This Feb. 19, 2013, file photo shows OxyContin pills arranged for a photo at a pharmacy in Montpelier, Vt. Credit: Toby Talbot / AP

Maine health care providers have issued steadily fewer opioid prescriptions for about a decade, yet the state still had the highest opioid prescription rate in New England in 2020, according to data from the U.S. Centers for Disease Control and Prevention.

The steady fall shows the progress the state has made in dispensing fewer of the opioids that powered an addiction epidemic that has killed thousands of Mainers, as well as the effects of a 2016 state law that restricted opioid prescriptions. Maine’s opioid prescription rate has been lower than the nation’s as a whole since 2017.

But Maine’s still relatively high rate for New England is a relic of opioid manufacturers’ strategy years ago of targeting areas that had worked in manual labor-intensive jobs such as manufacturing and lobstering, according to substance use experts.

Maine Attorney General Aaron Frey announced last week that the state had reached a $130 million agreement with Johnson & Johnson for the company’s role in manufacturing opioids. Native American tribes reached a federal $590 million settlement with the drug company earlier this week.

As settlements have moved forward and prescriptions have dropped, however, drug overdoses in Maine have continued to rise. More than 630 Mainers died from overdoses in 2021, setting an annual record.

Maine health care providers issued 40.3 opioid prescriptions for every 100 residents in 2020.

New Hampshire’s opioid prescription rate in 2020 was 35.2 per 100 residents. Vermont’s was 34.8, Massachusetts’ was 33.3, Connecticut’s rate was 37, and Rhode Island’s was 36.5.

The overall prescription rate in the U.S. was 43.3 prescriptions per 100 people, while Alabama had the highest rate at 80.4 and Hawaii had the lowest at 27.3.

Those numbers don’t include opioid agonists like methadone or buprenorphine, commonly known as Suboxone, which are used to treat substance use disorders.

Maine’s 2020 dispensing rate is less than half its peak rate in 2011, when prescribers issued 93.1 opioid prescriptions for every 100 residents. Substance use experts pointed to that decline as evidence of the state’s success in tightening prescription regulations and making it harder for people to procure opioids like OxyContin.

But Maine’s current status as the state with the highest opioid prescription rate in New England is a reflection of its role as one of the states pharmaceutical executives specifically targeted for opioid marketing, said Gordon Smith, the director of Maine’s opioid response.

Salespeople for Purdue Pharma, the company that makes OxyContin, aggressively targeted states like Maine, West Virginia, Virginia and Kentucky because they had a critical mass of workers in injury-prone job sectors like lobstering, forestry and mining and were likely to seek pain relief treatment.

“We may not be at the average New England level because we’ve had the furthest to come,” Smith said.

Noah Nesin, an innovation adviser for Penobscot Community Health Care in Bangor and its former chief medical officer, said that overprescription is still a problem in Maine, noting that while Maine had reduced its rate by more than half in recent years, the current rate is still substantially higher than in 1999.

The majority of such prescriptions are likely for people with long-term opioid prescriptions who were prescribed the drugs before a 2016 law made it harder for people to secure those drugs, Nesin said.

Tapering patients off of such drugs is difficult, as people who have taken opioids for an extended period worry about how they’ll respond when off of opioids, so doctors may be reluctant to stop prescribing, Nesin said.

“They’re very worried, understandably so, about, ‘What’s my life going to be like without this pain medicine?’” Nesin said.

There is also the possibility that a small group of prescribers don’t believe opioids are dangerous and continue to prescribe them in high numbers, he said.

Maine’s opioid epidemic became more deadly as the rate of opioid prescriptions fell because those who had become addicted turned to cheaper, more easily available street drugs like fentanyl and heroin as it became harder to access prescription opioids, said Jeff Barkin, a Portland-based psychiatrist and president of the Maine Medical Association.

“The illegal market is not stupid,” Barkin said. “They understood that and probably increased the purity and decreased the price in response, and that’s when you saw a problem, from prescription drugs beginning to inflect into illicit drugs.”

Seventy percent of Maine’s fatal overdoses in 2021 were due to fentanyl, a synthetic opioid that is 80 to 100 times more potent than morphine. Fentanyl is increasingly cut into street drugs, and because it cannot be tasted or smelled, people often unknowingly ingest drugs laced with the powerful opioid and overdose.

It’s fairly easy for people to go from taking legitimate opioid prescriptions to developing substance use disorder, said Jacquie Wilks, the executive director of Together Place Peer Run Recovery Center in Bangor.

One woman she works with was prescribed Vicodin, a combination non-opioid and opioid pain reliever, when she had a cesarean section. When her doctor stopped prescribing the drug, she started buying other drugs on the street before approaching Together Place to receive treatment for substance use disorder.

“It just started out with a simple prescription from a doctor saying, ‘I know you have some pain, here, take this,’ and then, next thing you know, she was pretty hardcore,” Wilks said.

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Lia Russell

Lia Russell is a reporter on the city desk for the Bangor Daily News. Send tips to LRussell@bangordailynews.com.