As John Nichols tries to go about his daily life, he aches and his knees and hips hurt, among other daily pains.

“It feels like someone is stabbing a knife in my neck and it’s stuck in there, and every time I move it gets stabbed,” he said, describing his daily pain level as a 7 on a scale of 1 to 10.

A few months ago, his pain was at level 3. He could still do the simple things he needs to do to live his life – mow his lawn, do his dishes or go fishing with his son. Nichols, 50, of Winslow, is one of many patients with chronic pain who fear the worst as they are weaned off their opiate medications by their doctors: the loss of quality of life.

“You think I want to lay on the couch my whole life?” Nichols said. “I’m really scared.”

Now he and thousands of others like him are bracing for the pain while the effects of a new state law take hold. The law aims to reduce the amount of medication that can be prescribed to patients, with some exceptions, as the state grapples with a growing opiate abuse epidemic. At the same time, some central Maine patients on opiate medication for chronic pain treatment say they shouldn’t be punished for others’ illegal drug use with new medication limits, and even some medical professionals fear the short-term effects of the law.

And while patients concerned about medication limits may be able to qualify for exceptions, two of the people interviewed weren’t aware of exceptions and already were being tapered off their medications by doctors. Another said there’s scant information available about how to apply and qualify.

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L.D. 1646, introduced by Gov. Paul LePage during the 2016 session, is meant to prevent opiate abuse and bolster prescription monitoring to prevent people from “doctor shopping.”

Limiting prescriptions is among the most controversial aspects of the bill, called “An Act to Prevent Opiate Abuse by Strengthening the Controlled Substances Prescription Monitoring Program.” New patients are limited to a dosage amount of less than 100 morphine milligram equivalents, or MME, of opiates, and those already taking medications above the limit must taper to less than 100 MME by July 1, 2017. Medical professionals measure opiates by morphine milligram equivalents to figure out corresponding dosages of different medications.

Meanwhile, there’s a growing body of evidence that using opioid medication to treat chronic pain is worse for patients over the long term, but those already using such treatment now might have no other choice.

The Maine Medical Association worked with the LePage administration to compromise on some aspects of the bill and ensure there would be exceptions for patients who need high dosages of the medications. A number of doctors have said they understand that something needed to be done to curb the growing opiate abuse epidemic, but some still wish measures could have been taken without legislation.

“I hate having medicine legislated,” said Steve Diaz, chief medical officer for MaineGeneral Medical Center in Augusta. “I believe as a profession we physicians should be policing ourselves and have the wherewithal to provide guidelines. But I think the issue here is the opioid epidemic was getting worse, and there was no national or state medical response to rein it in.”

The legislation also limits the amount of opiates that can be prescribed for daily use as well how much can be supplied within a certain period. A patient can’t be prescribed more than a 30-day supply of opioids for chronic pain treatment, or a seven-day supply for acute pain treatment. It also requires prescribers who have the capability to prescribe all opiates electronically to do so.

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The Prescription Monitoring Program will require prescribers to check prescription monitoring information for a patient’s records at the initial time of prescribing an opioid and every 90 days afterward, unless it is in a hospital or facility setting. Prescribers also must complete three hours of education on opioid medication prescribing every two years.

MAKING EXCEPTIONS

About 16,000 patients in Maine are prescribed more than 100 morphine milligram equivalents, according to Gordon Smith, executive vice president of the Maine Medical Association. About 1,300 Maine patients are prescribed more than 300 MME.

“Even at 200 morphine milligram equivalents, you have a 1 in 32 chance of dying within the next two-and-a-half years,” Smith said. “That’s a mortality rate that’s very, very high.”

According to the state attorney general’s office, Maine had 286 drug overdose deaths in 2016 through Sept. 30, exceeding the 272 deaths in all of 2015. Most of those deaths were fueled by the opioid epidemic.

The Maine Medical Association, a statewide organization aimed at supporting Maine physicians as well as the health of the state’s citizens, ultimately backed L.D. 1646 after the LePage administration agreed to lengthen the maximum supply for prescriptions. A number of exceptions also are included in the legislation.

