Interview with David Kispert, MD

Kate Chichester
Kate Chichester
CCSME Executive Director

What is your role with the Opioid Treatment Programs (OTPs), and why did you gravitate to working in addictions and OTPs?

I am a medical director at CAP Quality Care in Westbrook, Maine, and Comprehensive Treatment Center (CTC) in South Portland, Maine, both of which are opioid treatment programs in the greater Portland area. I’m dual-boarded in internal medicine and addiction medicine. The reason why I got into the field is I went into internal medicine because I felt I spent half of medical school learning about all these different organ systems and pathophysiology, and I said to myself, I just spent all this time learning it; I might as well put it into practice. I went into internal medicine with an open mind, and then, while I was practicing in residency, I gravitated toward individuals with substance use disorders. Thankfully, I don’t have any lived experience, although there are some family members peripherally that suffer from addiction. I found the work humanizing and enjoyed working with this marginalized population due to all the associated misunderstandings and stigma. I have a little bit of a drive for advocacy as well. Internal medicine and addiction medicine worked well together in dedicating myself to a particular subspecialty. So, I took it upon myself to pursue additional training in the form of a fellowship. After my fellowship in 2020, I started working at a buprenorphine program in Biddeford. It was a relatively small program, and you got to work closely and know the patients well. However, one of the challenges with buprenorphine is retention and treatment. When patients are failing that modality in outpatient settings, all there is buprenorphine; there’s no other medication available in that setting. What they would say is that we need to refer them to a methadone program, which is how I found my way into OTPs and, in part, because that was the job available. Although I had some knowledge from my fellowship with methadone, I didn’t have much experience with what happens when you refer someone to a methadone clinic and what it looks like. However, I found my way into several OTPs and gained that experience. I enjoy working at OTPs because I feel like with methadone, in particular, for the many patients, it’s the only remaining option when other forms of MOUD fail.

There’s a lot of stigmas around methadone clinics and about the patients and how they do. There are a lot of claims made about methadone that may or may not be accurate, but the patients come every day to dose, and I tell them when they come in, trust this process; come back every day, and I will get you to where you want to be.

It’s gratifying to see the progression of someone’s treatment over weeks, months, and years and how they can turn their life around. It’s great to be a part of that.

David Kispert
MD
Kate Chichester
Kate Chichester
CCSME Executive Director

How has fentanyl changed the role of methadone and buprenorphine for OUD?

Since the initiation of fentanyl into the drug supply ten years or more ago, the level of opioid dependency has grown substantially. People using heroin who used recreationally and were able to maintain some functionality drastically changed as fentanyl entered the drug supply with higher potency and shorter half-life. People needed to use it more frequently throughout the day and had difficulty sustaining their lives. People using fentanyl fell through the gaps, so having an OTP available to individuals who are struggling with fentanyl use disorder is necessary. Buprenorphine also plays a role in addressing the need, and at one of my clinics, we offer both buprenorphine and methadone. Having both tools at your disposal to work with patients concurrently is excellent. However, it’s an arms race, the way I see it, where dealers and manufacturers are tinkering with the drug supply and making it stronger and stronger. Unfortunately, we’re handcuffed with what we have available to us. With how much the opioid crisis is affecting individuals and how much healthcare dollars are being spent, why do we only have two medications for opioid use disorders at the end of the day? But with the medicines that we have available to us, buprenorphine is a great drug, and methadone is uniquely positioned as you can keep going up on the dose. You can reach a state where patients are under control, and that’s the goal of these medications.

David Kispert
MD
Kate Chichester
Kate Chichester
CCSME Executive Director

How is the transition from buprenorphine to methadone to methadone to buprenorphine best handled?

It’s one of the big questions in the field. You hear a lot about micro or low dose induction. It is where there’s a full opioid agonist, whether that’s methadone or fentanyl, being used by the patient, and the patient is being transitioned onto buprenorphine. Patients should continue to use, whether it’s illicit or prescribed, while receiving small increasing doses of buprenorphine every day over a week or even longer. So instead of full-blown precipitated withdrawal, if they do experience anything, it’s mild, and the buprenorphine sneaks up on the opioid receptor. The goal is that someone can continue on their full agonist treatment or drug use, and at the same time, they’re getting these escalating doses of buprenorphine to the point where they get to a standard dose, which is typically eight-milligram strips a couple of times a day. Then, they can stop the fentanyl, or they can stop the methadone altogether.

In theory, it’s great. In practice, I’m only getting about 60 to 70% of the people who make this transition onto buprenorphine smoothly. I have other providers in the area who are doing things more rapidly. I think the jury’s still up in the air. We’re all trying to find the right approach to make that transition successfully, but there’s no surefire way.

