As the state tightened access to opioids, the illegal drug trade created a deadly new era in Maine’s opioid crisis.

By the time Maine lawmakers passed a bill that significantly stemmed the flow of pharmaceutical opioids into the state, a booming illicit market for fentanyl and methamphetamine was already on the horizon, ready to usher in a new, deadlier era of the opioid epidemic.

It took only about three years from the first known case of a Mainer dying of non-pharmaceutical fentanyl for illicit drugs to completely transform Maine’s opioid epidemic.

In 2013, Maine’s Office of the Chief Medical Examiner recorded the first case of non-pharmaceutical fentanyl in a toxicology report for a person who died of a drug overdose.

Three years later, in 2016, more Mainers died from illicit drug-related overdoses than from pharmaceutical-related overdoses for the first time since the University of Maine began collecting data 20 years earlier.

It was a stark change from what Maine had seen in the previous two decades, when the opioid epidemic was fueled primarily by pharmaceutical drugs like opioid painkillers.

In 1997, a year after drugmaker Purdue Pharma introduced its highly addictive painkiller OxyContin, 30 Mainers died from overdoses where a pharmaceutical drug was a factor, at least half of which could be attributed to a pharmaceutical opioid.

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In the same year, there were eight drug deaths related to an illicit non-pharmaceutical drug.

According to researchers at the University of Maine, most drug-related deaths involve more than one type of drug and very often include alcohol.

As of 2016, the year Maine passed a law cracking down on opioid prescriptions, the number of deaths in Maine related to non-pharmaceutical drugs exceeded that of overdoses related to prescription drugs, by 259 to 231, powered by fentanyl. This trend continued and in 2020, the last full year of data, deaths had climbed to 399 and 322, respectively.

As of September 2021, with three months left to report, 284 Mainers had died of a pharmaceutical drug-related overdose. That pales in comparison to the nearly 400 people who died of non-pharmacy related overdoses.

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WHAT THE 2016 LAW MISSED

Purdue Pharma OxyContin Pills 15 milligrams. Andrée Kehn/Sun Journal

When Maine lawmakers passed the bill that strengthened the state’s prescription monitoring program and, for the first time, placed restrictions on how clinicians could prescribe opioid painkillers, law enforcement officials State and other key leaders have launched a public information campaign on how to safely wean — or taper — patients off drugs.

Although the law requires prescribers to reduce high daily doses of opioids for patients, it does not specify how they do this.

It is impossible to say for sure how many people who developed substance use disorders while using a prescription pharmaceutical opioid turned to illicit drugs after changes to Maine law in 2016. But, when the law went into effect and dramatically reduced legal access to prescription opioids, experts say there was a growing market for non-pharmaceutical illicit drugs that was able to meet the demand created by the changes in the law.

One such drug was familiar to Maine: heroin.

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An extensive study conducted by the Administration of Addiction and Mental Health Services in 2013 data collected annually from 2002 to 2011 by the National Survey on Drug Use and Health found that people who had used heroin at least once in the previous 12 months were 19 times more likely to having started their drug use with a pharmaceutical opioid than without.

A 2014 retrospective study of heroin use over 50 years published in the Journal of the American Medical Association found that following Purdue’s release of the “abuse deterrent” reformulation of OxyContin in 2010, the use of the prescription drug dropped dramatically. “However, an unintended result has been the increase in the abuse of other opioids, including heroin.”

Heroin-related deaths in Maine peaked in 2016, when 120 Mainers died, a 15-fold increase from 2010. There were 675 fatal and suspected non-fatal overdoses in Maine emergency rooms in 2017, the first year Maine CDC data is available.

FENTANYL: ‘THE ELEPHANT IN THE BEDROOM’

But soon, heroin was no longer the only option.

As pharmaceutical opioid laws got tougher, “people started switching (to illicit drugs) and the international drug trade was like, ‘Well, what do we have to give them? There are a lot of these people who are addicted, we could intervene here,” said Dr. Marcella Sorg, a forensic anthropologist who is one of the state’s leading experts in monitoring deaths related to the drugs and director of UMaine’s rural drug and alcohol research program. .

