How did you get interested in substance use disorders, and what keeps you motivated to do your work with people using drugs?
I grew up around enough of it to understand mental health and addiction a little bit before I even started my education and training. When I went to the Physician Assistant program, I found that addiction was a very, very small part of the psych part of our didactic experience, and it certainly wasn’t built into any of our rotations. However, in my primary care rotation, the provider had a buprenorphine program one day a week out of a super rural primary care practice in Cooper’s Mills. He offered this experience to his students but said if it’s not your thing and you don’t want it, I’ll send you to be with somebody else that day. But I was curious. I didn’t know anything about buprenorphine at all, and I ended up doing it every week that I was on that rotation. It was my favorite part of the work there. I didn’t see myself going into recovery work because it wasn’t a field I felt had the potential to work in at the time. Still, even so, I got some experience at Riverview and Augusta during my psych rotation. Then, when I started my work in the nursing home, they had a big brain injury unit, and most of the folks that were coming in had some substance use disorders. I loved treating the mental health issues that come with brain injury patients and understanding the addiction piece was a bonus. I started getting more and more mental health experience where I was doing coverage, but I still had very little addiction-specific experience before starting at New Horizons. Dr. Nesin, knowing that I enjoyed the psych part of my job and loved the brain injury unit, suggested that I might like withdrawal management and asked if I would help start a program there. I got lucky in timing and who I was around at the time to work in addictions.
For many folks who work in recovery, it’s a patient population where we feel passionate about our work with them. It comes naturally. Even though the work can be more challenging, sadder, and more difficult in some ways, it comes naturally to me. It’s easier to stay motivated when you feel connected with what people are going through, genuinely enjoy their company, want to spend time with them, and want to be able to help them. I’ve found that it’s true for most patients I’ve worked with over the years in all my settings, but for some reason, it’s been the recovery folks that it’s always felt more instant. I have rarely not gotten there with a recovery patient, but sometimes it takes time to get there.
Reflecting on your experiences across diverse populations and settings, how would you characterize the needs, challenges, and successes you’ve seen
Across all the populations, I think the success is that there’s continually more awareness, understanding, and comfort with addiction than ten years ago. We have a long way to go, but I am continuously impressed with how much awareness we have now compared to what we did and how far we have come with conversations that are not as stigmatizing and offensive.
In terms of challenges, I think the geriatric crew faces one of the more challenging battles because it’s not part of the training for geriatricians. It’s not on most people’s radars, even though we’re seeing dramatic increases in alcohol use disorder and our opioid use disorder folks are aging. Most people have accepted that addiction happens in younger folks, but we turn a blind eye as they get older and don’t consider what their experiences are going to be like and how we need to adapt what we’re doing for treatment. Granted, it is still a smaller percentage of the geriatric population with SUDs compared to our younger folks, so it’s easier for people in healthcare to say it’s not their thing or they don’t know about it.
Then, of course, the unhoused population has its own completely unique set of challenges to managing withdrawal and recovery and all the risks they face from an infectious disease standpoint.
With the unhoused population, what are the types of things you do or the messages you provide to help people stay safe and minimize risk?
So much of the work we’re doing with street medicine and outreach is a shift from talking about treatment to trying to actively engage in recovery and make sure that other medical and mental health needs are met, along with establishing rapport beyond what we’re doing in any other setting by radically meeting them where they’re at. We might say, “I don’t know the lived experience of homelessness in this encampment, so I need you to tell me how I can be useful and what you’re interested in for treatment if anything.” Much of it is relationship-building. Stop pretending; we know what will keep them safe, but ask them instead. Also, try to sneak in tidbits they may not know. These guys have a lot more experience in many areas, but they haven’t necessarily been to medical school. We don’t want to come in lecturing folks, but once you have a relationship with someone, it’s very easy to say, “Hey, just a heads up, there’s a lot of Hep C and HIV out here. Are you using by injection right now? Are you getting access to clean needles? Here’s a needle exchange. Here are some ways you can limit risk. If you’re ever interested in stuff that might help prevent this from happening or getting screened, it would be worth getting screened for, and here’s how”. For a lot of patients and a lot of the medical community, there’s still a myth about Hep C not being treatable and a myth about HIV being a death sentence. That’s the window of opportunity to say if you did get Hep C or HIV, it is worth doing these other steps. I have a ton of patients that have done well with this approach. Again, it becomes better when you’ve had time to build rapport, and they may trust you as someone who knows what they’re doing. So, you tell them you’ve had patients do really well on the treatment, and it’s not a big deal or commitment. There’s a window here for us to reinforce and to recommend, not to force anyone, but to give them the information they need to make the decisions on their own.
