Maine lawmakers approved one of the strictest opioid prescribing laws in the country last spring to help address the state’s growing drug epidemic. But doctors worry the law could have the unintended consequence of creating new addicts.

About 16,000 Mainers are currently prescribed high doses of opioids for chronic and acute pain, and the new law means many will have their prescriptions reduced.

A physicians group says that could leave patients vulnerable if no safeguards are in place. Those patients may go to the streets to acquire pills illegally – or start using heroin as a substitute.

About three of four new heroin users first abused prescription painkillers, according to the American Society of Addiction Medicine.

The Maine Medical Association, which represents doctors, is launching an aggressive public education program to ensure that the effort to solve one addiction problem doesn’t push people into another.

“We don’t want to just throw people off of this medication. We don’t want people to start getting pills from the streets or taking heroin,” said Gordon Smith, executive vice president of the medical association.

The law goes into effect Friday, and by 2017, thousands of people will be required to lower their doses, some to one-third to one-half of what they are currently prescribed. The law sets maximum doses for many patients at 100 morphine milligram equivalents per day, and mandates that doctors use the state’s prescription monitoring program to track the number and type of prescriptions each patient receives.

Experts say if implemented correctly, the law will have many benefits.

“There is light at the end of that prescription,” said Denise Swyers of Brunswick, who suffers from chronic pain. Swyers was a long-time opioid user but now no longer takes them. She said the quality of her life has improved, and her pain level is the same now as when she was taking opioids, an experience that reflects research on the topic. Swyers now gets pain relief through meditation, exercise, hobbies, ice packs and Advil, as recommended by her doctors.

Smith said his group is touring the state to educate physicians about how best to wean patients off high doses of opioids – 100 morphine milligram equivalents or higher. He said there will be at least 50 meetings with groups of physicians by the end of the year to discuss the new law.

‘A HARD BRIDGE TO CROSS’

The medical association hosted a conference July 14 in the Augusta area to advise doctors on what to say to patients whose doses are being reduced, how to spot signs of addiction and other tips to make the transition smoother.

Eva Quirion, a nurse practitioner in Bangor, said the doctor-patient conversations will be difficult, especially for patients who have been taking the painkillers for years or decades.

“If you say, ‘I have a great idea to help you with your pain, let’s take away your pain pills,’ it sounds like crazy talk,” Quirion said.

But it’s a necessary conversation, and the message will be more effective as more doctors realize the dangers of opioids, Smith said.

Another point Smith and others are trying to drive home is that opioids don’t work for chronic pain. Whether that knowledge is reaching family physicians in Portland, Lewiston, Bangor or Caribou is unknown – there has been no scientific survey of Maine doctors to see what their perceptions are, Smith said.

“Opioids have no proven efficacy for the treatment of chronic pain,” said Dr. Elizabeth Fowlie Mock of Holden. Chronic pain is mild or severe pain that lasts more than three months, according to medical definitions.

The law does provide exceptions to the dosage cap to those who are suffering from acute pain, such as end-of-life, cancer and after-surgery pain.

Pain specialists say many of the 16,000 patients should taper to a lower dose or be weaned completely off opioids, because of their ineffectiveness for chronic pain and because they carry a high risk of overdose. It’s unclear how many physicians are up-to-date on the research compared with those who still go by the prevailing standards of the early- to mid-2000s, when doctors were encouraged to prescribe opioids for many pain conditions.

HIGH USE OF LONG-TERM OPIOIDS IN MAINE

Maine has the highest rate in the nation of prescriptions issued for long-term, extended-release opioids, according to a 2014 report by the U.S. Centers for Disease Control and Prevention. The long-term opioids, prescribed for chronic pain, are the most likely to be abused, according to the CDC. Maine doctors were prescribing those opioids at a rate more than twice the national average, according to the 2014 report, the latest available.

Maine had a record 272 drug overdose deaths in 2015, most caused by heroin, fentanyl or abuse of prescription opioids.

Now doctors have to try to undo the damage they helped cause, Mock said.

“It’s a really hard bridge to cross, but we have to cross this bridge,” she said.

On a recent day at her Brunswick home, Swyers carefully worked on her artwork – checkerboard and diamond-shaped patterns filling in the outline of a fish. Swyers and a regular group of four artists were practicing “zen tangle,” a meditative form of art that helps her create art and relieve pain at the same time.

The camaraderie also makes her feel better, Swyers said.

Swyers said she was on 50 to 75 morphine milligram equivalents per day of oxycodone to treat fibromyalgia and myofascial pain syndrome, and she had slowly become a “zombie” because she was prescribed ever higher doses as her tolerance increased.

“I was in a fog. I didn’t do anything except sit in my chair,” said Swyers, who estimated she was taking opioids for eight years.

After she stopped taking high doses of oxycodone to treat chronic pain, Denise Swyers of Brunswick, second from left, discovered her pain was the same without the drugs, an experience that aligns with research on the topic. She also found that spending time with friends helped relieve her pain.

After she stopped taking high doses of oxycodone to treat chronic pain, Denise Swyers of Brunswick, second from left, discovered her pain was the same without the drugs, an experience that aligns with research on the topic. She also found that spending time with friends helped relieve her pain. Derek Davis/Staff Photographer

‘JUST LIVING FOR MY NEXT PILL’

Swyers said she quit “cold turkey” once she heard her slurred speech on her voice mail message.

“I sounded like I was drunk, and I said, ‘That’s it, I’m done,’ ” Swyers said. She quit taking opioids six years ago, she said.

Swyers, 68, said her life immediately changed for the better as her mental sharpness returned and she began enjoying hobbies again, including kayaking, art and reading. Her pain was the same as when she was taking opioids, meaning the pills didn’t help at all, she said.

“When I was taking opioids, I was just living for my next pill,” Swyers said.

Her husband, Bill, became a caretaker, making decisions for her because she was “out of it” most of the time.

“Looking back, I can’t even remember a lot of it. It’s like a whole section of my life is just gone,” Swyers said.

She described her pain as a dull ache primarily in her neck, back, hips and shoulders.

“What I learned is that hurt doesn’t equal harm,” said Swyers, who has worked in sales. “When the brain is distracted, the pain is a lot less.”

Dr. Heidi Decker, a primary care physician in Wilton, said she’s grateful for the new law, which she can refer to when talking with patients who are resistant to seeing their dosage reduced. But the conversations with patients are still difficult – one patient who had taken opioids for many years stormed out of her office when she told him he needed to cut back.

“I thought to myself, ‘Have I just created another heroin addict?’ ” Decker said.

DEALING WITH PATIENT RESISTANCE

Dr. Stephen Hull, director of Mercy Hospital’s Pain Center, said he would like to be optimistic about the fate of the 16,000 patients, but he expects many will resist.

“We don’t know how successful they are going to be on the lower doses,” Hull said.

But the law is needed, because while opioids are useful for acute pain – such as for end-of-life care or post-surgery – they have been proven ineffective and counterproductive at controlling chronic pain, he said.

Patients taking 50 morphine milligram equivalent doses are twice as likely to die from an overdose as a patient who is not taking any opioids, and they are nine times more likely to die at 100 morphine milligram equivalents.

“We have been treating chronic diseases that are not life-threatening with drugs that are,” Hull said.

Dr. Noah Nesin, of Penobscot Community Health, said weaning people off opioids is the right thing to do.

“Let’s make a commitment to engaging with these patients, no matter how badly they treat us, no matter how angry they get, no matter how much they say we’re ruining their lives,” he said.