What got you interested in addiction as a family practitioner?
I spent some time away from Maine while serving in the military. When I moved back, I was looking for employment, and I happened to see that Merrimac, a methadone clinic in Portland and Lewiston, was looking for an interim medical director. Having come from the military and then private practice, I was very familiar with the overprescribing of opioids which has led to our current opioid crisis, but I felt very ill equipped. A recruiter reached out to me and asked if I would apply. I thought, “Let me check it out.” The advertisement stated they were prepared to train the right candidate, but I was still extremely nervous with no formal training and hearing several people around me saying, “You’re crazy, don’t do this.” But, because of what I witnessed happening in the military and in private practice, I wanted to learn how I could help and possibly make a difference.
When I started at Merrimack, I was greeted by the most amazing and welcoming staff. And meeting the patients? It may sound dorky, but it was magical. They were not only amazingly grateful but incredibly understanding of my own learning curve as a practitioner. The experience reawakened my love of medicine. I had become so burnt out on family medicine. I had begun to question what I was going to do with the rest of my life. Now, I’m so grateful I had the opportunity. The teamwork, the comradery, and the patients all served to reinvigorate my love for caring for people.
Let’s talk about your experience in the military –can you tell us what that experience taught you and how it might be integrated into your practice today?
I was in residency when 9/11 happened, so we had many folks getting deployed. Then, when I became a staff physician, we began to see patients coming back from Iraq injured. Some of them also had significant mental health challenges, including PTSD. Many who were injured were getting placed on opiates without much guidance because, at the time, the providers were being told that you can’t become physiologically addicted to these medications and you don’t have to worry about a ceiling. We had some soldiers who overdosed, which was heartbreaking. They had survived Iraq only to come home and die. The opioid crisis had begun to emerge among the soldiers affected by war, but behavioral health consequences were also rising. I distinctly remember one soldier who had injured his back in Iraq. He was taking very high doses of both immediate-acting and long-acting opioids. It had been over a year since he had returned home. He was unable to return to work, and he was having trouble with his family. I remember telling him that the pain medication was probably doing more damage than good. I admitted him to our small community hospital in Kansas, but I was unable to find a facility or program that could help him with his opioid use disorder. Eventually, his case manager found him a civilian program a few states away, and even then, it did not provide what we had hoped for him.
What complicates things in situations like this is chronic pain. I remember thinking there has to be a better way to help patients with substance use disorder, especially for those who have both substance use disorder and chronic pain. But, at the time—this was around 2008-2011—there really wasn’t much out there. I know things have changed a lot, and I’m very thankful for that, but at the time, there was a profound lack of resources. When I made it back to Maine, those kinds of stories stuck with me because this patient was far from alone in his experience. I thought we can do better as a medical community. So that was the inspiration for me to work in recovery medicine.
How did these experiences prepare you to think about how substance use disorders converge with chronic pain? What are your reflections on your experiences caring for patients who are struggling with chronic pain and SUDs?
Yes, this area of medicine is very complex. Chronic pain and development of an opioid use disorder can happen to anyone. There are certainly plenty of people who have chronic pain that don’t develop a use disorder, but when other risk factors are at play, it complicates the picture. However, just because opioid use disorder has developed does not mean the patients shouldn’t still get care for their chronic pain. It is, however, a real challenge for both providers and patients. The patients often feel their pain is minimized and even encounter people who think they’re lying about the pain because you can’t see it. It can be really heartbreaking trying to help patients with this hidden disability as they navigate a medical system looking for safe and appropriate care.
Even in private practice, before we had guidance in tapering, I had many patients that I was trying to help taper to safer levels. I had one patient who was in graduate school who had a very minor procedure on his thumb. He developed significant pain and came to me on very high doses of Percocet and other opioids. I wanted to help him have pain relief without requiring high doses of these medications. Situations like that these are really hard on medical staff and providers because of the fear of accidental overdosing a patient and also staying within State and CDC guidelines. It’s also incredible difficult for patients and their families because so much mistrust toward the medical community may have built up over time. It can be confusing when one doctor tells a patient that it’s ok to be on high doses of opioids and then another tells them that it’s not safe and they need to taper. Success in building a relationship between the provider and the patient relies on engaging the patient and sometimes meeting them where they’re at. It is also ok to move slowly when trying to taper a patient. Offering frequent pauses is also very acceptable. It’s important to remember that tapering is not a sprint but a slow and steady marathon in a safer direction.
What do you think is the most significant barrier to expanding treatment and support for recovery here in Maine?
The barrier lies in what clinics and healthcare facilities are lacking right now – resources. People are a resource – never having enough providers but also never enough medical assistants, support staff, behavioral clinicians, recovery coaches, etc. The prescriber and the medication prescribed are just a piece of the puzzle. The heart of a program lies in having a whole host of recovery offerings that support the patient.
Having endorsement from leadership is also very important. If your leadership doesn’t prioritize recovery and promotes it, it makes it that much more challenging when trying to do this work.
Where do you see prevention fitting in the continuum of care?
