How did you become interested in addictions and nutrition and their interrelationships?
In a couple of ways. Many of us who work in the field have some personal connection, which is also true for me. Also, it was a progression through my experiences as a primary care physician. I loved what I was doing with individuals who experienced substance use issues, and decided I wanted to do more of it.
Early on, in my family medicine residency, which I completed in 1997, here at Maine Medical Center, I had a lot of exposure to people using substances. Then, while out in rural Washington for a couple of years, I saw a lot of methamphetamine use; interestingly, opioids were not as big of a problem yet. After being recruited back to Boston two months before the pandemic hit, I worked at a community health center across the street from Boston Medical Center. In that area, there are a lot of people who are using substances on the corner of Melnea Cass Boulevard and Massachusetts Avenue, which is considered the epicenter of the region’s opioid addiction crisis. As part of my primary care practice, I found I was treating people for substance use. We had a small recovery services program, so I became a part of that program and was able to provide both primary care and substance use treatment for my panel of patients. I loved it and decided I wanted to pursue board certification in addiction medicine, which I did, through the practice pathway.
Where does nutrition fit?
I’ve been interested in nutrition since I went into medicine. In medical school, we receive very little nutrition education, maybe four hours out of the four years is pretty average, but so much of what we see in primary care is diet-related, such as diabetes and high cholesterol. You end up talking about food with people a lot. I wanted to learn more and tell them the right things. In my first residency program, I started a farmer’s market in the basement of our little community hospital in Boston. Then, in 2019, while I was in Washington, I applied for a small grant from the American Academy of Family Physicians to look at providing medically tailored meal kits to patients with heart failure. I was awarded that grant and then completed the project in Boston. I saw what providing fresh, nutritious food and cooking together could do for people. It was impressive and inspiring, and kept my interest in doing this work. While in my addiction medicine practice in Boston, I started thinking about, well, what are the links between nutrition and substance use? What are the nutritional implications of substance use disorders? I found that there’s some excellent basic science about that, especially for alcohol, but also some for opiate use and stimulants . There have been studies on nutritional interventions for substance use disorders in animals and some in people, specifically with alcohol use disorder, which shows a significant impact on brain health, gut health, liver health, etc. The basic science is compelling; people who have food insecurity and nutritional deficiencies earlier in life are more likely to have substance use disorders. However, nobody is looking at doing a nutritional intervention for people with substance use disorder or doing a food as medicine program for people with substance use disorders; nothing out there. There’s this big gap. Maine is in the process of applying for a Medicaid 1115 waiver that will include food as medicine. Right now, MaineCare will not pay for food. However, Massachusetts, New York, and many other states do have this 1115 waiver, which allows innovation trials for Medicaid to pay for food. It is a very compelling medical intervention that is needed.
What fulfills you as you work with this population?
As a family medicine physician, I have always loved getting to know my patients and having this longitudinal relationship with them. In substance use treatment, it’s even more of that. We see people sometimes twice every two weeks, occasionally weekly, and definitely every month. Getting to know my patients is one of my favorite things about this work. The other incredible experience is seeing the huge transformations people make in their lives with access to treatment. It helps us feel that what we are doing and how we are doing it makes a huge difference. At the Portland Comprehensive Addiction Medicine (CAM) program, we hear a lot of patients say, “I’ve never been treated so nicely…it just feels like a family [with the whole team].” Those comments are so valuable to all of us, the whole team. It isn’t just the clinicians; it’s our entire office, and every single person who works there cares deeply about what we are doing and communicates that to our patients. Working in that kind of environment is something you don’t find very often; it’s fulfilling and palpable. I think all those things are why I want to continue this work. It’s life-changing for the people we serve, so if I can be a part of that, that’s great.
Having completed your master’s in public health at the University of New England, participated in the Hanley Health Leadership Development program and will soon complete your leadership in Prevention Medicine fellowship at Maine Medical Center this year. What are your leadership goals for advancing prevention?
That has changed over the course of my fellowship this year because the climate has changed so much. I have always been very interested in advocacy on the healthcare spectrum, specifically moving towards more universal healthcare. But at this point, we must focus on preserving what we have or not losing ground. I think that all of these leadership programs have helped me be poised to feel much more comfortable doing that kind of advocacy work, getting involved, and speaking with legislators. Making sure that we preserve Medicaid is probably the most critical thing that we can do in Maine right now to make sure that people continue to have access to treatment for substance use disorders. I see that as my central leadership, advocacy, and prevention task. It’s making sure that people continue to have access to the treatment.
You have mentioned the concept of food as medicine. Please share more about this and some of your current projects and research.
Food as medicine is a straightforward concept. You can use food as a treatment. Many health issues and chronic diseases faced in the United States due to the food landscape have existed for a long time. Thinking about food and nutrition as a medical treatment is how I see food as medicine. Programs are emerging to focus on this, such as the Food is Medicine Institute at the Friedman School of Nutrition Science and Policy at Tufts University, which opened in October 2023. More on this topic will be emerging.
Right now, I have three main projects. One of them is a research grant that we received from the MaineHealth Institute for Research. It is not substance use-related. It looks at the emotional and social effects of providing a meal kit-type intervention for school-age children, six to 12, and is just getting started. This new area of research, looking at food as medicine for our mental health, is exciting. I’m working on this joint project with Merelise Ametti, PhD, MPH, Postdoctoral Fellow at the MaineHealth Center for Clinical Translational Sciences. We have instituted two other projects. One is a lifestyle medicine group at Portland CAM. These types of lifestyle groups have been happening through the MaineHealth Integrative Medicine department. The one at CAM is brand new and uniquely focuses on substance use. We’ve done two pilot groups and they’ve gone very well. The third project is a partnership with the Good Shepherd Food Bank to distribute fresh produce at CAM, and we secured a refrigerator from the MaineHealth Innovation Center through philanthropic funding to store the food. It has been a very successful startup. In February, we distributed 280 lbs. of produce, and 603 lbs. of produce in March. The patients are very engaged, asking for recipes and talking about how they are using the produce. Seeing people get excited about the produce, taking it, and using it has been great.
What thoughts or suggestions can you share with other treatment providers about addiction and nutrition?
One thing that we’ve learned, and I’ve learned this too, in implementing the lifestyle medicine group, is how prevalent eating disorders are in our population. The prevalence rate of eating disorders among people with substance use disorders is around 35%. We are not well equipped as a system to screen for and treat those eating disorders. It is critical to look for disordered eating among our population. Then work on improving our ability to improve our treatment and treatment access.
Also, ask your patients about nutrition. Substance use has so many nutritional effects, and we are learning more about how gut bacteria are essential for physical and mental health and produce significant amounts of serotonin. So, talk to people about eating fruits and vegetables, ask about their fiber intake, and what can replenish and heal gut health, like probiotics or fermented foods. It’s not a 100% treatment, but it can certainly help their mental health, mood, and anxiety as they go through recovery. We don’t think about nutrition and other lifestyle factors, like exercise, which can make a big difference for people. The other thing that needs to be talked about is the significant amount of weight gain that can happen in early recovery, and for some people, that alone can be a huge trigger for relapse. So, talking about weight gain, acknowledging that, and working with it is essential.
Is there anything else you want to share that I haven’t asked?
I love to collaborate with people. If anybody reads this article and says, “Hey, that’s cool. I want to do something like that,” please reach out.