Dr. Alane O’Connor DNP is the Director of Perinatal Addiction Medicine at MaineHealth Maine Medical Center and served as the medical director of the Maine Maternal Opioid Misuse (MaineMOM) Initiative, a 5-year, $5 million federal grant to expand access to substance use treatment for pregnant and postpartum women. She has trained hundreds of resident physicians and fellows and is core faculty in Maine’s only addiction medicine fellowship. Dr. O’Connor has published more than a dozen peer-reviewed manuscripts on maternal and infant outcomes following treatment with medication for opioid use disorder during pregnancy as well as related postpartum healthcare utilization and health policy. , She developed a partnership with Portland Fire Department’s Mobile Medical Outreach (MMO) team after recognizing that some of her most at-risk pregnant women were not accessing health care in traditional settings. Project Lifeline is a nationally innovative medical and community paramedicine program that delivers street medicine services to unhoused pregnant and postpartum women with substance use disorder who live in tents, shelters, vehicles, and on the street.
Beyond caring for pregnant women, Dr. O’Connor works in the correctional system as the Director of Addiction Medicine at Somerset County Jail and Franklin County Detention Center and is the clinical advisor to the Maine Sheriffs’ Association. In this capacity, she developed and implemented a nationally innovative program using a monthly injectable medication (rather than a daily pill) to treat incarcerate individuals with opioid use disorder. The outcomes, published in Health & Justice, showed that the injectable medication expanded access to treatment during incarceration, improved treatment continuation after release and reduced the risk of post-release drug overdose death. The project gained nationwide attention and was featured on the front page of the New York Times and a related podcast.
Dr. O’Connor lectures regionally and nationally on substance use disorder to a variety of audiences including medical providers, the child welfare system, the correctional system and judiciary, as well as law enforcement. She is a member of the Maine Maternal Fetal and Infant Mortality Review Panel and co-chairs Maine’s Opioid Response Clinical Advisory Committee which advises the state’s opioid response director on clinical and public policy issues.
How did you become interested in addiction?
Addiction really found me. I was back in Maine, where I grew up, practicing rural family medicine in Somerset County in 2006 or 2007. We were seeing more of the opioid epidemic, and people would come into the office seeking help for their opioid addiction. At that point, methadone was the only option. Buprenorphine was very new on the scene, and people wanted an alternative that offered more privacy. That was a big motivator. People wanted to be able to go to a medical office without anyone knowing why they were there. There was a lot of stigma, so people sought us out for buprenorphine. I had a couple of patients at first, and then more came. It was the kind of thing where if you build it, they will come. People came because it afforded so much more privacy than the methadone clinic, because people didn’t know what you were there for. You could be there for anxiety, depression, or anything. People really appreciated that, especially at that time.
You’ve grown a practice treating pregnant people. How did it emerge for you?
It’s been a joy to provide care for pregnant people. Again, the situation was that people didn’t want to be on methadone and came to us. At that time, buprenorphine use during pregnancy was almost nonexistent. It was a decision to provide this care because no one else was doing it. Providers were frankly afraid of pregnant patients with substance use disorders. So, we developed a program that was supportive and provided medication, counseling, and prenatal care all in one setting, reducing barriers. People were coming from two and a half hours away to get care because we were the only ones offering buprenorphine. What I really love about working with people who are pregnant is that it’s a tremendous turning point in their lives where you can have a significant impact.
Most pregnancies – up to 85% — are unplanned, and I think people can use that opportunity to change the trajectory of their lives. That pregnancy can be the motivation to enter recovery, improve their life, and make healthy decisions for themselves and their baby. I think that’s the absolute joy of working with pregnant patients.
You’ve also made strides in treating individuals in the correctional systems of Somerset and Franklin counties in Maine, and that work has been recognized statewide and nationally. What drew you to this work?
That has also been a tremendous source of joy. I got connected to Somerset County Jail because I was one of the first members of their alternative sentencing program many years ago. It was at least 10 to 12 years ago when the district attorney and the Sheriff of Somerset County started an alternative sentencing program. They did not have a judge, so they brought together a group of experts to serve in that capacity, create treatment plans, and then adjust them as needed. And so, I started working with Sheriff Lancaster. Then, during a meeting in 2021, we were discussing the challenges of providing substance use treatment in jails and how difficult it was to treat everyone with the daily form of buprenorphine.
