What are some of the challenges you see from the provider’s perspective around recognizing and treating substance use disorders?
I think as a provider, specifically a primary care physician, the biggest barrier was my misconceptions going into it. I thought this was going to be much more difficult to do at a primary care level than I ultimately found. As I began to provide this care, those misconceptions quite quickly fell away. It had started out as something I was reluctant to do, and it became something that I have not only come to love to do but have found to be one of the most rewarding and impactful parts of my practice as a primary care provider. That journey is one that I think many would also find relatively easy if they could get past those hurdles and provide this care. I worked in emergency departments and on code teams for more than 20 years and I have told some of my colleagues that short of intubating somebody to save their life, there’s probably no more impactful work that I do than providing care for people with opioid use disorder with buprenorphine. I love this work.
A significant barrier is the misconception that care of patients with OUD with buprenorphine is very complicated clinical care – it isn’t. While far from simple, it is no more complex than any other kind of work I do with patients with a serious illness. The medications are not new. In fact, they’re very familiar to us. We prescribe opioids in substantial dosages all the time, which probably has more risk of patient harm than buprenorphine does. Most of us are familiar with treating use disorders such as alcohol use disorder with some degree of comfort. It’s a routine part of our care to take people through alcohol withdrawal and maintenance with medications. Yes, you have to refill their medications on a frequent basis, but I have to do that with all my patients who are on chronic opioids. The clinical medicine is not as difficult as many of us feared. In fact, once you get into it, most of us would find it quite familiar.
In what way is it impactful? What do you see in your practice doing this type of work?
Here is an example of that: I saw a patient of mine several months ago. He was out of prison and two years into his recovery. He had rekindled important relationships and had a job he liked. He felt like he was contributing to his community. He spoke about simple pleasures like mowing his own lawn in a house that was his, creating meaningful everyday routines, and even driving past a police car without fear of being arrested. And I thought about the profound change in his life that came from him doing his work and I providing him with OUD treatment with buprenorphine.
Every day that I see patients I hear those stories and the profound impact on their lives. It is lifesaving work – it’s just extraordinary. To share that work and joy with those patients and be an active part of something so meaningful is so enriching to my practice and to my life.
Let’s talk about the administrative side. What are the challenges administrators have to support the work of the individual providers?
Administrators have so much to worry about, so many other challenges. But they need to see this as lifesaving priority work, and to support this work. I think the conversation with administrators usually starts with the providers moving through fear and various misconceptions into wanting to do this, and then standing up and taking that interest to their organizations to say, “I would like to be able to do this. Can you help support me in that work?” I think that is the most important step in getting leadership administrative engagement.
But I also think administrators, organizational leaders can take the first step. They can and should call their organizations into this work, and can go to providers and say, “Let’s help – we can make a profound difference. How can I support you providers in taking on this care?
Administrators also need to get past misconceptions, one of which is about these patients. Some administrative folks are worried about safety, staff, comfort, et cetera. There’s some misconception that these are difficult or demanding patients. While some are, especially early in their recovery when still unstable, fearful, really sick, I have absolutely not found them to be persistently difficult to manage or care for; in fact, I find these patients perhaps less challenging and more cooperative because they’re so appreciative of the care that they’re getting.
Another misconception is that you need a lot of resources to be able to do this in primary care, e.g. that you need an embedded counselor, substantial time in schedules, et cetera. The majority of patients that I take care of for opioid use disorder don’t see a counselor on a regular basis for a wide variety of reasons. It was previously routine that in order to treat someone for a use disorder in primary care they had to be in counseling. It’s now understood that this was a huge barrier to accessing care, and an unnecessary one. In fact, it is now recommended that we not refuse to provide MOUD care for patients who are not in counseling. And while I certainly encourage many of my patients to see counselors and participate in 12-step programs, I don’t require it and I don’t refuse to take them if they don’t have access to counseling. In addition, I find that if you are listening for it, you can get good insight into some of the mental health issues—such as anxiety, PTSD, depression, ADHD, etc.—that may be related to their opioid use disorder. If these folks have a comorbid condition in a mental health domain, most of us in primary care routinely provide that kind of care, including medication, already. I also routinely set assignments for my patients to work on breaking the connection between their mental health struggles and their opioid use.
If providers can get past their barriers to be able to say to the leadership of your organization that you would like to be able to do this, then I think we’ve overcome one of the biggest barriers to getting administrative support for this. And if administrators can also get past their barriers then I think they can figure out together how to provide this care in a safe, effective, efficient, sustainable way that can have more benefit to patients than many other kinds of care we routinely provide.
You’re launching a new campaign to save lives of those affected by opioids here in Maine. What motivated you to take on this leadership challenge?
People who’ve known me for years would tell you that I’m a pie-eyed optimist. I would say I am a restless improver. That’s why I like taking care of family medicine patients and why I got into leadership. There’s a tremendous case to be made for growing the engagement of healthcare professionals and organizations in this work. With tools and medical knowledge that are available to us and a group of resourceful partnership organizations hoping to see us get more involved in this, this might be the most impactful near-term healthcare initiative in Maine. If you look strictly at the numbers, it’s the equivalent of saving the entire graduating class of an average-sized Maine High school every year.
How do you envision this happening?
I hope to kindle two levels of interest within the healthcare community in Maine. One is at the organizational leadership level, where I hope to kindle leadership interest in having an impact on one of Maine’s most important public health issues. I want them to sign their organizations onto this work in a public and meaningful way. Second, I hope to inspire more of my colleagues in primary care, emergency medicine, paramedical community, nursing, et cetera to all see the potential of this to be rewarding to them, and to get them all involved in effective MOUD care. Many of them are exhausted from the last several years, and if they’re looking for something that could be uplifting to help mitigate that kind of burn out, this could be it. By inspiring at those two levels, I believe we can bring healthcare organizations and providers more effectively into partnerships with state government and other organizations in Maine that have been advocating and educating for years. I want to get all of healthcare involved in this work.
What else do you want your colleagues out in the field to know about this topic?
There are so many resources and organizations out there right now who want to help you do this work if you are a primary care provider or any other specialty provider. There are folks at the state level who want to help and bring resources like a MOUD provider hotline to the table. There’s going to be a Project ECHO group to support this. You have colleagues who are willing to do the induction piece, which is a little more complicated, and then turn patients over to you for you to do the MOUD maintenance piece with buprenorphine. If you’re feeling like you’re ready to put your toe in this water, reach out to these resources. There are a lot of us who would love to help you join us in this work.
My ultimate goal, in particular among my primary care colleagues, is that we all at a minimum step forward and take care of the OUD patients in our own practice and be willing to provide buprenorphine and MOUD care for those patients of ours who have opioid use disorder. We all have them in our practices. If we could get to that point, I think we could have access really for just about everybody in Maine who would want treatment.
There’s help out there for providers and leaders. And like recovery, you just need to be able to put out your hand and…
Someone will grab it.