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

It only took about three years from the first known instance of a Mainer dying from nonpharmaceutical fentanyl for illicit drugs to completely transform the opioid epidemic in Maine.

In 2013, the Maine Office of the Chief Medical Examiner recorded the first instance of nonpharmaceutical fentanyl on a toxicology report for an individual who had 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 dramatic shift from what Maine experienced over the two decades prior, during which the opioid epidemic was mainly fueled by pharmaceutical drugs like opioid painkillers.

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

The same year, there were eight drug-induced deaths related to a nonpharmaceutical, illicit drug.

Most drug deaths involve more than one type of drug and very often include alcohol, according to researchers at the University of Maine.

Starting in 2016, the year Maine passed a law clamping down on opioid prescriptions, the number of deaths in Maine related to nonpharmaceutical drugs outpaced those from prescription drug-related overdoses, 259 to 231, fueled by fentanyl. That trend continued and by 2020, the last full year of data, deaths had climbed to 399 and 322, respectively.

As of September 2021, with three months still to report, 284 Mainers had died of a pharmaceutical drug-related overdose. That pales in comparison to the nearly 400 individuals who had died from a nonpharmaceutical-related overdose.

WHAT THE 2016 LAW MISSED

When Maine legislators passed the bill that strengthened the state’s prescription monitoring program and, for the first time, put restrictions on how clinicians could prescribe opioid pain medications, state officials and other key leaders set out on a public information campaign on how to safely wean — or taper — patients off the drugs.

While the law mandated that prescribers reduce patients on high daily doses of opioids, it did not mandate how they go about it.

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 in Maine law in 2016. But, when the law took effect and significantly reduced legal access to prescription opioids, experts say there was a growing market of nonpharmaceutical, illicit drugs that was able to meet the demand created by the law changes.

One of those drugs was familiar to Maine: heroin.

A massive study by the Substance Abuse and Mental Health Services Administration in 2013 of data collected annually from 2002 to 2011 by the National Survey on Drug Use and Health found that individuals who had used heroin at least once in the 12 months prior were 19 times more likely to have initiated 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, use of the prescription drug dropped dramatically. “However, an unanticipated outcome was increases 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 suspected fatal and nonfatal overdoses in Maine emergency rooms in 2017, the earliest year that data from the Maine CDC are available.

FENTANYL: ‘THE ELEPHANT IN THE ROOM’

But soon, heroin wasn’t the only option.

As the laws around pharmaceutical opioids tightened, “people started switching (to illicit drugs) and the international drug trade was saying, ‘Well, what do we got to give them? There’s a lot of these people that are addicted, we could step in here,’” said Dr. Marcella Sorg, a forensic anthropologist who is one of the state’s leading experts on drug death surveillance and the director of UMaine’s Rural Drug and Alcohol Research Program.

“And heroin is what they had. And so heroin was the go-to at that point, and the number of deaths due to heroin started to rise.”

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

It is easy to disguise fentanyl as another drug, such as oxycodone. An individual may unknowingly take a tablet of fentanyl, thinking it’s oxycodone, for example. Just two milligrams of fentanyl — the size of two grains of salt — can be deadly, even for regular drug users, according to the U.S. Drug Enforcement Administration.

The first instance of nonpharmaceutical fentanyl in Maine showed up on a toxicology report in 2013, according to annual drug death reports from the Office of the Maine Attorney General and the Margaret Chase Smith Policy Center.

“That is what started building gradually, and since 2015 it has been the elephant in the room,” Sorg said.

In 2015, for the first time in Maine there were more deaths related to nonpharmaceutical, illicit opioids drugs than to pharmaceutical opioids. The next year, drug deaths related to all illicit drugs surpassed those due to all pharmaceuticals.

Compounding the impact of these highly deadly opioids was the increasing availability of cheap stimulants, like cocaine and methamphetamine, that can be used in combination with drugs like fentanyl and heroin.

A nonpharmaceutical opioid was listed as a co-intoxicant in the majority of all drug deaths in 2020 where cocaine or methamphetamine was a factor, according to the Maine Drug Death Report for 2020.

THE HARD WORK OF TAPERING PROGRAMS

When Dr. Candice McElroy became medical director at Sacopee Valley Health Center in Porter in 2019 and realized more than 200 patients were receiving high daily doses of prescription opioids, she was concerned that improperly reducing or stopping the drugs could send some patients into withdrawal or searching for another supplier. Some of the patients had been taking the medications for years.

“We couldn’t just stop their medications, 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 also wasn’t good management, (it) wasn’t good medicine.”

The gradual process of weaning patients off their medications, or tapering, not only makes withdrawal less severe but lessens the possibility of a dependence on the drug transforming into an addiction.

It’s a complicated, time-consuming process that can take anywhere from weeks to years, depending on the patient, McElroy said. She and the other physicians had to review each patient’s medical history and have ongoing discussions with them as they went through the tapering process, and in some cases transition to medication-assisted treatment if necessary.

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

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

Very few of the patients went to the health center for pain management alone, “which made it really difficult because patients would say ‘Well, you know, I was getting my diabetes medications and my blood pressure medications and my pain medications,’ basically saying, ‘I trusted you guys with my care — all of my care,’” McElroy said.

“There were some patients who became angry about not just us tapering them, but angry about the fact that they had become dependent on those medications.”

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

Over the course of 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 medications entirely through tapering, while some others were still in the process.

The number of patients on opioids has decreased by nearly 70% as of July 1, McElroy said. The daily morphine milligram equivalent — once just below Maine’s palliative care threshold — also dropped by 70%.

Coming next week: We look at how the opioid epidemic has put growing pressure on schools and the child welfare system as the state grapples with this multi-generational crisis. And we will look at possible solutions from state officials, lawmakers and recovery advocates.

The project was produced in partnership with the USC Annenberg Center for Health Journalism through its 2021 Data Fellowship program.

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