Please read Mark’s letter below.. Mark reached out to me some 8-9 yrs ago as the MT medical board was starting to “go after him.”
As I understand it, one or more large practices in Maine have decided that all pain pts will be treated with Buprenorphine for pain management.
In Reading the Maine’s Pain Management Policies. It would seem that -collectively – Maine’s legal and healthcare professionals are violating their own law in regards to at least Brandy.
Opioid Prescribing Limits**: Maine’s 2017 law restricts opioid prescriptions to ≤100 morphine milligram equivalents (MME)/day for chronic pain, with exceptions for palliative care, cancer, and substance use disorder treatment
Here is: Maine’s Pain Management Policies
Maine’s approach to pain management does not mandate the universal use of buprenorphine for all pain patients, but its regulations encourage cautious opioid prescribing while allowing flexibility for evidence-based treatments. The literature supports buprenorphine’s efficacy in managing chronic pain, particularly in high-intensity cases, with studies showing sustained pain relief and reduced tolerance development. For patients with high CYP-450 metabolism, pharmacokinetic interactions are manageable and rarely clinically significant.
### Maine’s Pain Management Policies
– **Opioid Prescribing Limits**: Maine’s 2017 law restricts opioid prescriptions to ≤100 morphine milligram equivalents (MME)/day for chronic pain, with exceptions for palliative care, cancer, and substance use disorder treatment[1].
– **Non-Opioid First Approach**: Clinicians must prioritize non-opioid therapies and use “Universal Precautions” (risk assessment, monitoring) when prescribing controlled substances[2][3].
– **Buprenorphine in Practice**: While not explicitly mandated, buprenorphine is permitted under exceptions for medication-assisted treatment (MAT) and chronic pain[1][3].
### Buprenorphine’s Efficacy in Pain Management
– **Chronic Pain**:
– A 36-month study of transdermal buprenorphine patches demonstrated sustained pain reduction (NRS scores decreased by 4.2–5.1 points) and high patient satisfaction (PGIC scores improved by 76%)[5].
– Systematic reviews found buprenorphine rotation from full opioids maintained or improved analgesia in 53–83% of patients, with fewer adverse effects than traditional opioids[10].
– **High-Intensity Pain**:
– Perioperative protocols recommend continuing buprenorphine and supplementing with short-acting opioids for acute pain, as abrupt discontinuation risks withdrawal[4].
– Partial agonism at µ-opioid receptors provides a “ceiling effect,” reducing respiratory depression risk while maintaining analgesia[11].
### CYP-450 Metabolism Considerations
– **Pharmacokinetics**: Buprenorphine is metabolized primarily by CYP3A4 and CYP2D6, with inhibitory effects on both enzymes[6][7][13].
– **Drug Interactions**:
– **Inhibitors (e.g., ciprofloxacin)**: Increase buprenorphine exposure by 33–44% but are unlikely to require dose adjustments[8][12].
– **Inducers (e.g., rifampin)**: Reduce exposure by 28%, which may necessitate monitoring[8].
– **High/Ultra-High Metabolizers**: Limited data suggest therapeutic doses remain effective, as buprenorphine’s high receptor affinity offsets rapid metabolism[6][8].
### Key Recommendations
1. **Chronic Pain**: Consider transdermal buprenorphine for long-term management due to its stable efficacy and low tolerance risk[5][10].
2. **CYP-450 Interactions**: Monitor patients on concurrent CYP3A4 inhibitors/inducers, though dose adjustments are rarely needed[8][12].
3. **Acute Pain**: Maintain buprenorphine and add short-acting opioids rather than discontinuing therapy[4].
Buprenorphine’s pharmacological profile and clinical evidence position it as a safer alternative to full opioids, aligning with Maine’s emphasis on risk mitigation without compromising pain control.
