Interview with Samuela Albert Manages, MD, FAAFP

Kate Chichester
Kate Chichester
CCSME Executive Director

Let’s start at the beginning – how did you end up in Northern Maine?

I tell everyone that is the million-dollar question! My sister and I were born and raised in Sierra Leone, West Africa. My parents wanted to give us a better life and better opportunities, they were able to get our green cards and I remember I was about 11 when my sister and I came to the US and later became naturalized citizens.  I learned later we had lived in Philadelphia before moving to Maryland, and it was so cold. I remember the first time seeing snow, I freaked out, and asking my mom what the white stuff was coming from the sky. Because of course I had never seen snow in West Africa! We actually got sick as we acclimated to the different weather changes but still, we all knew we had better opportunities than back home. I started middle school in Montgomery County, and we later moved to Capital Heights, where my parents still live today.

Samuela Albert Manages
MD, FAAFP
Kate Chichester
Kate Chichester
CCSME Executive Director

So West Africa to Maryland! And then the Caribbean and New Jersey as well?

Yes – I went to undergraduate at the University of Maryland, College Park and then attended Ross University School of Medicine in Dominica, unfortunately destruction of hurricane Maria in 2017 on the island, school moved to Barbados. The first two years at Ross are what I call the “book years” were spent on campus in Dominica and then the last two years, our clinical years were in the US. I pre matched and graduated from UMDNJ-Robert Wood Johnson @CentraState Family Medicine Residency, now known as Rutgers Health Robert Wood Johnson Medical School in NJ.

Samuela Albert Manages
MD, FAAFP
Kate Chichester
Kate Chichester
CCSME Executive Director

… and then up here to Maine.

Yes, during my third year of residency, I remember listening to a panel of practitioners from all different walks of life as part of my training – community health/FQHC, private practice, military, etc. I’ve always been interested in working in urban or rural community, “boots on the ground” to go where they need physicians. I moved to Maine, because my then fiancé wanted to move back to be close to his family. This was my first contract after graduating residency and I have enjoyed working at Pines Health Services-FQHC for the past 15 years. Although my relationship ended, I have built a relationship with the community and my work family, and the decision was easy for me to stay.  I have served as volunteer clinical preceptor for Maine Medical Center/Tufts University LIC, UNE Physician Assistant and MCPHS trainees.

Samuela Albert Manages
MD, FAAFP
Kate Chichester
Kate Chichester
CCSME Executive Director

What is it about working in rural Maine and practicing in a rural setting that has kept you in Maine?

I lived in Miami and Brooklyn, NY during my rotations, but I like the peace and quiet in rural communities. Up here the crime rate is low, I get to enjoy many outdoor activities like camping, ice fishing, sledding, and hunting and Maine has a good school system. Rural medicine practice is unique in the sense I get to know my patients, their family, and the Acadian Culture. You develop relationships that sometimes can be missed when you’re in bigger cities and you’re just a number. That’s why I like practicing here. We also get to be creative in treating complex conditions and even regular conditions because we do not have a GI specialist, a rheumatologist, a neurologist, etc. So, I’ve developed additional skills. For example, I treat Hep B and Hep C, I am a DOT medical examiner for our CDL and bus drivers, I do psychiatric med management, I do joint injections and minor surgical procedures, like removing lesions or laceration wound repair.

Samuela Albert Manages
MD, FAAFP
Kate Chichester
Kate Chichester
CCSME Executive Director

You have been able to develop a skillset to respond to the needs of your patients and your community, which you might not have had the opportunity to do in a specialized practice in a big city. Where does addiction medicine fall in all that?

I started having an interest in addiction medicine during residency. It wasn’t part of our curriculum, but our program director was the one who introduced us to treatment of opioid addiction with Suboxone. He had his waiver, and he would see SUD patients. He gave us a talk on buprenorphine and strongly encouraged all of us to pursue getting the waiver once we got our license. I admit I wasn’t paying much attention to the overdose rates when I first arrived in Maine, but what I quickly noticed in my practice was that I was seeing more and more patients with substance use disorders. Maybe they had presented with chronic pain and started on hydrocodone, Percocet or Oxycontin. Now they are no longer able to get those prescriptions, so they may experience withdrawal and start supplementing with something like heroin or fentanyl. I started thinking about it. So, in 2011, I did my waiver for buprenorphine, and that’s when I started working one day per week at AMHC doing MAT, we were also able to provide treatment with Sublocade and Vivitrol and for opioid and alcohol use disorder. And despite the focus on opioids, I was now seeing a lot of methamphetamines used too. But there was still something missing, people who were falling through the cracks. I realized I needed more in-depth training. I had the option to take the clinical experience path, where I would take the exam after meeting clinical hours or fellowship path, I decided to do a fellowship because I wanted to build on my knowledge and gain in-depth experience in comprehensive addiction treatment. I knew doing Addiction Medicine Fellowship would be most valuable to adolescents and adults struggling in my rural community.  So, I applied and matched to my first choice Massachusetts General Hospital-Harvard Medical School, Boston MA.