The transition from buprenorphine to methadone is significantly easier in that all you do is give a methadone, you say, don’t take buprenorphine again, and you’ll be all set. However, providers need to know that the transition to getting to a stable dose of methadone can take weeks. So, they’re on buprenorphine mono or combination product; they stop that, they’re started on methadone, we’re dictated by federal guidelines, which say we can only give you 30 milligrams of methadone the first day –although by the time this is published again the rules might change. Although the transition guidelines have been loosened recently, they are still painfully slow. Patients need to be aware that when they come into the clinic on day one, they will not feel a hundred percent better immediately; it can take weeks. That’s something that prescribers can make their patients aware of when they’re talking about going into a methadone clinic.

David Kispert
MD
Kate Chichester
Kate Chichester
CCSME Executive Director

What do other prescribers/providers need to know about OTPs?

No OTPs are alike. I think smaller clinics in the 200s size have the ability to pay more attention to individual patients. Some OTPs are much larger, so patients navigate more independently, with some more harm reduction focused. Right now, there are regulation changes underway, and when you think of methadone clinics, you think of daily dosing, but that’s going to be changing soon. The rules are already there. It is taking a little bit of time to trickle up into Maine, but it will make methadone more accessible. If you’re doing what you need to do and you can stop your illicit use or at least cut down significantly, you will be talking about take home medication in months with what used to be years. It’s something that I’m trying to institute and transition into my clinics, but there are inevitably challenges in terms of culture and how to practically manage who can get take homes and who can’t. But at the end of the day, what we’re hoping to achieve is making methadone more accessible for our patients.

David Kispert
MD
Kate Chichester
Kate Chichester
CCSME Executive Director

What continues to re-energize you in this work?

I have the luxury of seeing patients along the spectrum of recovery. For some people that have been in recovery for decades, they’ve stabilized on methadone, and they may or may not be tapering off, and you get to see them doing well. You’re sitting across from them, person to person. You get to know about them, get to learn about them as a person. You also get to work with people who are just entering treatment. Maybe it’s for the first time, and there’s a lot of questions, uncertainty, and frustration around what happens now that they’re seeking treatment. I can support them. It’s great to have diversity, meet with a patient who’s been stable for ten years in your one appointment, be with someone who’s been in the clinic for a couple of weeks, and things are improving in the next.

I get to make sure that patients are safe with their medications, that they are safe, and that the community is safe; those are the two big things that energize me. I give them a chance at recovery, cheerlead, and say, look, you’re doing okay. That’s the message I tell every patient across the desk: Look, you’re doing okay. You’re coming back every day. You’re in recovery whether you’re using or not. That’s energizing. I like working with people along the spectrum of recovery who are genuine. You can get down to brass tax. I try to hold myself to a high professional standard, but if you need a level with someone, you can level with someone, and they will appreciate it.

David Kispert
MD
Kate Chichester
Kate Chichester
CCSME Executive Director

Do you have anything else you want to share?

I’ve met many excellent providers in Maine who are doing the best they can. However, I wish we could implement new ideas faster. For instance, patients deserve more take-home now, and we need to support the Modernizing Opioid Treatment Act. Implementing universal healthcare would make resources more available and reduce fragmentation.

Opioid use disorder treatment should be seen in the same realm as anemia or high blood pressure treatment by primary care. We don’t have enough providers that are properly trained or willing to participate in the treatment of addictions. I think there’s a lot of stigma and frustration because providers, more times than not, did not have the best experience with people who are struggling with addiction or mental illness because they feel hamstrung because they don’t have the tools and a pill that will fix it by itself. Addiction and mental health is a much larger societal issue. People have experienced adverse childhood experiences or, in the instance of the opioid epidemic, doctors being misinformed about the addictive properties of the medication they were prescribing. As doctors, we need to recognize how much real influence we have in the disease process. That’s something I’m constantly humbled by and try to remind myself of. During those 15 minutes that I have with a patient, I can adjust their medications, but they’re going to spend 99.9% of their lives outside of the clinic. As a society, we need to give people more resources– provide case management and give people appropriate amounts for disability so they can afford their rent and have the resources to enjoy their lives. I see what I do often as treating quality of life, helping people have a good life, a job, or having their children back. I think specifically that my role in OTP is like, look, you’re down in the dumps, you’re unhoused, or you are spending three or four hundred dollars a day on drugs using eight to 10 times a day. How can we give you a higher quality of life? And if you keep returning, I can guarantee you a higher quality of life. Unfortunately, many things are pressing against people in society that stifle the recovery process. We need to do better.

We need to have more people like you treating addiction, speaking out, and a society and a healthcare system that values people to support their recovery in multiple ways.

David Kispert
MD