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“And heroin is what they had. And so heroin was the benchmark at that time, and the number of heroin deaths started to rise.

Then, around 2012 and 2013, illicit drug manufacturers, mainly in China and Mexico, discovered how to easily and cheaply produce fentanyl, a synthetic opioid 50 times more potent than heroin and 100 times more potent than morphine, as well as the stimulant methamphetamine.

It’s easy to disguise fentanyl as another drug, like oxycodone. An individual may unknowingly take a fentanyl tablet, thinking it is oxycodone, for example. According to United States Drug Enforcement Administration.

The first case of non-pharmaceutical fentanyl in Maine appeared in a toxicology report in 2013, according to the Maine Attorney General’s Office Annual Drug Death Reports and Margaret Chase Smith Policy Center.

“That’s what started to build gradually, and since 2015 it’s been the elephant in the room,” Sorg said.

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In 2015, for the first time in Maine, there were more deaths related to non-pharmaceutical illicit opioids than to pharmaceutical opioids. The following year, drug deaths from all illicit drugs exceeded those from all pharmaceuticals.

The increasing availability of cheap stimulants, like cocaine and methamphetamine, which can be used in combination with drugs like fentanyl and heroin, has compounded the impact of these highly lethal opioids.

According to Maine Drug Deaths Report for 2020.

THE DIFFICULT WORK OF REDUCTION PROGRAMS

Dr. Candice McElroy, seen March 14, is medical director of Sacopee Valley Health Center in Porter. McElroy said when she started working at the center in 2019, she realized doctors there were prescribing opioids at high levels. Andrée Kehn/Sun Journal

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When Dr. Candice McElroy became medical director of Sacopee Valley Health Center in Porter in 2019 and realized that more than 200 patients were receiving high daily doses of prescription opioids, she feared that inappropriately reducing or stopping the drugs would not sends some patients into withdrawal or research. for another supplier. Some patients had been taking medication for years.

“We couldn’t just stop their meds because they would go into withdrawal,” she said. (Read more about Dr. McElroy in Part 1 of Legacy of Pain.)

“And it wasn’t really their fault that they were prescribed the way they were, but it wasn’t good management either, (it) wasn’t good medicine.”

The gradual process of weaning patients off their drugs, or tapering off, not only makes the withdrawal less severe, but decreases the possibility that a drug addiction will turn into an addiction.

It’s a complicated and time-consuming process that can take anywhere from weeks to years, depending on the patient, McElroy said. She and the other doctors had to review each patient’s medical history and have ongoing discussions with them throughout the process of tapering and, in some cases, transitioning to drug treatment if necessary.

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It also requires patient buy-in. When McElroy arrived at the clinic and started this process, “there was definitely a lot of tension.” Very few identified as having an opioid use disorder, she said.

“What I often heard (was), ‘You’re doing this to me because these other people are using drugs.’ Thus, patients identified themselves as being punished because of people they saw as very separate from themselves who were using illegal drugs on the street.

Very few patients came to the health center just for pain management, “which made it very difficult because patients were like, ‘Well, you know, I was on my diabetes meds, my blood pressure meds and my painkillers,” “I trusted you guys with my care — all my care,” McElroy said.

“Some patients got angry not only because we reduced them, but also because they had become dependent on these drugs.”

McElroy wondered if she would have taken the job, uprooting her family from York and moving them to rural western Maine, if all of this had been revealed to her. She’s not sure she would have.

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For the past two years, McElroy and the other physicians at the health center have been working to implement a practice-wide tapering program. As of last summer, more than half of the patients McElroy inherited in 2019 were able to come off opioid medication entirely through tapering, while others were still in treatment.

The number of patients on opioids was down nearly 70% as of July 1, McElroy said. Morphine’s daily milligram equivalent — once just below Maine’s hospice threshold — has also dropped 70 percent.

Coming next week: We examine how the opioid epidemic has placed growing strain on schools and the child welfare system as the state grapples with this multi-generational crisis. And we’ll look at possible solutions from state officials, lawmakers, and stimulus advocates.

The project was carried out in partnership with the USC Annenberg Center for Health Journalism through its 2021 Data Fellowship Program.

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