My Journey from Primary Care towards Addiction Medicine
(Lack of) Training in Addiction Medicine
Although my training and most of my career in medicine has been in Internal Medicine, I now practice 80-90% Addiction Medicine. I wanted to share my journey, and why I made the choice to focus on Addiction Medicine and leave Primary Care.
I completed my residency in Internal Medicine at George Washington University in 1988. Like most newly minted physicians, I had almost no training in substance use disorders. In medical school, we had one day devoted to drugs of abuse, taught by the pharmacology department. I remember a lot about that day, as I was fascinated from the beginning about addiction and why it is such a common human affliction.
During residency, I treated many patients with addiction, but I mostly didn’t know what I was doing, and missed many opportunities to diagnose SUDs or help patients move towards recovery. Like many of us, I learned to dislike these patients – they seemed self-destructive, demanding, and difficult. You could never trust what they told you – they would rarely admit to extent or nature of their drug or alcohol use. We would work for days to patch them up, only to have them come back in a few weeks or months with the same situation. Many of them, especially heroin users, would discharge AMA long before their treatment was completed. What was wrong with these people?
I stayed on the faculty of George Washington University for 5 years after completing my residency, teaching students, residents, and fellows and eventually directing the outpatient clinic for our department. This was a tremendous experience, as I made the transition from student to resident to attending physician, practicing alongside my mentors. I knew, though, that I wanted to leave the “big city” and settle in an area with mountains, skiing, hiking, and other outdoor activities.
I moved to Kalispell, Montana in 1993 to join a group practice of 4 other physicians. This was before the “opioid crisis” and also before the hospitalist system was developed – we “did it all” in those days – inpatient, outpatient, ICU, nursing facilities, ER, dialysis unit, etc. This was an exhilarating but challenging time, with on-call duties requiring frequent nighttime trips to the ER or hospital. Most of our patients were geriatric with multiple and complex medical issues – but we did not deal with addictions in any substantive fashion.
Getting Started in Addiction Medicine
I started working part time at Pathways, a combined psychiatric and chemical dependency facility, in 1994 – I needed some extra work at that time, and they needed some additional help. I was working with Dr. Richard Wise (now retired) – he taught me the basics of Addiction Medicine. I learned the 6 ASAM dimensions, memorized the DSM-4 criteria (back then we used the terms “Substance Abuse” and “Substance Dependence” rather than the current “Substance Use Disorder.”) We had separate inpatient units for adults and adolescents, and we had programs of 21 to 28 days, taking on all types of SUDs. Our primary focus was on alcohol, but we also admitted many patients with opioid or methamphetamine addictions.
We treated complex withdrawal syndromes and worked with the counselors and psychiatrists while patients made their way through the program. They subsequently “graduated,” and after that we did not usually have much contact or follow up – this was the standard of care at the time, which in many ways has not changed since then.
We started seeing more patients addicted to opioids as the crisis was developing.
I remember going to an ASAM course in Pain and Addiction where we learned about pseudo-addiction and were told that patients being treated with opioids "only for pain" would be unlikely to become addicted (which turned out to be false). The teaching at that time was, if the patient still had pain with non-opioid treatment, then a regimen of a long-acting opioid with short-acting “rescue” opioids should be started. If the patient still had pain, the dose should be increased. There was no maximum dose.
For years we treated opioid withdrawal at Pathways symptomatically, sometimes with a short opioid taper. Few patients made it through the full program, and most all of those who left early relapsed immediately. Methadone, an effective treatment modality developed in the 1960s, was not available in Montana, and we had few tools to help patients with opioid addictions.
Early Experiences with Suboxone
Buprenorphine – initially only available as the “stop sign” orange tablet Suboxone – was approved by the FDA in October of 2002. I was able to treat my first patient in March of 2003 (it was the earliest our pharmacist could obtain it). He started on buprenorphine in my office, as was the original recommendation, and after a rocky period of stabilization, did extremely well. He was followed by others who showed remarkable improvement even after a short period of treatment. This was a revolution for us who were trying to treat OUD – we finally had an effective treatment!
