have passed laws restricting opioid prescriptions.
It was the over-prescribing of those painkillers, and a subsequent crackdown by the authorities, that led to the current crisis, in which users have turned to cheaper, illicit drugs like heroin. More and more, that heroin has been laced with an even stronger synthetic opioid known as fentanyl.
Fueled by those drugs, the number of overdose deaths has been climbing in Maine, reaching an all-time high of 376 deaths in 2016 — more than one a day. Across the nation, more people now die from overdoses than traffic accidents.
Now, as the medical community tries to scale back its opioid prescribing, experts agree on the importance of studies like the one published in July for demonstrating possible progress, setbacks and disparities.
“We should closely scrutinize counties that have disproportionately higher rates of opioid prescribing,” said Caleb Alexander, co-director of the John Hopkins Center for Drug Safety and Effectiveness. “As patients, as family members, as clinicians, it’s important that as a community we do everything we can to account for the outliers; outliers good and outliers bad.”
CHANGES AT TOGUS
To resolve the overdose crisis, experts have called for reducing opioid prescribing and increasing access to addiction treatment — recommendations the medical community has broadly embraced, but that can be difficult for providers to achieve for various reasons.
In 2016, the CDC recommended tighter opioid prescribing limits for the nation’s doctors, and later that year Maine passed one of the strictest opioid prescribing laws in the country.
Under the new law, which took effect on July 1 of this year, physicians are not allowed to prescribe their patients more than 100 morphine milligram equivalents per day, which is a uniform measurement for the amount of opioids in a substance.
The law includes a handful of exceptions, including for terminal cancer patients and those in hospice care — however, some advocates have argued there should be more exceptions for patients who have used opioids to treat other conditions.
Because Togus is a federal facility, it’s not bound by state law, but it has been moving in that direction for several years and significantly reduced the number of Maine veterans who are beneath the new limit, according to Johnston.
About a year-and-a-half ago, more than 250 of the system’s patients were taking opioids at a greater level than 100 morphine milligram equivalents per day.
Now, Johnston said, “We have two (patients at that level) that are known to us, both of whom are in the process of taper. In both cases, they’re coming from such high numbers, it would be clinically inappropriate to get the slope of the curve down any steeper. … They’ll be at zero within some short period in the future.”
The total portion of Togus patients who receive opioid medications has also been decreasing and has consistently been lower than the rate for the whole Department of Veterans Affairs, Johnston added.
As of June, about 2,700 of the roughly 36,000 veterans — 7.6 percent — who receive medications through Togus had received an opioid in the previous 12 months, Johnston said. That was down from 9.5 percent a year-and-a-half earlier.
“Long before the legislation in Maine, we were already making changes in prescribing practices to mitigate risk,” Johnston said. “It’s gratifying, both in the number of folks who receive any opiate and (the amounts prescribed).”
UNEVEN IMPROVEMENTS
It’s one thing for a centralized, federally funded health care system like Togus to change its opioid prescribing.
It’s another for family doctors in remote areas like Somerset or Piscataquis county to do the same, said John Gale, a research associate in the Maine Rural Health Research Center at the University of Southern Maine, who has researched drug addiction in rural areas of the country.
The CDC study found that Somerset County saw a 9 percent increase in the number of opioids that were prescribed per person between 2010 and 2015. It also showed that Somerset, Piscataquis and Kennebec counties were in the top quarter of U.S. counties for opioid prescribing in 2015.
Those numbers hint at the uneven distribution of prescribing practices that the CDC researchers found across the country. As the authors of the study note, in 2015, six times more opioids were dispensed per person in the nation’s highest prescribing counties than in the lowest, suggesting that patients receive different care depending on where they live.
The exact reason for those disparities can be hard to determine, according to Alexander, the co-director of the John Hopkins Center for Drug Safety and Effectiveness. Just one pharmacy that dispenses many pills, or a single patient who receives many prescriptions, could skew the totals in a given county, he said.
Though not familiar with the specific prescribing patterns in Somerset, Piscataquis and Kennebec counties, Gale suggested a few reasons that more rural areas might have higher per capita opioid prescribing rates
There are not many pain specialists working in those rural areas, and the doctors who are there may not have the time or resources to offer alternative therapies, Gale said. Those areas also probably have higher numbers of patients working in forestry or farming, industries that are more likely to cause injuries and chronic pain.
Gale recalled a conversation he had with the administrator of a health center in a rural, low-income area, who said he didn’t have the resources to understand whether some patients were coming to the health center for a new complaint or were trying to fill a drug addiction.
“This is just my impression, but in rural areas, the average age of providers is a little older, and that may influence it too,” Gale said. “This is the way we have done things for a long time. I’d hesitate to say the doctors are doing a bad job, but there are complicating factors. … It’s not as easy as saying we’ve got bad docs who are prescribing irresponsibly, we have drug-seeking patients or we have people who are just weak. Chronic pain is a very difficult thing to manage.”
Charles Eichacker — 621-5642
Twitter: @ceichacker
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