LEWISTON — Need a prescription for pain pills?
You may be asked to pee in a cup.
In an effort to combat Maine's high rate of prescription drug addiction, doctors are asking patients to sign a controlled-substances agreement that, in part, allows the doctor to ask for a blood or urine sample at any time to ensure patients are taking their pills, rather than selling them, and are taking those pills only.
Patients who don't sign likely won't get prescriptions. And those who fail the test will have some explaining to do.
"Everybody is under pressure to have policies that do everything they can to tighten up the prescribing of opiates," said Gordon Smith, executive vice president of the Maine Medical Association.
Maine has had a prescription drug problem for years. The state has the highest per-capita rate of opiate addiction in the nation, and more Mainers are seeking treatment for painkillers than for alcohol. The number of babies born with opiate withdrawal symptoms has skyrocketed. And this week Maine had its 50th pharmacy robbery of 2012, a crime that experts say is directly tied to prescription drug addiction. Maine had half that number of robberies in 2011; not long ago it had none.
State leaders and doctors have tried to do something about prescription drug abuse. Most recently, the state created the Prescription Monitoring Program, an electronic database that tracks every patient receiving a controlled substance prescription in Maine. Once a week, pharmacists upload into the system the names of patients getting controlled drugs. Doctors then can go into the database and see whether their patients have more prescriptions from more doctors than they should.
The state also has created a task force to address prescription drug abuse, and MaineCare is working to limit the number of painkiller prescriptions Medicaid patients can get.
The Maine Board of Licensure in Medicine and the Maine Board of Osteopathic Licensure took on the issue of prescription drug abuse as far back as the late 1990s. They created guidelines covering what was expected of their doctors when they wrote prescriptions for controlled substances.
In 2010, the boards reviewed and strengthened those guidelines, and three more licensing boards — for dentists, nurses and podiatrists — signed on. Since then, more medical practices and hospitals have followed that guidance.
The guidelines recommend, in part, that doctors create a controlled substances contract or agreement with their patients at high risk for substance abuse or with a history of addiction. The guidelines provide no template for such a contract, but they do suggest including 14 terms, such as:
* The doctor may call the police if illegal activity is suspected.
* The doctor's office may ask to count the patient's pills at any time.
* Patients may lose their prescriptions for violating the contract.
* The patient must submit to blood or urine tests if requested.
It's up to each medical practice and hospital to design its own contract, determine who must sign the agreement and decide what will happen if a patient refuses.
Central Maine Medical Center in Lewiston wants its doctors to get an agreement signed by all patients whose treatment continues "beyond a few prescriptions," unless it's for end-of-life care. The hospital leaves it up to individual doctors to decide whether to give out a prescription to a patient who won't sign.
"I think, depending upon your level of comfort with the patient, you might or might not decide to proceed with prescribing," said Ned Claxton, medical staff president. "I think providers are somewhat more reluctant now to go ahead and prescribe."
Across the city, St. Mary's Regional Medical Center adopted an official policy this fall. It requires doctors to get agreements signed by all patients who receive three or more new or renewed prescriptions for controlled substances within six months. It calls the agreements voluntary for patients. However, those who don't sign won't get their prescriptions.
"It's there to protect the patient and to protect our providers, both; to protect the community," St. Mary's spokeswoman Jennifer Radel said. "You don't want this patient to get addicted to a prescription drug. The doctors wouldn't be doing their job if that were the case. We're doing what we can to prevent it."
In general in Maine, patients or their insurers must pay for any drug test ordered.
Many people involved in medicine and substance-abuse prevention like the shift toward controlled-substance agreements. Michael Kelley, chief medical officer of behavioral health at St. Mary's, believes such agreements help separate narcotics from other prescriptions.
"It re-emphasizes the fact that these are serious medications that actually have a strong addiction potential," he said. "I actually want my patients to be a little scared of these medications."
Smith, at the Maine Medical Association, believes the contracts and drug-testing stipulation can help start potentially uncomfortable conversations between doctors and patients about addiction.
"These are good doctors," he said. "But they're trained to believe their patients. I can show you case after case where I, as a lay person, go through the medical record and say, 'What a red flag, and you didn't react to that?' And it's just because they've got 30 patients in front of them a day and they're just trying to do the best they can and some of them have unfortunately not paid as much attention to this and the risks. They've erred in favor of believing their patient in the face of all evidence to the contrary."
But some patients chafe at the idea of drug-testing and feel mistrusted by their doctors. Guy Cousins, director of the Maine Office of Substance Abuse, has heard from some of them. He equates random drug-screening to a medical test.
"There are so many chronic conditions out there that, because of the medication that you're on, you have to have lab tests done, you have to have liver function tests done," he said. "These are just kind of like normal medical procedures that help ensure that the care that's being instituted is done in a way that looks out for the person's best interest."
It's unclear how often patients are drug tested by their doctors or how many are being tested in Maine.
"It depends on the patient and the medication that's being given," Kelley said of St. Mary's. "Certainly, some medications are far more abuseable than others. So I think doctors prescribing, say, OxyContin, which has got a massive street value, tend to test a little bit more often than something lower, like codeine. And of course patients have vulnerabilities. So if you've got a patient with three relatives with heavy substance abuse, you're going to be a little more cautious."
It's also unclear whether controlled-substances agreements and random drug tests are doing any good. Maine's addiction numbers remain high, as do the number of babies born with prescription opiates in their systems.
But Smith said the state's Prescription Monitoring Program shows that doctors wrote about 300,000 fewer narcotics prescriptions in 2011, the first time he's seen a decline. The number still hovers around 2 million, he said.
Smith called the agreements "one essential element" in an overall plan to address addiction in Maine.
"I believe it's getting better," he said. "I think there's a lot of attention being focused on it."