Samuela Albert Manages
MD, FAAFP
Kate Chichester
Kate Chichester
CCSME Executive Director

In what ways has the fellowship been especially helpful for you?

I am now able to do the full scope of addiction medicine – adolescents, pregnancy, adults, inpatient, outpatient, etc. I feel if I had chosen clinical hour’s path, I wouldn’t have been able to get the comprehensive education to do all that. For example, I was even able to do rotations with Street medicine team/Boston Health Care for Homeless Program, MGH Bridge, HOPE (caring for pregnant patient and children) and Co-occurring disorder with addiction clinic, Hepatology, Boston Children Hospital and Withdrawal Management (Detox) program. Now if I see someone with alcohol use or any other substance use, I know how to treat them and navigate them through the system to get the help they need.

Samuela Albert Manages
MD, FAAFP
Kate Chichester
Kate Chichester
CCSME Executive Director

How are you integrating all those experiences into your current practice?

I’ve recently started the process of building an OBAT Clinic (office-based addiction treatment) within Pines Health, with the ultimate goal to create a low barrier comprehensive addiction treatment and behavioral health care to serve the needs of our community. I’m still seeing patients for primary care including pediatrics, but the majority of my patients are for SUD treatment. If patients go to the ER with substance issues and they don’t have primary care, I am available to take them on for their primary care needs.

Samuela Albert Manages
MD, FAAFP
Kate Chichester
Kate Chichester
CCSME Executive Director

What would you say to the prescribers who may still be on the sidelines to get them interested in treating their existing patients who have substance use disorders?

First and foremost, I hear concerns like, “I don’t want those people in my waiting room,” or “My schedule is already full, and those patients need more time.” They’re not wrong about the time, the second part is addressing the knowledge gap. We hear about buprenorphine or methadone and how wonderful they are, but the majority of patients we see with substance use disorder are users of multiple substances. It’s not just opioids, it may be stimulant or alcohol. So, if you are going to start treating patients, you have to be able to ask detailed questions when you’re doing your initial intake to know what’s in front of you. For example, if your patient is withdrawing from benzos and you don’t ask about benzos, it can interfere with other things. One of my goals to address this by providing mini educational talks, because I know everyone is busy to help this gap – start basic with language, stigma, racism, and then move on to substances, pain management in patients who use substances, perioperative pain management, etc. Right now, I’m here for my colleagues, we use Epic, and they’ll send me messages like, Hey, do you have a few minutes for me to run a case by you? And the ER will do the same and they’ve done really well. I provide recommendations and so far, the flow has worked. I’m also planning to work with the ER providers to create protocol for buprenorphine and methadone. My hope is also to recruit recovery coaches and substance use counselors to join our team here. It would be great to have them in the ER and our primary care office to help our patients navigate through recovery.

Samuela Albert Manages
MD, FAAFP
Kate Chichester
Kate Chichester
CCSME Executive Director

What motivates you to continue this work?

What motivates me is something I see almost every day when I walk into the room: a patient who is afraid because our healthcare system has mistreated, devalued, and continue to shame them. But by the end of the visit, they tell me that they feel relieved, less anxious, and comfortable enough to share their story. I have this sign-up in my exam rooms that says, “Safe space, safe with me.” I always tell my patients them; this is a safe space for you, a no-judgement zone, a place where you’ll be treated with dignity and respect. Unfortunately, we in the healthcare system have historically been really bad at this. I see that over and over. The other thing that gets me motivated is that we’re usually so focused on the negative things about addiction that we don’t celebrate the positives of folks who are successfully on medication. They have reduced their use, and some are no longer using substances, they have their kids and loved ones back in their lives, they’re working, and they describe feeling like themselves again. Others might be looking for these massive changes or a full and immediate stop, but we like to celebrate these little improvements and talk to them about harm reduction. If someone tells me they’re drinking heavy six nights a week, and later they come back and say they’re drinking four nights, I say let’s celebrate that.

Samuela Albert Manages
MD, FAAFP
Kate Chichester
Kate Chichester
CCSME Executive Director

Tell us how you recruit providers and get them up to Northern Maine.

If anyone is interested, I would love to have them here! I’m currently working with a couple of folks who are interested, including Advanced Practice Providers, who have voiced interest.

Samuela Albert Manages
MD, FAAFP
Kate Chichester
Kate Chichester
CCSME Executive Director

I can see that you have a talent for translating your own energy and motivation to others.

I hope so. To me, the biggest thing is getting the information about addiction treatment out to healthcare providers and communities. This way, we all take steps to support recovery.

Samuela Albert Manages
MD, FAAFP