Citations:
[1] https://academic.oup.com/ajhp/article/73/12/854/5101528
[2] https://regulations.justia.com/states/maine/02/380/chapter-21/section-380-21-4/
[3] https://www.maine.gov/boardofnursing/laws-rules/Chapter%2021%2005.27.20.pdf
[4] https://www.painphysicianjournal.com/current/pdf?article=NTAwMQ%3D%3D&journal=109
[5] https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2024.1454601/full
[6] https://pubmed.ncbi.nlm.nih.gov/12756210/
[7] https://www.jstage.jst.go.jp/article/bpb/25/5/25_5_682/_pdf
[8] https://pubmed.ncbi.nlm.nih.gov/33750027/
[9] https://www.themainewire.com/2025/02/mainecare-spending-on-suboxone-has-surged-since-2019/
[10] https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2784021
[11] https://en.wikipedia.org/wiki/Buprenorphine
[12] https://www.drugs.com/drug-interactions/buprenorphine-with-ciprofloxacin-438-0-672-0.html?professional=1
[13] https://go.drugbank.com/drugs/DB00921
[14] https://www.maine.gov/sos/cec/rules/10/144/ch101/c2s089.docx
[15] https://library.samhsa.gov/sites/default/files/pep21-06-01-002.pdf
[16] https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/me-sud-care-initiative-midpoint-assessment-03282024.pdf
[17] https://mesudlearningcommunity.org/wp-content/uploads/2023/02/Prior-Authorization-Processes-Buprenorphine-FAQ-July2021.pdf
[18] https://lawatlas.org/sites/default/files/2025-03/VS%20Buprenorphine%20Policy%20Brief_March2025_final_3.26.25.pdf
[19] https://www.azdhs.gov/documents/prevention/womens-childrens-health/injury-prevention/opioid-prevention/appendix-b-state-by-state-summary.pdf
[20] https://www.maine.gov/boardofnursing/news.html?id=10822550
[21] https://www.mainehealth.org/care-services/behavioral-health-care/substance-use-disorder-care-addiction/opioid-use-disorder-care-mainehealth-behavioral-health/opioid-provider-resources-mainehealth-behavioral-health
[22] https://www.samhsa.gov/substance-use/treatment/find-treatment/buprenorphine-practitioner-locator
[23] https://www.federalregister.gov/documents/2025/01/17/2025-01049/expansion-of-buprenorphine-treatment-via-telemedicine-encounter
[24] https://www.mainehealth.org/health-care-professionals/clinical-guidelines-protocols/substance-use-disorder-clinical-guidelines
[25] https://pmc.ncbi.nlm.nih.gov/articles/PMC8163969/
[26] https://pmc.ncbi.nlm.nih.gov/articles/PMC8567798/
[27] https://pcssnow.org/wp-content/uploads/2022/03/PCSS-GuidanceTreatmentOfAcutePainInPatientsReceivingBup.Fiellin-SrivastavaUpdate_03_24_22.pdf
[28] https://www.ncbi.nlm.nih.gov/books/NBK459126/
[29] https://www.dovepress.com/frontline-perspectives-on-buprenorphine-for-the-management-of-chronic–peer-reviewed-fulltext-article-JMDH
[30] https://accpjournals.onlinelibrary.wiley.com/doi/10.1002/phar.2676
[31] https://academic.oup.com/painmedicine/article-abstract/25/12/691/7716541
[32] https://academic.oup.com/painmedicine/article/21/4/714/5699282
[33] https://www.va.gov/formularyadvisor/DOC_PDF/CRE_Buprenorphine_for_Chronic_Pain_MAR_2024.pdf
[34] https://www.tandfonline.com/doi/full/10.2217/pmt-2020-0013
[35] https://pmc.ncbi.nlm.nih.gov/articles/PMC4675640/
[36] https://pmc.ncbi.nlm.nih.gov/articles/PMC4283787/
[37] https://www.recoveryanswers.org/research-post/tried-true-methadone-shows-superiority-buprenorphine/
[38] https://www.tandfonline.com/doi/full/10.1080/00325481.2016.1128307
[39] https://www.oaepublish.com/articles/jtgg.2020.35
[40] https://www.bccsu.ca/wp-content/uploads/2022/06/Buprenorphine-Naloxone-Drug-Drug-Interactions.pdf
[41] https://www.jstage.jst.go.jp/article/bpb/25/5/25_5_682/_article/-char/en
[42] https://academic.oup.com/cid/article/43/Supplement_4/S216/282268
[43] https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1002/prp2.271
[44] https://legislature.maine.gov/legis/statutes/22/title22sec3174-UU.pdf
[45] https://micismaine.org/wp-content/uploads/2019-MICIS-Opioid-Law-Presentation-11.2019.pdf
[46] https://www.samhsa.gov/substance-use/treatment/statutes-regulations-guidelines/mat-act
[47] https://mainedrugdata.org/focus-area-2023-2025-treatment/
[48] https://pubmed.ncbi.nlm.nih.gov/38340973/
[49] https://pmc.ncbi.nlm.nih.gov/articles/PMC7709797/
—
Answer from Perplexity: pplx.ai/share
To whom it may concern:
Brandy Stokes reached out to me by referral through Steve Ariens.
