Maine is set to close out 2024 as a year that saw a continued decline in drug overdose deaths. But while the top official responsible for coordinating the state’s response to the opioid crisis is glad to see the trend, he’s not celebrating.

That’s because the approximately 500 total overdose deaths projected for this year is still far too high, Gordon Smith, Maine’s director of opioid response, said in an interview.

“One death is too many, but 500 is a catastrophe. It’s simply better than 720 [in 2022],” he said, referring to the year when Maine saw its greatest number of overdose deaths.

Across Maine, 405 people died after overdosing between January and October, according to the Maine Drug Data Hub. That official count represents a 20 percent decrease compared with the same time period in 2023. It continues the decline first seen in 2023, when fatal overdoses decreased 16 percent compared with 2022.

The reasons for the decline are not truly known, Smith said, but it is probably at least partially due to the decreasing potency of fentanyl, a powerful manmade opioid that is the most frequent cause of death. There are also more services in Maine to help people with an addiction to opioids than in the past.

The Bangor Daily News spoke with Smith about the changes he has seen since his position in state government was created in 2019, after fentanyl turned Maine’s ongoing opioid crisis even more deadly. From distributing hundreds of thousands of doses of overdose-reversing naloxone, to training more than 2,000 people as peer recovery coaches, to expanding access to treatment, Maine has significantly boosted help for people who need it, Smith said.

For instance, more than 5,000 people are currently receiving methadone, the most ever, Smith said. Providers in Maine are also prescribing a record 16,000 to 20,000 people with buprenorphine, another medication for opioid use disorder. While people can have success with an abstinence-based approach to treatment, he said, medications such as methadone and buprenorphine have been shown to increase people’s odds of staying in long-term recovery.

The following Q&A has been condensed:

Gordon Smith, state of Maine: I think one of the reasons that this is all going better now is that so many people are willing to take some help medically, and we’ve really encouraged the medical community to step up and make that available in all the primary care practices, in all the emergency departments — low-barrier access to buprenorphine. We’re only down to three to five [predominantly small, rural] emergency departments in Maine that aren’t ready to do that, and we’re working with them to make sure that they do get ready to do it.

Erin Rhoda, BDN: I don’t know that any ERs a number of years ago were prescribing buprenorphine. Is that right?

Smith: None were.

You’re recalling, in Executive Order 2, which established my position in February of 2019 … we said the first thing I’m going to do is buy 35,000 doses of naloxone. … Now it’s truly the thing that’s making the biggest difference in keeping people alive. The data in [the state’s monthly overdose report] is startling: 95 percent of people that overdose in Maine today are surviving their overdose. That’s remarkable. …

The second thing we said in that executive order, after we purchased 35,000 doses of naloxone, was we were going to ask every emergency department to have low-barrier access available to buprenorphine, to any patient that came in after an overdose or was otherwise struggling with substances. …

One of my favorite things in that executive order was we asked every prison and facility and every jail to make sure that people who had a substance use disorder were treated for their illness and had medication available, meaning buprenorphine generally.

Because it’s just stunning, as a health care lawyer, that in 2019, two decades after the Americans with Disabilities Act, that people with substance use disorder were not treated when they were incarcerated. And that’s still true in the majority of carceral settings in this country. …

Almost 50 percent of the [inmates in Maine’s prison system] are on medication for substance use disorder. Which sounds like an insane amount except we know that 70 or 80 percent of them have a substance use disorder. In many of the jails also the numbers are up around 50 percent, sometimes more.

Rhoda: Are all jails now offering treatment?

Smith: They’re all offering treatment. They’re all offering medication. They’re not necessarily all offering the injectable version of buprenorphine. The goal would be to offer all [U.S. Food and Drug Administration] approved products for substance use disorder and in all of their versions — injectable, film, pills, whichever works for that particular resident of the jail, but almost no jail or facility at this point is able to offer all those versions.

Rhoda: [The jails offering medication] seems like a huge change.

Smith: There’s not a single facility, Erin, that is where we’d like to have them right now, but they’re all way, way better than it was. The reason that they’re not further along is really resources. … We’ve made some more state money available to them. The governor did $4 million in the last budget, more money for the jails for these purposes, but it really is an issue of resources.

And you know, in the grand scheme of things I’d really prefer to not see people with substance use disorder in jail. I’d like to see a lot more diversion. …. The treatment courts are trucking along. We’ve got one in … every county except Aroostook County, and we’ve got a great plan up there that Todd Collins, [the district attorney], and a whole bunch of people worked on, but we need $750,000 a year to do it, and nobody has come up with that money. So we’ll try again.