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Smith, the association’s executive vice president, said he thinks there are enough exceptions to account for nearly every patient’s situation.

Physicians can prescribe opioid medication above the new legal limit for pain related to cancer treatment, end-of-life care, treatment for substance abuse and palliative care. Palliative care, as defined by state law, is patient-centered care that aims to optimize quality of life by anticipating and treating “suffering caused by a medical illness or physical injury or condition.”

Patients suffering from chronic pain, such as those who talked with the Morning Sentinel, most likely could qualify for the palliative exception, but it’s unclear how they would go about qualifying for it. Nichols said his doctor hasn’t talked with him about finding a way to keep his normal dosages, and it’s unclear if patients would be able to qualify for an exception without a doctor’s cooperation or effort.

‘IT’S GOING TO MAKE IT WORSE’

Kate Carll, 60, of Hallowell, was taking up to 1,200 morphine milligram equivalents of methadone in one day after a back surgery eight years ago and other injuries left her with severe, chronic pain in her back, legs and feet. Her doctor, James Wilson at MaineGeneral Physiatry, now has switched her to a different opiate painkiller, oxymorphone, and lowered her dosage to 20 milligrams, or 60 MME, per day. A MaineGeneral spokeswoman said the health care system would not be able to discuss individual patients, even with that patient’s permission.

“I can’t be on more than 20 milligrams a day – that’s breakfast food,” Carll said. “I understand the law. I totally understand what they were trying to do, but it’s going to make it worse. I’m going to end up in a nursing home, and as a result, they’re spending more money on me.”

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Because her new dose is not strong enough, Carll said, she has had increasing difficulty walking. She now uses a cane and has a hunch in her back. She doesn’t think she would ever look to street drugs to help with the discomfort, but worries she’ll eventually be confined to a wheelchair and a nursing home.

So Carll did some research and found the palliative care exception, she said, determining that she could qualify, and her doctor agreed to work with her to get the exception.

“That was not offered to me; that was because I dug,” she said.

However, she said it’s not clear yet what the process will be. Carll will get the paperwork to start the process and sign a contract, and at the end her doctor will be able to prescribe her medication up to a “therapeutic level,” though she said that probably won’t be at the level she was at before. Carll also said she’s afraid a lot of people with chronic pain will “fall through the cracks” and either won’t realize there’s an exception or won’t be offered a chance to use it.

Samantha Edwards, spokesperson for the Department of Health and Human Services, did not respond to multiple requests for comment on the law and the palliative care exception.

Smith, from the Maine Medical Association, said paperwork shouldn’t be involved for those who qualify for the exception. However, he also acknowledged that it’s been difficult to raise awareness about the exceptions, even in the medical community.

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“One would hope that the providers and the patients work together,” Smith said. If not, there is the option of going to a different provider, but he acknowledged that “very few people in the current environment are very enthusiastic” about patients with severe chronic pain.

The new law won’t be enforced until a much later date, he said. For the prescription monitoring component, enforcement will begin March 1. The state will begin enforcing opioid limits as late as October.

This gives patients, their families and prescribers the opportunity to attend public hearings and argue for more exceptions.

PATIENT PAIN

Jeff Miller, 54, of Albion said he started taking methadone about five years ago.

Miller was in a snowmobile accident in 1997, breaking his left ankle, hip, elbow, heel, both his scapulae and his nose. The accident also broke six of his ribs and compressed some of his vertebrae. At first he was prescribed Percocet for the pain. He never wanted to start taking methadone, but it was recommended because of its longer release time, he said.

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Miller was taking nine 10-milligram methadone pills per day in the late summer, which equals 1,080-milligram morphine equivalents, and now has been tapered to less than five 10-milligram pills per day.

Now he’s afraid he’ll return to the same level of pain he had after the accident.

“I’m going to start back where I was, and I’m going to have a craving for this stuff,” Miller said. “What are we going do?”

Madeline St. Amour can be contacted at 861-9239 or at:

[email protected]

Twitter: madelinestamour


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