At the time she was in the middle of a forced taper instituted by Eva Quirion, Np, DNP.
This was reported to be a “compassionate taper“, and indeed it was slow. But it was not compassionate. Brandy metabolizes opiates and super rapid ultra metabolism.
Prior to the forced taper, she had been stable on 30 mg oxycodone 30 tablets a day. She was started on this regimen by all the smart doctors in Boston that took care of her after her ankle fracture osteomyelitis pick line sepsis, endocarditis valve replacement and diffuse complex regional pain syndrome.
Dr. Loeffler took care of her for over eight years and she was stable. Disabled but stable. She formally taught eighth grade. She raised three boys as a single mother, and I’ve never met anyone with the persistence and tenacity that this patient demonstrates.
At any rate, she was down to 22 tablets of 30 mg oxycodone a day and she was in active withdrawal:
She had blood pressure levels over 220/180.
Chest pain at a level above nine out of 10, and was forced to go to bed, unable to care for herself.
Naturally, she was suicidal at this time.
She’s a very religious person and would not or could not complete suicide without violating her most core values.
In considering taking her on as a Pain refugee,
I spoke to Dr. Loeffler, Dr. Adams , and nurse practitioner Matthews.
I spoke to her pharmacy, Hannaford pharmacy, and the pharmacist there was quite compassionate and eager to restore Brandy’s previous level of pain, relief and functionality.
I believe her name is Grace.
I queried Grace about the prescription drug registry and Grace! told me that Brandi had used one pharmacy and a stable dose of these pain pills for years. There were no early refills, etc.
She was highly trusted and highly responsible according to Grace the Hannaford pharmacist.
I asked Grace if she was willing to fill the prescription if I sent one in and she said yes.
I was then of course, disturbed saddened, and upset when the prescription was canceled by Dr Quirion. I did not think she had the authority to override a prescription from another physician. I suspected a HIPAA violation had occurred, and I immediately reported it to the board of pharmacy in Maine.
Hannaford then pharmacy refused to fill any prescription from me for Brandy.
At this point, she was having trouble keeping her blood pressure under control and she couldn’t get anyone to fill her blood pressure medication’s either.
We were able to find a Walgreens pharmacy to Phil one weeks worth of her medication’s to keep her alive.
Brandi had already notified Dr. query on that she was seeking help from someone who would treat her palliative care, under MAINe palliative care program B. ( due to Brandy’s advocacy. The palliative care program was already in place.)
I made it clear to the Hannaford pharmacy people and their supervisors up the line that I was considering that she was abandoned by this pharmacy, arbitrarily and capriciously.
At any rate for the next year, Brandi was able to beg and plead for one or two weeks of her life-saving medication from numerous compassionate pharmacies in Maine. That would only treat her for that one week or two.
Ultimately, she was able to find for herself a pharmacy in New Hampshire that would fill three weeks worth of her medication’s prescribed by me.
Brandi now travels four hours each way to New Hampshire to fill her prescriptions every three weeks.
Because of the severity of her pain and hypertension and flare of her complex, regional pain syndrome, Brandy developed swelling, blisters, and weeping lesions on her lower extremities, which were very difficult to manage and disqualify her from WATER physical therapy.
Once her pain management regimen was restored, she was able to heal these circumstances.
It took months for her legs to heal.
I attribute this difficult. To the interruption of her stable pain regimen. I suspect it also relates to the hypertension that was secondary to her pain. This hypertension was unfortunately unresponsive to the limited amount of blood pressure medicine. She was still able to use from her stash.
