When Maine’s opiate prescribing law took effect in January 2017, Debra Gerrish of Winter Harbor was one of an estimated 13,000 individuals who were taking prescribed doses of painkillers above the newly adopted daily limit, the equivalent of 100 milligrams of morphine per day. The medication relieved her debilitating back and neck pain, the result of old workplace injuries and other physical trauma.
It never made her drowsy or high, she said. It just let her get on with her life.
Gerrish, 55, said she used the drug oxycodone for nearly a decade, most recently at a dose of 300 mg per day spread over six smaller doses. The new regulations required her doctor to taper her dose sharply, and after a falling-out over the process, Gerrish said she was asked to seek a new provider. Unable to find one who would prescribe the painkiller and continue the taper, she said, “I just quit on my own, cold turkey.”
She says she hasn’t had access to opioids in over a year. Instead, Gerrish says she is one of an unknown number of Mainers who suffer from real and debilitating pain due to the new prescribing regulations, which are aimed at decreasing the flow of addictive painkillers into Maine communities.
“There are many people this has happened to,” Gerrish said during an interview in the kitchen of her tidy raised ranch.
While she agrees with the goals of the new regulations, she says there should be broader exemptions for people who, like her, can’t manage the routines of daily living without the medications they have come to rely on.
She says she’s tried cortisone injections, physical therapy, cognitive behavioral therapy, over-the-counter pain medications and more, all to no avail. Sometimes, a chiropractic session helps a little. But on bad days, the days when it hurts to move her head or hold a book, when she can’t walk across the kitchen or stand at the sink to wash her dishes, she sometimes thinks about turning to heroin, which she says is readily available in her small town.
“It would be easy to get some,” she said with a small shrug. “I’d just have to ask a few people.”
Experts say the number of Mainers like Gerrish is small, that most of the 13,000 have successfully been weaned to lower, allowable doses or to other pain-management strategies, or else have entered addiction treatment programs. Some, however, may have turned to street drugs, as Gerrish contemplates.
Gordon Smith, executive vice president of the Maine Medical Association, hears from some of those who are hoping to regain access to their medication, at doses like they had before the law took effect. The organization supported the prescribing law, passed in 2016, and the regulations it put in place.
“[Pain patients] feel that physicians see this as a black and white issue and are unwilling to engage with them about how they’re feeling,” Smith said. “It’s difficult when you’re a law-abiding citizen … to all of a sudden have your doctor say, ‘Unfortunately, you’ve become addicted to your medication and we need to get you off it.’”
In Maine, the number of prescriptions filled for opioid painkillers has been declining for several years, reflecting growing concern over addiction and overdose deaths. But in 2017, the year the law took effect, prescriptions dropped a full 13 percent over the previous year, for a cumulative decrease of 32 percent since 2013, according to new data.
Smith says Maine prescribers have long been concerned about prescribing painkillers, but have found it difficult to confront patients about their drug use.
“Doctors like this law because it automatically begins the conversation with patients about changing treatment,” he said. “And most are comfortable using it as leverage for changing how they manage pain.”
Some patients qualify for exemptions to the new regulations. These include people with pain related to cancer as well as those in hospice care or approaching the end of life. There is also a subjectively-worded palliative care exemption for those whose pain “substantially affects” their quality of life, according to language developed by the state’s Palliative Care and Quality of Life Interdisciplinary Council and adopted for reference by the new prescribing law.
“Patients do not need to be terminally ill to be deserving of palliative care,” Smith said, but the rule is not intended to create a pathway for patients to continue to use addictive painkillers inappropriately or unnecessarily.
“The science calls for most patients with chronic pain to get off opioids,” he said. “It has been demonstrated that it’s not helping their pain, that it can actually make it worse. And it’s putting lives at risk.”
A number of recent studies have shown that opioid painkillers provide little, if any, improvement over non-opioid painkillers for managing chronic pain, and some show that over-the-counter drugs like Advil and Tylenol are as effective as opiates in relieving some kinds of acute pain.
There’s some evidence as well that overuse of opioid drugs over time diminishes the body’s ability to cope with pain and intensifies the experience of that pain.
Studies like these, within the context of the nationwide crisis in opiate abuse, addiction and overdose, have prompted the U.S. Centers for Disease Control and Prevention to develop specific recommendations for the use of opioids in managing most kinds of pain. These recommendations are the basis for Maine’s new regulations.
At St. Joseph Healthcare in Bangor, nurse practitioner Eva Quirion, who specializes in pain care, says many people have become dependent on opioid painkillers through no fault of their own.
“Most of them have just been doing what their prescriber told them to,” she said. “Nobody meant to do any harm, but a lot of harm has been done.”
She helps patients taper slowly off these drugs and offers them instead a combination of non-addictive pain relievers, physical therapy and cognitive behavioral therapy.
The new law, she said, is “a good start. It sends the message that these medications are not safe to use at high levels or over long periods.” Doctors and regulators have known for many years that opioid painkillers were causing serious problems with addiction, she said, and yet little was done.
“We’ve had lots of time and we haven’t fixed it,” she said. “So now we have a law.”
In Winter Harbor, Gerrish is hoping a new medical provider in a neighboring community will find her qualified for a palliative care exemption and give her access to the medication she feels she needs. The last doctor she approached “just looked at me and said I was a drug addict,” she said, grimacing at the memory. But at her present level of discomfort, she said, she is unable to accomplish even the basic care of her home and a three-unit rental building she owns nearby.
“I just can’t do it, and I can’t afford to pay someone else,” she said. “I’m going to lose everything.”
Gerrish said she understands and supports the intent of the law.
“People shouldn’t have [these drugs] if they don’t need them, and they shouldn’t be overprescribed,” she said. “But this is killing me. I’m just trying to live my life.”
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