Prevention is so critical – primary, secondary, and tertiary. Primary prevention can start early in the formative years by engaging local school systems. Non-profit organizations like Voices of Hope target the youth by bringing awareness and promoting prevention through film. I’ve been more involved in tertiary prevention – where somebody already has a use disorder, but now we’re preventing things like overdosing by offering Narcan. The state has done a really good job with that. Tertiary prevention can also include making testing for HIV and Hepatitis C more accessible or distributing wound care kits as we see the rise in devastating wounds caused by Xylazine use. I have also been involved in some primary prevention work, participating in some community forums at local high schools. I think the whole prevention spectrum is critical, and any work in prevention can make a difference no matter what direction you come at it from.
Turning to the topic of primary care physicians around the state, how might they start to support prevention in their own practices?
I would say primary care is where secondary prevention comes in – meaning, for example, your patient might be dabbling in substance use, and a primary care provider is in a unique position to screen patients with just one question like, “In the last 12 months, have you used any illicit substances or alcohol?” Sometimes the patient doesn’t want to talk about it, because they may be ashamed or uncomfortable. By getting that conversation started, you can learn a lot and have an opportunity to intervene. You can delve into more detailed screenings as well. Screening is a great stepping-stone to potentially preventing a patient from developing a use disorder.
One of your current positions is as a medical director of an OTP. Where does methadone fit into that continuum of care, and how do you think the stigma around methadone can best be addressed?
Methadone is a good option to have for MOUD. There is lots of data that support its effectiveness in managing opioid use disorder. Unfortunately, it does have a bad rap, even with providers. I recently admitted a patient who shared with me that her provider told her, “I don’t believe in methadone, so you need to get off it as soon as you can, and we’ll switch you to Suboxone.” The patient was in tears and felt like that’s what her primary care provider said, so it must be right—and trying to reconcile that as a patient and as a provider is a huge challenge. Methadone can be a great alternative to buprenorphine, where the individual may need more support, more structure, and more accountability than seeing their provider a few times to once a month. It’s a shame that this idea of methadone not being a good medication still permeates the medical community. Some of that may be due to methadone not having a ceiling effect. For many, the ceiling effect of buprenorphine is what appeals to providers, meaning the patient just feels “normal” on buprenorphine, and they don’t experience the high. What people fail to realize is that when methadone is correctly dosed, individuals should feel normal, and they won’t have withdrawals. I think that to help reduce the stigma, the option of methadone needs to be discussed more. Last year at the Governor’s Opioid Summit, a representative from one of the methadone clinics had the opportunity to present, and I think there needs to be more of that kind of visibility out there. People do recover when taking methadone. One of the biggest misconceptions is that you start methadone and you’re on it forever – and it’s not just providers who think that but patients, too. I recently ran into a physician who now works in addiction medicine but had been in a situation where he was struggling with opioid use disorder. Buprenorphine was not working for him. He began MOUD with methadone and really embraced that program. He eventually moved into long-term recovery, was able to wean off methadone, and now works as an addiction specialist. As a community and a state, we need to highlight these success stories where methadone can play a critical role in successful recovery for the right individual.
What would you say to prescribers who are still on the sidelines for recognizing and treating even their own patients with substance use disorders?
I’ve personally tried to sway some providers and had some success but also a lot of resistance. Some of this resistance has to do with feeling overwhelmed – I hear from providers, “I already have enough on my plate, I can barely manage what I have now, and now you’re asking me to do something that seems even more complicated.” This goes back to giving the providers the resources and support they need. In the beginning, that may look like carving out a little extra time in their schedule. Once a provider gets used to it, they will likely discover that there is little difference between managing OUD and other chronic illnesses like hypertension or diabetes.
Many primary care providers are trying group visits for their patients with OUD, which has helped with their time constraints. They might be able to see five to eight patients in that hour, whereas normally they’d only be able to see two to four. Even better, in a group setting, the patients hold each other accountable. Settings like these can be more impact for some people in recovery.
We’ve talked a lot about what got you into this field and what’s needed moving forward, but what motivates you to continue moving forward and being a leader in treatment for substance use disorders?
It’s about the patients. If it were just about prescribing medications and staying up to date with literature, I wouldn’t stay in it. I need to be with patients – that’s what keeps me motivated. The people I’ve had the privilege of caring for have been so inspiring. They show such vulnerability at a time when there is great pain and need. I feel so blessed and grateful that they’re willing to show themselves to me in that way. It’s an honor to take care of people at their most vulnerable. To be there when they open up and share, to be a part of it all, is so moving. I can’t say enough how thankful I am that my career took me down this pathway because I wouldn’t still be in medicine if it hadn’t.
Is there anything else that you want to share with your colleagues out there?
I think I’ve already said it in so many words, but it’s just so important to treat patients with substance use disorders like any other patient. It’s just another disease, and they deserve treatment like everyone else does. Placing them into a category that does not allow them to get the care they need is simply not right. The more we can stand up for these patients and get them the help they need, the more we normalize it as just another disease that we know how to care for. I applaud the people who are already doing this amazing work, and I can only hope that more people will join us.
It’s what medicine is about – offering treatment to your patients and getting them what they need.
Exactly.