It is very difficult to provide the daily form of buprenorphine in a correctional setting because it’s very labor-intensive to deliver. It was hard to move people throughout the facility, and there was a lot of diversion and misuse. We started talking about the extended-release medication and its benefits, which I had seen in my practice outside the jail. The Sheriff didn’t know about it, but it was an opportunity to try something different, something completely new. The state was willing to partner with us. I’m incredibly grateful, as we never would’ve gotten this program off the ground without the support of Gordon Smith, the Opioid Response Director, and the Office of Behavioral Health, which provided a tremendous amount of upfront funding. Since then, we’ve been able to keep it moving forward with funding from the Maine Recovery Council, the Maine Department of Public Safety, and the Somerset County Commissioners, and we’ve expanded it to other jails including the jail in Franklin.
Excitingly, Somerset County Jail has boarding contracts with several other counties, so we are able to expand access to the extended-release buprenorphine program for individuals in other counties by bringing them to our jail rather than bringing the program to their jail. It was just finding another creative solution to the challenge. We published the preliminary outcomes of our program in Health & Justice. Relative to the daily form of buprenorphine, the extended-release medication expands access to treatment in the facility and improves treatment continuation post-release. There was also a dramatic decline in overdose deaths, which I’m incredibly proud of. When I think about the overdose death situation, the rate in Somerset County is falling faster every year than the rate in the state of Maine. I think this is just so compelling. I think about the parents who haven’t had to bury their children and the children who haven’t had to bury their parents, and that makes going to work every day worth it.
What are the things that help make a difference? Tell us about the training you have been providing for the child welfare system.
The most important thing is to educate the folks that interact with patients with substance use disorder. People come in with their own experiences and what they’ve seen. Many still struggle to see it as a chronic, treatable disease. Those of us who have been in the field a long time know this, but people still struggle with it. They still think it’s a choice. That’s particularly true when it comes to opinions about pregnant people. I hear weekly, “How did they do this to their baby? Why aren’t we putting them in jail for using drugs during pregnancy?” They don’t see it as a chronic disease. So, my work in the Office of Child and Family Services is to provide education on return to use, how to intervene, and the importance of treatment engagement.
You want to encourage people to engage with services, not go underground and not tell the truth, because the more we work collaboratively as a system to help families become well, the better the system will work. The educational piece has been really important and very well received. I enjoy talking with all the districts, the new and experienced workers. They can bring cases to discuss when I’m teaching, which is really helpful because there’s nothing like real-world experience to highlight all the different pieces and the challenges. It’s not easy work at all, making decisions, and some treatment providers don’t collaborate particularly well with the child welfare division. It works best when we’re all collaborative and on the same page, and we can model that moving forward.
Your work has extended to shaping policy in Maine; you co-chair the Maine Opioid Response Clinical Advisory Committee and serve on the Maine Maternal, Fetal, and Infant Mortality Review Panel. How would you characterize your contributions to the field, including shaping policy and your publications?
From a research perspective, I felt it was important to publish the outcomes of our work with pregnant patients because prospective studies are rare. It’s not ethically appropriate to say, ” Let’s test this medication on pregnant patients.” We don’t do that. In our program, we had a lot of retrospective data because we had treated so many patients. We published one of the largest papers in the world, at least at that time, on maternal buprenorphine dose and the lack of a relationship between maternal dose and infant withdrawal symptoms. This is hugely important from an educational perspective because moms often will try to cut back on their dose, thinking, “Maybe my baby’s withdrawal won’t be as severe if I’m on half the medication.” Being able to counsel them that “no, that’s not the case. We actually want you on the dose of medication where you feel well” shows your patient that you care about them and that you are studying and trying to understand it, so you can help them make the best decisions for their pregnancy. It also shows your level of commitment in a different way. From a policy perspective, I think we have a Governor and an Opioid Response Director who are really interested in our thoughts. I’ve practiced for a long time, and that hasn’t always been the case. It is an opportunity now to come together as a group and provide experiences and evidence to help guide public policy.
One of my favorite phrases is disruptive innovation. I’ve always believed change doesn’t happen on the margins. Change happens when you take a system and say, “Let’s do something completely different.” That’s certainly what we’ve done in the jail system, but significant improvements in outcomes come with significant changes, and you must be willing to make them. I’ve had people willing to do it in their facilities and settings, and others willing to help provide financial and philosophical support. You have to have all those pieces in place.
What did you find most fulfilling, and what were your biggest challenges?
The biggest challenge is still stigma. Stigma shows up every day in how people treat my patients, whether they’re incarcerated or pregnant. People hold very strong negative opinions about them. What they have is a treatable chronic disease. We’ve made tremendous progress, particularly in the correctional system, but there is still a long way to go.
