Opioid prescribing in Maine has plummeted over the past five years, including a 14.1 percent decline in 2018, a positive sign as the state battles to control an epidemic of substance use disorder that has fueled an overdose rate of one death every day.

Since 2013, Maine opioid prescriptions have fallen by 41.5 percent, according to recently released statistics. The drop is happening as Maine and other states apply limits that reflect widening recognition of the role prescription drugs play in the opioid crisis.

Maine’s five-year drop was the seventh-highest in the country, and its year-over-year decline was the 12th highest among the states and District of Columbia. Opioid prescribing nationwide declined on average 32.9 percent from 2013-18, and 12.4 percent in 2018 alone. The nation’s capital experienced the steepest drop, with 52.3 percent fewer opioid prescriptions in 2018 compared to 2013.

“This is a very significant reduction in opioid prescribing in Maine, and in terms of a population health issue, this is a good thing,” said Dr. Noah Nesin, chief medical officer of Penobscot Community Health Center in Bangor. “To the extent that the prescriber is fully engaged with their patients, and conducts a rational and compassionate tapering program, quality of life improves. But some patients are getting the rug pulled out from under them, and they are not having a positive experience.”

At Nesin’s clinic, 77 percent of patients who previously used opioids for chronic pain now no longer use them, he said. They employ a “multifaceted” approach that can include therapy, yoga, nutrition and over-the-counter medications. There is no evidence that opioids are effective at controlling chronic pain, Nesin said, and opioid drugs can cause overdoses and lead to substance use disorder.

With less opioid prescribing, there are more patients like Drew Floyd of Portland, who was weaned off opioids for chronic back pain two years ago. Floyd, a Mercy Hospital patient, had tapered to a low dose of opioids before the law that would have required her to do so went into effect.

Floyd, 38, said she uses a combination of therapy, exercise, osteopathic adjustments and medical marijuana to control her pain.

“Overall, the pain is not any worse than when I was taking opioids, and I no longer get terrible headaches and I don’t have nearly as many stomach problems,” said Floyd, who previously was taking vicodin, Oxycontin and tramadol opioid painkillers. “The pros outweigh the cons.”

She said she has to rest more, which is better for her body. When she was taking painkillers, she would “overdo things,” which ultimately made her feel worse, she said.

Nesin said patients at Penobscot Community Health Center who are weaned off opioids have a better quality of life and have generally been successful at controlling their pain.

The total number of opioid prescriptions written in Maine fell from 1.1 million – or the equivalent of nearly one opioid prescription for every Maine resident in 2013 – to 646,986 in 2018, according to IQVIA, a health care research company in North Carolina.

Drug overdose deaths in Maine declined from 417 in 2017 to 354 in 2018, the first reduction after years in which the overdose death toll mounted. However, experts cautioned against drawing a connection between prescribing and overdose deaths, as the opioid crisis is a complex issue involving many factors, including whether a state has strong prevention and treatment programs and the availability of illicit opioids, such as heroin and fentanyl.

Still, the role of prescription drugs in fueling substance use disorder is significant. Four of five new heroin users started by abusing prescription painkillers, according to the American Society of Addiction Medicine.

Gordon Smith, Maine’s opioid response director, said the most likely reason for the reduction in drug overdose deaths in 2018 is wider access to naloxone, a life-saving antidote to opioids.

Smith and other experts said that Maine’s strict prescribing law – which fully went into effect in 2017 – is likely a contributing factor to prescribing rates declining.

He pointed out that the law not only sets prescribing limits, but also requires doctors to take continuing education courses on opioid prescribing. Those courses, he said, have raised awareness among physicians of the dangers of opioids.

“Now virtually every prescriber understands they have to be careful when prescribing opioids,” Smith said.

Maine was one of the first states to approve strict prescribing rules for opioids in 2016, and since then 27 other states have passed laws or developed strict prescribing rules, such as limits on dosage. Maine, for example, limits dosages to 100 morphine milligram equivalents per day for non-acute pain, with several exceptions, such as for cancer patients.

“Less opioid prescribing will clearly correlate with better outcomes societally,” said Michael Kleinrock, research director for the IQVIA Institute for Human Data Science, and a Sanford resident.

Nevada recently approved tough new prescribing standards, and the state experienced the biggest year-over-year drop in opioid prescribing in the nation in 2018, at 22.5 percent.

Kleinrock said it remains to be seen what levels of opioid prescribing will provide the correct mix of controlling pain for certain patients while not contributing to substance use disorder and overdose deaths. He said he expects prescribing will continue to decline to return to early 2000s levels. Currently, opioid prescribing has plummeted to roughly mid-2000s levels in the U.S. but is still about twice as prevalent as the 1990s, before opioid prescribing for chronic pain became widespread.

Increased awareness among patients also may be playing a role in reduced prescribing.

Dr. Charles Pattavina, who heads up the Emergency Department at St. Joseph Hospital in Bangor, said there’s been a noticeable change in patient attitudes toward opioids in recent years.

“We’ve been seeing more people who want less pain medication in emergency departments,” said Pattavina, who is also chairman of the Maine Medical Association. “Because of all the well-deserved news about the opioid crisis, many patients seem more reluctant to have a dose or a prescription for an opioid medication. They’d rather put up with some pain than take any risks.”

Kleinrock said another factor that led to the increase in opioid prescribing is shorter hospital stays. Decades ago, patients would stay longer in the hospital after surgery, and by then often their pain had reduced to the point that they didn’t need a pain prescription. But with patients discharged a day or two after surgery, doctors were prescribing opioids for use at home, often for longer amounts than necessary.

“The dynamic is not as simple as overprescribing resulting in addiction, debilitation and death, tragic as they are. It’s much more complicated than that,” Kleinrock said.

For instance, prevention and treatment programs are crucial, as is Medicaid expansion, which makes treatment more accessible to patients with substance use disorder who couldn’t afford treatment and lacked health insurance.

Maine implemented Medicaid expansion this year, bringing medication-assisted treatment to potentially thousands of Mainers. Gov. Janet Mills is making responding to the opioid crisis one of her highest priorities.

Andrew MacLean, a spokesman for the Maine Medical Association, said while in some cases the prescribing law has “put a strain on physician-patient relationships” because some patients believe they’re not getting adequate pain relief, the law is having an overall positive effect by reducing unneeded opioid prescribing.

MacLean said more doctors are pursuing alternatives to opioids for pain management, and that’s also been helpful.

“”The law has probably struck the right balance,” he said.