There is a lot of the work in street medicine with the unhoused. I might be treating the abscess today, but what I’m hoping is that by treating the abscess today, I can then offer something like, “Hey, if you were ever interested in recovery treatment, if you want to get on Suboxone, you can come down and see me. If you want to get screened for Hep C or HIV, here’s what we look for. If you want to get treatment, here’s what we offer. Here’s what we could do for preventative care”. At the moment, I’m taking care of what is most helpful to them but showing all these other potential open-door options. I’ve had patients who have come in for a pap and, at the end, have said they have been using it for a few years now and are interested in treatment. There’s more opportunity to keep folks safe if you can have honest conversations with them. If you want to do harm reduction, you have to get to a place where people trust what you’re saying out loud and are willing to have a conversation with you. You have to get the door open.
In your role as lead PA at New Horizon’s withdrawal management facility, what changes have you seen in the needs of the people presenting for withdrawal and initiation of MOUD?
When I started, it was heroin and not fentanyl or xylazine, so that’s been a huge change. I think the biggest challenge that we face right now as a medical community that’s affecting withdrawal management is the lack of primary care access and the resulting wait times at walk-in care and emergency rooms. In withdrawal management, we’re getting folks who would love to have a primary care provider to see for some of their other chronic issues. Some of them would love to see a psychiatrist for their mental health needs. But they’re coming to us in withdrawal management for their walk-in care needs because access to everything else is so strained. Then, we can only set people up with so much on discharge when their next primary care appointment isn’t for 18 months. It all affects withdrawal, recovery, and long-term success. It’s hard to manage their anxiety and depression without treatment while they’re trying to get into early recovery. Another piece is their other chronic medical conditions – for example if their diabetes is poorly controlled and it makes them feel awful every day. Both pieces make it harder to maintain recovery, and that’s true for every chronic condition. It’s all recovery. If we spend 30 minutes of the appointment talking about blood pressure, then long-term recovery success includes blood pressure being under control. It includes you getting your gynecology needs addressed; it includes you getting your birth control. It’s everything. We can’t silo health or mental health in a community where we have very little primary care access and very little psychiatry access. There was a time when you could have a patient make a follow-up in a week with their primary care provider to address X, Y, and Z, and it might happen. Now, we’re going to try to address as much as we can while they’re with us because we know that might not be in the cards for them.
When we talk about withdrawal management, the name is somewhat of a misnomer in terms of what these programs do. Can you speak to the initiation of buprenorphine within those settings as well?
There was a time pretty recently when we didn’t start buprenorphine or methadone as a part of withdrawal management. Now, the standard of care is to get started on MOUD when you are in withdrawal. A lot of folks still believe that there’s a path where you go through withdrawal and don’t offer MOUD. That path doesn’t exist. MOUD is part of the care now. The hard part is there was a time when it wasn’t part of the care. That transition slowly trickled in. Unfortunately, not everyone can start methadone because of OTP availability, but there’s no reason at this point you can’t offer buprenorphine as part of the treatment for withdrawal. Withdrawal management is not just getting through withdrawal; it’s getting on treatment as well.
What would you say to prescribers who might still be hesitant to recognize and treat patients have SUD?
I talk about this a lot in my nursing home population. I understand there’s been a lot of new stuff for us, and it’s hard to digest much of the newer medicine. This is something a lot of us did not have when we started. I’ve only been out of school for ten or so years – we didn’t have it as a part of our didactic. So, I understand that many people are coming into this with absolutely no experience or reference, and I think that’s fine. I also continually point out that we had never heard of COVID five years ago. Still, we’ve adapted to treating COVID – to Paxlovid, a completely new vaccination set, when we initially gave IV monoclonal antibodies. We’ve done many things that we didn’t know how to do initially, so we’re capable of learning how to do it. I would argue buprenorphine is even easier to prescribe than Paxlovid. We’ve done harder things and adapted to harder things.
There are a couple of reassuring pieces. One is that buprenorphine is a reasonably safe medication. It’s much safer than morphine, oxycodone, and other meds that we prescribe regularly and don’t feel qualms about, although we should. If you can offer and get people on treatment, it makes a big difference in your work with your patients.
Is there anything else that I haven’t asked that you would like to share?
Addiction medicine is a wonderful field of medicine. It can seem intimidating from the outside, but it’s a very fulfilling field. A lot of people don’t realize this. I take my geriatric students with me to New Horizons or other settings I’m in, and they are surprised at how much they enjoy this patient population. It’s just not on their radar. It is just a great field of medicine to work in!