Stigma within healthcare continues to be a challenge. I see discharge notes that tell a patient to stop using cocaine. When you think about how unreasonable this is, would you tell someone to stop being depressed or stop having diabetes or any other chronic disease? It’s very frustrating. If there’s one thing I wish I could do more of, it’s reducing stigma. I teach in many systems, including law enforcement, judiciary, and child welfare. I teach physicians in training, including fellows. I have a learner with me almost every day. An OB resident told me last week that what they appreciate most about working with me is hearing how I talk to people about their substance use disorder. It’s not the magic of medication changes or this or that. It’s really just normalizing conversations about substance use disorder and talking to them; they’re just any other patient. Honestly, I don’t know any other way to talk to anyone but demystifying that whole piece is really important for learners and helps them provide better care. That is important. Every part of what I do, the policy, the teaching, the education, the publishing, and the work with patients, I love in its own way, and there are different challenges to every aspect of it. I had a patient in the office yesterday who just gave us a card that said, “I’ll never be able to thank you enough for supporting me during this pregnancy.” There she is, holding her baby, and that’s a complete gift to be part of it. It’s incredibly rewarding to be a champion for moms who are really vulnerable and marginalized. And I have a great team supporting me in that effort, for sure. My biggest success from a personal perspective is being a voice and advocate, somebody who has the experience clinically and from a research perspective to be able to speak the truth about what I see.
What are your thoughts on being inducted into the Maine Women’s Hall of Fame?
I’m incredibly grateful to be inducted into the Maine Women’s Hall of Fame in March. I still can’t believe it. And to be mentioned in the same sentence as Frances Perkins is, frankly, amazing. I’ve really enjoyed learning more about her and how she stepped up to the plate and took the seat that was offered because she didn’t know the next time it would be offered to a woman. That’s become one of my favorite statements.
What I appreciate most is that, in celebrating the work I’ve done, it also recognizes the importance of the people I take care of, the lives that have been changed and helped, and, frankly, the ones we’ve lost. We have done a lot of work, but there have been many losses in this field. Celebrating the work I’ve done shows that the people I take care of are important. That’s not always the message they receive.
You touched many people and systems. Do you have any suggestions for other providers?
Try not to be fearful of people with substance use disorders; listen to them and be understanding. You don’t have to know everything about how to treat them but ask questions and be curious about their lives to understand their situations. In my presentations, I say I have never taken care of someone who said, “When I grow up, I want to be addicted to drugs and pregnant or incarcerated.” That’s not on anybody’s life plan. If you approach it from the perspective that this is not something anyone ever set out to do, but rather to understand what has happened to them that brought them to this point in their lives. Educating people about things like adverse childhood experiences and the connection to substance use disorder helps them understand how the person in front of them came to be there. Treat people with kindness. I learn from my patients every day. They are still the best teachers, and we need to listen to them. Making sure the voice of lived experience is part of the conversation is critically important.
Try not to be fearful of people with substance use disorders; listen to them and be understanding. You don’t have to know everything about how to treat them but ask questions and be curious about their lives to understand their situations. In my presentations, I say I have never taken care of someone who said, “When I grow up, I want to be addicted to drugs and pregnant or incarcerated.” That’s not on anybody’s life plan. If you approach it from the perspective that this is not something anyone ever set out to do, but rather to understand what has happened to them that brought them to this point in their lives. Educating people about things like adverse childhood experiences and the connection to substance use disorder helps them understand how the person in front of them came to be there. Treat people with kindness. I learn from my patients every day. They are still the best teachers, and we need to listen to them. Making sure the voice of lived experience is part of the conversation is critically important.
Is there anything you would like to reflect on?
If I could change anything about the pregnant patient situation, it would be more safe places for moms and babies to go together. We have an inadequate amount of resources. The biggest challenge in the carceral system is the financial aspect of providing substance use disorder treatment. The 1115 waiver will be a game-changer for the carceral system. Once there’s a mechanism to bill insurance and make it part of a consistent, system-wide approach that eliminates barriers between the community and the correctional system, and between the correctional system and the community, we’re going to make significant changes.
There will be fewer people incarcerated because they’ll be able to step out of the carceral system into a much better place, reenter the workforce, get housing, and do all those things. More people can access extended-release buprenorphine and make changes that help them live the lives they want to lead. Nobody wants to be in the throes of a substance use disorder. They want their lives to be in a better place. Walk the walk with your patients, no matter where they are, even if you wonder whether they’ll survive the week because of their substance use disorder. I tell them they will never walk alone. They all deserve care and compassion.