Why did you get interested in addictions as a family physician?
I’m not shy about telling people this wasn’t where I thought I would end up and certainly not where I started. I was a little bit skeptical about the medication for addiction treatment in the primary care setting. I didn’t buy in right away, and I understand the dilemma of my colleagues who are still in that space. I had been in practice for about six or seven years already, and I started noticing a significant gap in the care I was giving as a PCP. I found myself having conversations with my own patients, not knowing that they were struggling with addiction or maybe had even been through treatment programs. So many of the people we see every day are affected in some way by substance use. As their primary care physician, I felt like I let them down because I wasn’t aware of the struggle. I saw that they may not have trusted me, or they didn’t know they could talk to me about it. I was caught off guard.
And, back then, when you did identify someone in need of treatment for substance use, it was reinventing the wheel every single time, looking things up, trying to find resources, and making phone calls. It didn’t feel like an efficient way of doing things or effective. As my knowledge grew, and through my conversations with my patients and colleagues, I realized it was a real need in every practice, and we needed to meet that need. We were lucky at York Hospital because we already had the Cottage Program in our York Hospital system back then, and I connected with my colleagues who worked there. At that time, it was an abstinence-based program, and we didn’t offer medication. We were able to build the medication piece and grow and deliver the services that our patients needed. Addiction care became something I gravitated toward, and I now enjoy doing in both the addiction and family practice settings where I work.
How does working in both addiction care and family medicine benefit both practices?
I have the benefit and advantage of practicing in both settings and seeing how both areas interconnect regularly. Patients with high acuity need intense treatment with medication and counseling that can be adjacent to primary care. We encourage primary care providers to refer patients to the Recovery Center for stabilization, and then they’ll return to their practices. We built it that way.
Because time in the primary care office is limited, by creating that connection between settings, we have resources right there at our fingertips. It allows our colleagues who maybe aren’t as comfortable with addiction management to refer patients and get a consultation. From a primary care standpoint, we are familiar with this model of shared care. For example, if we have a patient with a complicated cardiac condition, we send them to a cardiologist to stabilize, and once stable, they come back to us for maintenance.
I am definitely at an advantage working in two different but connected settings. I work with a great team of counselors who quickly step in with support. As a primary care doctor, it helps because I don’t have to be afraid anymore to screen for substance use. I can offer help. I hope I am also providing my colleagues with safety and support because they know they can call me, and I can help them get their patients the support they need.
Are there any particular challenges in primary care related to engaging patients across their life spans in treatment and treatment?
This population is often complex to engage with. We have to work to gain their trust. Unfortunately, the doctor’s office wasn’t always the place where people with substance use problems felt like they could be comfortable and forthcoming. Any primary care physician right now would say time is our struggle, compounding any engagement issues. Trying to find the time in the day, trying to find the time that we need and want to give our patients, is a challenge. I don’t know a way of getting around it. We feel that crunch all the time.
Engagement with adolescents presents its own challenges. It takes time and patience to engage them in conversation about themselves, letting them know they can trust you and that you’re not just another adult telling them what to do. Normalizing the conversation and using a universal substance use screening tool, such as the CRAFFT, is critical. I think the key is making that conversation as ordinary as asking about their school day or what kind of vegetables they like.
Our patients are now getting used to these screenings and to the forms they fill out when they come in. The screening questions ask them how many vegetables they eat, how much activity they get, whether they smoke, and whether they use other substances, and we ask whether they think they need help with mental health. We try to make them comfortable talking about all of these topics in one place. Similarly, we have to help parents understand that it’s okay for their kids to answer those questions honestly and privately. In general, trying to normalize this as a part of general care is the approach I take. Once you uncover an issue, the next challenge is to gain the trust to treat the whole family. Maine AAP is a great resource. We need more options specifically for adolescents with substance use concerns.
What would you say to your colleagues who are still hesitant to recognize and treat their patients who may have substance use disorders?
We talk about this a lot. For one thing, we do hard things all the time, and this is difficult but not impossible. Certainly, it’s a comfort level. Utilizing the screening tools and the support you have from your other colleagues is a great place to start getting comfortable. I remember when we needed an X waiver to prescribe buprenorphine. I did the X waiver training, and I went home terrified because I thought, “Well, now I have this thing I can do and must do, and I really don’t know if I am good at it.” Writing that first prescription and giving that first dose was really scary, but the more I did it, the easier it got. I would tell my colleagues: do it once, and I’ll help you, and you’ll get satisfaction from helping somebody. You’ll gain more comfort.
How do you address stigma against medication for substance use disorders or substance use in general in both your practice and the community?
I talk about it like any other process: normalize the conversation and recognize the symptoms. It is a disease process, like any other disease process, and we have treatment options. It becomes something else that we do. Some people need to be gently reminded that people coming to us for help with SUD need help, and that’s what we’re here to do. It’s the stigma that stops people from asking for help and also the stigma that keeps us from offering it. We encounter stigma throughout the community at large and throughout the medical community.
Here at The Recovery Center, we have done training across the hospital continuum — pharmacy, lab, radiology, emergency department, primary care offices, specialist offices, surgical offices, and pre-op. We try to talk about it as much as possible and remind people that this disease isn’t limited to certain populations. Most of us have had some experience with someone who is affected by substance use. A lot of stigma comes from fear; normalizing the conversation helps. I think that in the relatively short time that I’ve been doing this work, I have seen the pendulum swing and improvement in stigma and bias.
What continues to motivate you to do this work?
I’ve seen people get better. It is a privilege for me that I’ve been in that room and have seen people get better. The chance that somebody can get better is motivating and that I can offer somebody a hand in getting better, then that’s what I want to do. I’ve seen people reconnect with their families and get their family’s trust back. It’s pretty amazing when you see that and how proud people are when they tell you about it. Watching a kid get their parent back is the best thing in the world. One of my favorite things about primary care and family medicine is that we get to see multiple generations of families. Recently I saw a woman who has been my patient for a long time both in primary care and for SUD treatment. Now she has a child and asked me to take care of him. She introduced me to her toddler with “This is Dr. Munroe. She saved my life.” You don’t hear that often. It’s been a privilege to be able to watch this.
It is also motivating to know that colleagues can reach out for support and that we are building and adapting our treatment program to the needs of our community.
Is there anything else I haven’t asked that you would like to share?
We have pretty good networks in Maine, but we’re still siloed. We need to do more to support each other, especially when it comes to patients with complex medical and behavioral health concerns. For example, it would be great to have a more integrated mental health system. It would be useful to have a pain medicine bridging program that we could all access. I think we need to supportour providers better, to give them the resources needed to feel comfortable taking on these challenging medical concerns.
Having a team of caring people is essential. I like being part of a team. I provide a prescription medication to help people feel well enough to sit in the room and get the counseling that they need and then connect with the other parts of their medical care that they may have been neglecting.
I’ve been in many rooms with colleagues throughout the state and the country, trying to implement medication management in their primary care offices. I think that’s fantastic, but I’ve heard people say, “It’s not hard; it is just another prescription.” I disagree with that. I believe this isn’t easy, and it’s a lot more than just a prescription. As primary care docs, we have never had to do this before.
We’ve never been in a crisis like we’re in now. I want to give my colleagues the grace to say,” I’m scared.” or “I’m uncomfortable with this.” That opens up the conversation to say let’s figure out how we can make it easier for you to do the work that is needed.