I SAY THIS IN NO UNCERTAIN TERMS: BECAUSE SHE WAS FIRED FROM THE ST. JOHN’S MEDICAL GROUP BY Eva, she was unable to get any of her standard medication‘s
In other words, she was completely abandoned for all her medical needs, would you curse to me as retribution.
She was given the diagnosis of chronic persistent, opioid dependence, CPOD.
There is no DSM code for this diagnosis and it is not been accepted by DSM five in the psychiatric diagnostic and statistical manual.( BY THIS I MEAN IT’S A NEW MADE UP DIAGNOSIS.)
It’s an unnecessarily redundant term given that her pain is chronic and persistent and her opioid dependence is obvious. She is dependent, but not addicted to the pain medication’s. That keep her alive.
In the time that I’ve been taking care of her, she has shown remarkable resilience and determination to stay alive.
She has been sorted by not having enough medication’s to travel to South Carolina to visit her two grandchildren, born 18 months and two weeks ago.
She’s dependent in many other ways also.:
She dependent on the generosity of random pharmacist throughout the state of Maine.
She depending on her son to drive her to New Hampshire every three weeks.
She’s depended on the compassion of her pharmacist in New Hampshire. Who sees many other Payne refugees from Maine who are not getting what they need.
And, of course, she’s dependent on my tenuous medical license.
The state of Maine sent me a cease and desist letter to get me to abandon Brandy.
We responded to the cease-and-desist letter by making sure that she and I meet in New Hampshire on video every time she gets her prescriptions filled in New Hampshire.
Brandy and I appeared on a panel discussing Pain Refugees with The Cato Institute, led by Dr Jeffrey Singer.
There are
No more Pain refugees in my practice that I can count.
Brandy is too strapped financially to pay for more than one or two of my visits over the last almost 2 years.
I have committed to standby Brandi as long as I possibly can. Because she’s lost three different providers, I’m aware that the same fate could land on me.
She has not been able to find anyone to assume her care within the state of Maine.
She’s not an addict.
An addict’s life falls apart when they take their substance.
A pain patient’s life comes back together when they get their relief.
Since her pain treatment has been restored, she’s become one of our leading advocates in the movement to protect patients in pain.
IF SHE LOSES HER PAIN CARE, HER RISK OF DEATH IS GREATER THAN 50%. HER BLOOD PRESSURE WAS OUT OF CONTROL AND SHE WAS NEAR DEATH WHEN I MET HER.
We have plenty of evidence of the harm caused to her by her forced taper, which is categorically and undeniably counter to the flawed CDC guidelines of 2016 and 2022
I remain at Brandi’s service, and I remain in awe of her tenacity and commitment to not only help herself but the likely 400,000 people suffering in Maine from the same fate.
I am eager to speak with anyone who reads this.
I’m also eager to rebut any accusations made by the Attorney General of the state of Maine, who asked me to break main law by abandoning Brandy.
By the way, I am now fully compliant with the seasoned assist order. I’m no longer treating Brandy in the state of Maine. Her prescriptions are filled in New Hampshire and she stands on the ground in New Hampshire when I visit with her.
She and I have also met in person within the last month.
Be advised that I’ve been operating under the Covid emergency guidelines extended by the dea through 2025. This allows for telemedicine for scheduled prescriptions, which began during Covid. These guidelines have been extended annually for the last five years.
Here’s the science behind Genetic pleomorphism:
It’s settled science. Anyone ignoring the fact that some patients metabolize opiates in an ultra rapid fashion is in denial or lying.
According to multisystem reviews, the chance of addiction for pain medication’s is less than one percent.
Those claiming that pain pills lead to risk of overdose death ignore the risk of untreated pain.
Ask yourself this question:
If there’s over prescribing, then statistically there has to be under prescribing as well.
This is a term that’s never been defined by dea skateboards of Medicine or any critic of pain management
Feel free to see below my book and movie about these topics.
I stand by Brandi and I stand ready to assist anyone who reads this and understanding the cruel ignorant and evil campaign against her and her doctors.
MarkIbsenMD
406–4 39–0752
Bestselling Author: Dr Bison’s Fables, An Allegory of The American Pain Refugee Crisis.
CDC: “24-126 million Americans in chronic pain”
Pain Warriors 2020 documentary, international Award-Winner, featuring Mark Ibsen MD
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Damn autocorrect!