Shared Decision Making: Helping prescribers taper opioid prescriptions in Maine

January 12, 2017

Maureen Fitzgerald
Editor, NIATx and ATTC Network Coordinating Office

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.

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
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. 

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

Related Resources





Maine Quality Counts Care for ME Resource List: Resources for Clinicians Responding to Maine's Opioid and heroin Crisis


Changing the world's relationship with alcohol through mobile technology

January 2, 2017

Chris Raine
CEO and Founder of Hello Sunday Morning


My parents have been dealing drugs their whole lives.

As general practitioners, they spend their days listening carefully to the patient's ailment and deciding which drug will be most likely to help them achieve their medical aims. You're depressed? Try these antidepressants. High cholesterol? Take a statin. Diabetic? Here is a syringe full of insulin. And through this ongoing dance between diagnosis and dose they are able to adjust a person's biology to help them live better, longer, and happier (most of the time).

I was never smart enough to get into medicine (thankfully) but I did manage to find myself picking up the family business of dealing drugs from a young age. From the age of 15 right through to 22, I made a career out of prescribing copious doses of the drug that billions of people consume but rarely consider its diagnosis: alcohol. It all started with selling bootlegged alcohol to other awkward high school boys at my boarding school. I made a tidy little profit selling it for all sorts of teenage boarding school ailments. Nervous about talking to girls at a party? "This here is called Dutch Courage." Want to do something you would never do sober? "Take four swigs of this." Can't dance? "Shots!"

The ATTC Network's Global Reach

December 21, 2016
Maureen Fitzgerald
Editor, NIATx and ATTC Network Coordinating Office 


You probably know that the ATTC Network serves the 50 U.S. states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the Pacific Islands of Guam, American Samoa, Palau, the Marshall Islands, Micronesia, and the Mariana Islands.

But did you know that the Network includes international Centers?



The Vietnam-HIV Addiction Technology Transfer Center (VHAATC) in Hanoi was established in 2011 with support from the President's Emergency Plan for Aids Relief  (PEPFAR) and SAMHSA.

An additional VHATTC site opened in Ho Chi Minh City in 2014. And in 2016, the Southeast Asia Regional HIV ATTC was established in Chiang Mai, Thailand.

How substance use disorders affect the family

December 12, 2016


Tracey M. Duncan, Ed.S., Ph.D., LPC, ACS
Assistant Professor
Department of Counselor Education
New Jersey City University
tduncan2@njcu.edu


It’s been well-documented that addiction is a family disease, affecting every member of the family in some way. Family members organize themselves according to their behavioral and emotional reactions to the loved one suffering from a substance use disorder. In many families, these responses flare up during the holiday season, when spending time with a sibling, parent, or child with an untreated substance use disorder can make family gatherings more stressful than joyful.

Taking Action to Address Opioid Misuse

December 6, 2016

Jeanne Pulvermacher, MS
Project Manager
ATTC Network Coordinating Office



If you scan the headlines in newspapers from across the country, you’ll see a few common words: opioids, heroin, Naloxone, prescription pain medications, drugs, overdose, HIV.  You may recall the 2015 HIV outbreak in Indiana that was fueled by injection drug use, mainly of oxymorphone (Opana), oxycodone, and methadone—all opioids. 

Standing Rock: Observations

November 23, 2016

Sean A. Bear, 1st
Training Coordinator and Senior Research Consultant National American Indian and Alaska Native Addiction Technology Transfer Center 



My name is Sean A. Bear, 1st. I am a member of the Meskwaki Tribe in Iowa and the Training Coordinator and Senior Research Consultant at the National American Indian and Alaska Native Addiction Technology Transfer Center (National AI/AN ATTC) located in the University of Iowa College of Public Health, Department of Community and Behavioral Health.  After a training event in Fargo, North Dakota, Dr. Skinstad (Director, National AI/AN ATTC) and I decided that it was important for me to make a site visit to the Standing Rock site of the pipeline protests to evaluate if there was any need for assistance from our Center to the participants of the demonstration and their providers. 

Many of us see how trauma-informed care and mental health first aid play a role in healing. It is important to understand that many people have experienced trauma in the past that play a role in their beliefs. In addition, many American Indian/Alaskan Natives have lived in poverty conditions, which has normally been forgotten (or invisible) as many are in rural and frontier areas of America.  It must be mentioned that Natives bring a whole new need for trauma-informed care, information that is needed at the table, as they and their ancestors have experienced historical trauma for generations.  Much as those in Europe whose relatives suffered through the Holocaust, trauma can be passed on genetically from parent to child. Native Americans have experienced not only trauma, but circumstances that also hinder the healing that is needed for recovery.  So, as we move forward in developing programming and care, we must also remember to make decisions that will benefit all peoples instead of pushing others, like the American Indians and Alaskan Natives, out by not understanding what they and their ancestry have experienced. 

While at Standing Rock, I made several observations that I want to share with you. 

Eight ways to overcome resistance to medication-assisted treatment

November 17, 2016

Maureen Fitzgerald
Editor, Addiction Technology Transfer Center & NIATx

Outcome studies and research will help get some patients, staff, and community members on board for medication-assisted treatment. But not everyone may embrace a treatment such as buprenorphine (Suboxone®) for opioid use disorders based on scientific evidence of its effectiveness. Lack of staff buy-in can easily sabotage the potential success of any MAT program.


Opposition to MAT can take many forms, from open hostility to subtle resistance.  

This can include segregating MAT clients from non-MAT clients in treatment groups. Or discounting sobriety accomplished with the help of medication as not “true” sobriety. Sometimes, MAT patients are told that they won’t be successful in long-term recovery because they haven’t suffered enough.