When did your interest in addictions emerge?
My interest started when I was a resident. During my residency at Maine Medical Center in Family Medicine, I met many people who had substance use disorder or unhealthy substance use. I enjoyed working with them and, in particular, people who had alcohol use disorder. I had several patients in the local community with alcohol use disorder and found that the relationship I developed with them could make a significant difference in their lives. I liked conversing with people about their goals, what’s important to them, what they want for their future, and what is meaningful for them. When I work with people who have substance use disorders, I get to have those types of conversations that I often don’t with people whom I saw for other conditions. And so, I did an elective in addictions as a resident and did the training for the buprenorphine waiver before I graduated. When I started as an attending physician at Scarborough Family Medicine, I met Steve Kirsch. The two of us had waivers and decided we would begin treating patients together. Treating SUDs and OUD was a big part of what I did from the beginning.
What do you find most fulfilling in your work with individuals with substance use issues?
I enjoy helping people through difficult times or situations, being there, and supporting them through behavior change. It is hard work, and I believe in treating people with respect and kindness. People face much stigma from society and, in particular, from the healthcare community when they have a substance use disorder. They come in with a lot of distrust and misgivings about forming a new relationship with a provider. It is rewarding for me to be able to form new relationships with people who trust me and believe that I’m genuine in my concern for them. It is transformation when people can change their outlook towards other healthcare providers. What I love about my work is when someone can get healthier, stop using substances or use less substances, and I watch somebody who was in a state where they had a lot of misery move towards health and recovery. It is inspiring to see what happens for them, what they can achieve, and how that transforms them, their family, and the community around them.
What thoughts do you have for practices that shy away from addictions due to concerns about the potential disruptive behaviors when people are still in the throes of the addictive process?
It’s complicated. You must have the support of your colleagues and the people in your practice to do this work. There is a need for training and education, and commitment to excellence. In my experience, when I treat people in a trauma-informed way and treat them with care and respect, the behaviors providers are worried about don’t happen very often. I do believe that the approach to the patient makes a big difference. However, at the same time, expect challenging behaviors can happen and be prepared for them. It is essential to ensure you’ve got a team that can process those challenges together and be united in how you approach the patient. The other thing we don’t talk about as much is that while the highs are really high, when you watch somebody go from a really hard place in their life to a much better one, the lows can be very low too. We lose people in the prime of their lives to a treatable condition. It’s never easy to lose a patient, but when you invest this much of your time, energy, and yourself in somebody, and then they still die from this disease, it’s tough on all of us. We have to be there to support each other and take care of ourselves and others to be able to do the work.
How did your interest in preceptorship and training residents, fellows, and other physicians in Addiction Medicine begin?
Right out of residency, I came on as a part-time clinical faculty in 2006. I was teaching UVM and UNE medical students and eventually Tufts medical students and residents in the primary care practice. While teaching them primary care, I was teaching them addiction medicine because I have been taking care of people with addictions. Like my passion for addiction work caused the shift in my career, I found that teaching learners about how to take care of people who have substance use disorder was the most fulfilling part of teaching. I wanted to do more of that, so when Maine Medical Center decided to start an addiction medicine fellowship, the opportunity became available to create that curriculum and complete the application to become an accredited training program. I was asked to apply for it. I’m grateful I took that opportunity because it has been an exciting career. It pushed me beyond my comfort zone. I do a lot of teaching, but I don’t consider myself a particularly strong academic or researcher. However, I’m a good manager and administrator of the program, and I know what I know and what I don’t know, what I’m good at, and what I’m not good at. I have so many incredibly talented colleagues in the community that I can tap to do the teaching. What I love is, in particular, for our fellows, we have about 40 faculty that come and teach over the course of the year. I love creating that community of learning more than anything else. I love that we’ve got people from all different disciplines all over the state interested in teaching and learning. They all come together to learn and bring their unique perspectives into it. It’s so much richer learning environment for everyone. We have built a unique learning experience for all levels of learners. We have students going to PRCC, and we’ve got residents going to the needle exchange, for example. In terms of more didactic materials or enduring materials, we have partnered with Tina Holt through the HRSA PrevMe grant to create online training focused on topics such as screening, pain management, and communications skills. It’s been fun to build content like that and to use my connections to pull together talented faculty. The one that I am probably the most excited about in the last few years is one that Andrea Truncali and I are doing on addressing stigma in healthcare towards people who use drugs. It’s more like a documentary-style training where we’ve interviewed people in recovery and healthcare providers talking about stigma, what it’s like on both sides of that equation, and having honest and open conversations about it. My vision is that we have facilitated discussions with staff in primary care and behavioral health offices who watch it together and explore their reactions. What does this bring up for you? How do you want to change the way you think about this issue? Only through those types of discussions can people grow in their understanding and ability to build relationships with individuals who have SUDs.
