September 17, 2019
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A Maine law helped slash opioid prescriptions. Some say it also had ‘a chilling effect.’

Caitlin Andrews | BDN
Caitlin Andrews | BDN
Dale Mosher, 74, talks about his long-term use of prescription painkillers he used to manage his chronic pain resulting from torn discs in his back at his Bowdoinham home on Aug. 27, 2019. Mosher used painkillers for over three decades before quitting around the time Maine put new prescribing laws into place. While he still has pain today, Mosher said he's wary of using painkillers again.

BOWDOINHAM, Maine — Dale Mosher didn’t think anything of picking up his friend’s 35-pound dog when he was 20 years old. But when he twisted his back while standing staggered on a flight of stairs, he tore three discs in his back and his life changed forever.

“I did everything you could do wrong,” Mosher said from his home in Bowdoinham.

That moment began Mosher’s relationship with chronic pain. Walking down the stairs or to the bathroom, even turning over in bed was impossible at times without prescription painkillers. Mosher, 74, said he started using painkillers in the 1980s, when his pain became more regular.

He said he couldn’t believe it when the Legislature limited painkiller dosages in 2016. Mosher doesn’t use prescription painkillers anymore, but said he would have had a poor quality of life without a combination of physical therapy, opioids and sometimes a brace.

“At that point in time, a lot of people were saying that they [opioids] don’t work,” Mosher said. “And I’m thinking to myself, ‘You’re stupid.’ I got to work — because if I didn’t have drugs, I was going on disability. That was the two choices.”

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As a response to the national opioid crisis, Maine was one of dozens of states to limit the supply of prescription painkillers in 2016, with the Legislature making exceptions for people with chronic pain the next year. It is one of a handful of states to set limits on the daily dosages for patients, along with Nevada, Arizona, Rhode Island and Tennessee.

The law has been part of a massive shift in opioid prescribing. Between 2015 and 2019, the number of Mainers at or over the new limit fell by 77 percent — from more than 29,000 people to less than 7,000. Three providers said they have gotten the majority of their patients off opioids.

It comes with a trade: Doctors and people with chronic pain say people who could benefit from opioids hesitate to do so because they fear becoming addicted and the stigma surrounding opioid use, and struggle to get their needs recognized by health care providers.

A sea change and ‘a chilling effect’

The original law passed in 2016 gave an estimated 13,000 individuals a year-long period to wean themselves below the daily threshold of 100 morphine milligram equivalents per day, but a lawsuit against the state spurred a 2017 amendment exempting people with chronic pain.

It was motivated by Maine’s opioid crisis, which drove drug overdose deaths to a high of 418 in 2017. It was driven by opioids like heroin and fentanyl, which killed 12 people in 2009 and 281 by 2017. Overdose deaths dropped by 15 percent last year amid a long-term drop in opioid prescriptions, which fell by 32 percent from 2013 to 2017, according to IQVIA.

The National Institute on Drug Abuse estimates about 21 percent to 29 percent of patients prescribed opioids for chronic pain misuse them, but only 8 percent to 12 percent develop an opioid use disorder. Of those who misuse prescription opioids, about 4 percent to 6 percent transition to heroin — but about 80 percent of people who use heroin misused prescription opioids first.

[More pain pills were handed out per person in Penobscot County than anywhere else in New England]

That was the idea behind the law, which also limited opioid prescriptions to 30-day supplies and required doctors to screen patients through the state’s prescription monitoring program.

“Because of the law, doctors are saying it’s better to have the patient come back after five days than to prescribe too many,” said Peter Michaud, an attorney with the Maine Medical Association. “They’d rather that than have them sit in a medicine cabinet where a grandchild can find them.”

But Dr. Alan Ross of Kennebec Medical Rehabilitation in Augusta said many patients tell him they are treated poorly by pharmacy staff and family because of a stigma around their prescriptions. At the same time, providers are becoming wary of prescribing pain medication at all, Ross said, causing some patients to struggle to find relief.

“There has been a chilling effect on physicians’ willingness to order opiates,” he said. “That’s a direct result of the law.”

That has affected people like Sam Shepard, a former pain education facilitator at the University of New England and a chronic pain patient who recently left Maine for a job in Colorado. During her five years here, she said she couldn’t find any primary care providers who would treat her for her back pain, which stems from an injury she sustained while working in health care.

Providers became even more skittish after the law changed, she said, so she drove to Vermont to see one who managed medications and offered other treatments — including platelet injections — that help manage her pain today, keeping her under Maine’s limit.

If the law came into play at the height of her injury, Shepard said she wouldn’t have been able to survive. She said the law made her feel like “the government now determines our quality of life.”

“It would have been devastating to me,” Shepard said. “I probably would have killed myself if I didn’t get relief. You just don’t want to live like that.”

Living without

Tapering patients off opioids can be a challenge for doctors if they don’t know how to reduce withdrawal symptoms or are uncomfortable with addressing a patient they think might have a substance use disorder, said Dr. Noah Nesin, the vice president and a family practitioner at Penobscot Community Health Care, a federally qualified health center.

Getting people off of high dosages requires educating them about opioid use, which has been shown to sometimes increase pain while having little effect on the pain itself, Nesin said. It can also require trying multiple methods, like neuropathic care, psychotherapy, anti-seizure medication and Tai chi. On this front, Nesin said his center has been successful.

[The Maine pharmacy that dispensed the most pain pills in opioid crisis’ early days was in Bangor]

Of the center’s 65,000 patients, he said roughly 330 use prescription opioids to treat chronic pain and fewer than five patients are above the threshold. That represents a 77 percent reduction of opioid use in the last seven years, he said.

The health center has been so successful on that front that Nesin said his group is working with others to develop a package of best practices that will be available to other providers at no cost through the Maine Department of Health and Human Services.

“If both the provider and the patient are fully engaged in [tapering], it results in a better quality of life,” Nesin said. “But if it’s handled poorly and someone isn’t educated about the emotional component of chronic pain and the stigma of opioid addiction, it can keep people from talking about it.”

Lindsay Crete, a spokesperson for Gov. Janet Mills, said the law has been successful in curbing prescribing practices that lead to addiction, adding the state will “continue to work to educate prescribers on the law” and work to further “reduce overprescribing and diversion.”

[Use this map to find out how many opioid pills your local pharmacy received]

In Bowdoinham, Mosher said he was on his way off prescription painkillers when the new law went into effect, and came off them fully after a prescription wasn’t filled while he was on vacation in Arizona. He hasn’t changed his mind on the law, but he has accomplished its goal.

He currently uses nothing stronger than Tylenol for his back pain, which he said is just “occasional” now. But there is still pain in his knees stemming from arthritis and a torn meniscus in the left. Sometimes, he can’t walk for long. If the Tylenol kicks, he doesn’t notice the pain.

Mosher said he has been afraid of becoming addicted to painkillers since he started taking them. And after 20 years of on-and-off use, he said he didn’t realize how groggy and clouded they made him until he quit for good.

“There was a clarity to the world that I didn’t realize was supposed to be there,” he said. “[It’s] like getting a new pair of glasses. I didn’t know I couldn’t see good — and then, holy moly.”

Related: The opioid crisis in Maine



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