Rhoda: I also remember when there were no detox beds [at facilities that medically supervise people through the acute stages of withdrawal].

Smith: We now have about 120, 130 detox beds because we’ve also been successful in getting the private places to open some beds to MaineCare, like Pine Tree in Portland and Libby Bay. We’ve got 10 beautiful Wabanaki beds [in Bangor] … but they’re not full. I think part of it is communicating to people who might need those beds that they’re not just for Indigenous Mainers, number one, and that they’re open for business.

Rhoda: When it comes to the overdose death rates, are you seeing really big declines in certain areas? Where in Maine have you seen the biggest declines?

Smith: Actually in Portland. It has not been uniform across the state. There are some counties that will see more deaths this year than last year. They tend to be smaller numbers, but still. …

We’ve seen the biggest decline really in the urban areas, and we’ve not done as well in reducing overdoses in some of the rural areas. We need to do a better job there. Some of it is hard to address. It takes a long time to get an ambulance out to Springfield, Maine, 20 miles east of Lincoln, right? Fentanyl acts very quickly. Too many people use alone. Why do they use alone? There’s a lot of shame and stigma associated with it.

Rhoda: Stimulants are continuing to increase as a cause of death in combination with other drugs like fentanyl. What do you make of that, why that’s happening?

Smith: I don’t think anybody knows. Not a week goes by that we’re not on some webinar with our federal partners and national people; we get together with our New England group all the time, we talk about these things. Nobody really knows. People don’t even know why the death rate is declining. We speculate.

There’s a North Carolina drug lab run by Dr. [Nabarun] Dasgupta. He posited eight different theories [for the decline in overdose deaths]. They all made sense to me: more naloxone, more treatment available. …

Now xylazine [a sedative added to fentanyl that is not as lethal] is a factor. We’re up to 14 to 16 percent xylazine. Oddly enough it might be some of these fillers that are helping to keep people alive. It’s still doing really bad things to them, you know, but they don’t die.

Rhoda: With xylazine, that’s a relatively new thing. Do you think that that filler is playing a role in the declining number of deaths?

Smith: It is one of the things that the researchers are speculating that may be part of why fewer people are dying. …

The fact is that nationwide we’ve seen a 10 to 12 percent decline, and not every state is doing what we’re doing, right? In some of the New England states, probably New Hampshire and Maine have seen the sharpest declines. But every state has seen some improvement. So it’s more than just what we’re doing.

Rhoda: Where does Maine stand exactly in its decrease of opioid deaths relative to the nation? We are falling faster?

Smith: Yes, but we were also higher to start with. We started from a pretty bad place in 2018, 2019. And so we’re coming down now towards the middle.

Rhoda: I’ve been reading about the declining toxicity of fentanyl. The fentanyl on the street is becoming weaker. Is that happening in Maine?

Smith: Probably. We don’t necessarily have enough drug checking and drug testing to know that. … It’s funny because we used to talk about fentanyl adultering everything else; now people want fentanyl, and it’s being adulterated with everything from xylazine to other fillers, including cocaine and meth.

So, again, we don’t have the sophisticated kind of drug-checking apparatus. We’ve got four new drug-checking machines that are just starting to be used. There’s one in Machias, one in Sanford, as part of Project DHARMA. It’s a federal grant run out of the Maine Medical Center. …

The whole idea is we’re going to start testing residual amounts of drugs — in syringes usually — at various sites around the state and then get that to the Colby drug lab and see what’s in these drugs. That will give us maybe a head start on what kind of drug policies we need in the state in reaction to that. So it’s possible in a year or two when you ask me the question about the strength of the fentanyl that I’d have actually good chemistry to answer that question, but it’s just starting.

Rhoda: What do you think next year will bring?

Smith: I don’t think we need a lot of new initiatives, but I think we need to put more resources into all the things we’re doing. We had one crisis receiving center [to help people with a range of mental health or substance use challenges]. Now we’re going to have five. We had three McAulay houses [for women in recovery and their children]. Now we’re going to have seven. We’ve got 1,000 recovery beds [at about 100 recovery residences]. We need probably 200 more in rural areas.

We need to just keep doing what we’re doing, lower the stigma, let people know we care about them, give them hope, and make sure when they’re ready today that we’ve got a bed for them, or an outpatient facility, whatever they need. That’s my hope.

Rhoda: A final note here: What do you want families to do if they have a loved one with addiction? If they’re reading this and they think, I really need to do something, what is your advice?

Smith: There are support groups for family members. We have 24 recovery community centers now. Call 211. Don’t suffer in silence alone, and don’t give up on your loved one.

Erin Rhoda is the editor of Maine Focus and may be reached at erhoda@bangordailynews.com.