What do you think is needed in medicine education preparation and in the field to support other physicians to gain confidence and willingness to address addictions?
I think several things need to happen. I do think we’re making progress. I love that the medical students are getting buprenorphine trained before they graduate. My understanding is that there’s more time spent in medical education now about addiction as a treatable condition and harm reduction. They’re getting way more than I got 20 years ago when I was in training. However, I think, especially for providers who are working, there needs to be an attitudinal shift towards thinking about use disorders or addiction as a chronic, treatable condition, just like diabetes, asthma, and other treatable chronic conditions. Actually, many of the evidence-based therapies for SUDs have better results than many other therapies for other chronic conditions.
I often hear others say, “I just don’t have the experience, or I don’t have the training, and so I don’t feel like I can address this.” I don’t think that we would accept that response for other conditions. If somebody said, “Look, I don’t feel qualified to treat hypertension; it’s just not my thing. I don’t feel like I got enough training in medical school. So if somebody shows up in my office and has hypertension, I’m going to send them to somebody else, or I’m just not going to do anything about it.” There’s plenty of education and training, and a response like that would sound crazy. We wouldn’t accept it for another condition. Why do we nod our heads and accept it for this? I think there are many stigmas because people who have substance use disorder behave in ways that are uncomfortable sometimes and unattractive at other times. That’s something that we need to address, we need to understand that our attitudes make all of those behaviors worse, and we need to figure out ways to improve them. We need to admit that we have stigmas and implicit biases towards people who use drugs and address them. We all have a responsibility to work on ourselves. It’s not okay that we can say that we don’t take care of this. More providers need training in trauma-informed care. I understand that when someone acts in a certain way, it may very well be a trauma reaction. It doesn’t make it any more pleasant, but it makes it more understandable. And when it’s more understandable, my reaction toward that can be different. And my processing of it can be different so that I feel more prepared the next time.
What has the shift from primary care to addiction care been like for you?
I stopped doing primary care in 2016, and since then, I’ve done all addiction medicine. I do primary care on the fly now because people walk in with things that I still need to address, and it’s sometimes quicker and easier for me to do it than say, “Why don’t you make an appointment with your primary care provider?” The shift to addiction medicine not only helped me to focus on the population that I was most passionate about serving, but it also gave me new opportunities for teaching that I didn’t have before. It also provided a vehicle for me to impact the healthcare system I work for significantly. Because there are not as many of us doing addiction medicine, my footprint on my healthcare system and the community could be more significant because of this work I’m doing.
Any suggestions or thoughts to share with PCPs across Maine who may be hesitant to embrace addiction treatment?
There are many more educational opportunities and training available than five years ago. Just as you try to stay current on other medical conditions, you can learn more and stay up to date with this. When you feel more comfortable with addiction medicine, which is not that complicated, you will feel more comfortable treating the patients. I started with patients who were already on buprenorphine and were pretty stable and doing well. That was a way that felt more comfortable to me as I was learning addiction medicine. As you grow in your confidence, you can treat patients who may have more severe disease or are struggling more because you’ll have that time and experience under your belt. I would also emphasize checking in with yourself and asking yourself if you’re not doing it because of a lack of education or because of discomfort in working with people with substance use disorder. Then ask yourself if you are prepared to address that because you wouldn’t avoid treating other medical conditions.
Anything else that you think you would like to share?
If you had told me 20 years ago that I would be doing the work I’m doing now, I would’ve been very surprised. This was not the direction I thought my career was going, but I don’t regret a minute of it. It has been the most rewarding work I can imagine ever doing in terms of taking care of the patients I do, teaching the people that I get to teach, and doing the work on systems-level to spread this practice. When I think back to 2006, there were maybe two or three of us in MaineHealth prescribing buprenorphine, and now we have hundreds of people doing that, and we have thousands of patients currently being cared for who have substance use disorders instead of 70 or 80. It’s incredible to me to have been part of that. I’ll be forever grateful for the opportunities I’ve had, and I’m proud of my role in it, teaching the many people I have. When I walk away from this work, I will feel good about what I did. My focus now is training the next generation who will continue this work when it’s time for me to step aside. I am so thrilled with the fellows we have, and I know that they will do an amazing job in the future, and I will not have to look back at all.