We started expanding our patient panels. We were initially limited to 30 patients, which I accumulated quickly. I saw them as outpatients along with my regular Internal Medicine/Geriatric population. When the limit was increased to 100, I kept my panel at 30, since I didn’t have time to take on additional patients.
We worked at providing expanded access to MOUD in the community – recruiting other physicians to take on patients and admitting many patients to Pathways for a short induction. After stabilization we could transfer the patients to other physicians in the area who felt comfortable continuing the treatment. While this allowed us to treat many more patients, as the opioid crisis developed, demand increased more rapidly than we could accommodate.
In 2009, I had an opportunity to work for VA Montana – they needed to start a buprenorphine program for veterans in Montana, and at the time did not have anyone on their staff who was prescribing it. I closed my internal medicine practice, transferred my patients to other physicians in town, and worked half time at the VA outpatient clinic and half time at Pathways. At VA Montana, we developed a program for treating veterans throughout the state with buprenorphine. It was a cooperative effort with the pharmacy, Behavioral Health department, medical and nursing providers, and the various outpatient clinics throughout the state. We were one of the first users of telemedicine to provide buprenorphine treatment. While initially our inductions were done mostly at one of the outpatient clinics, we were early adopters of home inductions. Eventually I was covering the entire state, being the only physician on staff with a buprenorphine waiver. We had over a dozen outpatient clinics (CBOCs or Community Based Outpatient Clinics), and all the patients I saw were at a CBOC using the secure equipment and data connections.
I was also able to consult on patients with other Substance Use Disorders – such as alcohol, gambling, benzodiazepines, or even gabapentin. Between my work at the VA and Pathways, I was able to work with many different SUDs in both inpatient and outpatient settings.
Our program at VA Montana was successful, providing an example for other VA systems for how to initiate an MOUD program using telemedicine. I retired from the VA until 2016 and turned the program over to other physicians (by that time there were several with waivers). By that time, we had over 80 patients in the program.
Moving Into Methadone for Treating OUDs
Methadone for treating OUD can only be performed at an Opioid Treatment Program (OTP), an entity that is licensed and certified by SAMHSA and the DEA. There were no OTPs in Montana until 2000, when the first one was opened in Missoula by a company called Community Medical Services, which is headquartered in Scottsdale, AZ. CMS was started over 30 years ago by a Family Medicine physician, George Stavros, who perceived a need for treatment of heroin users in the Phoenix area. Over the years, it became a family business with a half dozen clinics in AZ. They decided to branch out to Montana since it was an underserved area.
The second Montana clinic opened in Kalispell in 2011. At that time, I was still working for the VA half time in the mornings and Pathways in the afternoons. I was excited about learning about methadone treatment, so I signed up work at the OTP as well. Since most OTPs open early (in order to allow patients to get their medication and then go to work), I was able to see patients at CMS from 6-8 AM, then the VA from 8-12, then Pathways in the afternoon. Fortunately, all these facilities were within a short drive from one another.
I learned most of what I know about MOUD with methadone from Rick Christensen, PA-C, who had been deeply involved in methadone treatment for 30 years and was serving as the Chief Medical Officer for CMS. I went to AZ and spent a few days with him, seeing patients together, and then we were frequently in phone contact after I came back to Montana. Rick taught me a tremendous amount, and I will always be thankful to him for his depth of knowledge, patience, and commitment to his patients.
I found that by offering methadone as well as buprenorphine, we were able to successfully treat more patients. While buprenorphine works well for many, it is not effective for a lot of the more severely affected patients. I felt like when I was able to use methadone as well as other modalities for treating addiction that I was finally getting a full exposure to the field of Addiction Medicine.
Methadone Treatment in the Medical Community
Methadone has been used for treating OUD for over 50 years, and it is a well-established standard of care with thousands of peer-reviewed articles and extensive data concerning its effectiveness. However, methadone treatment for OUD was new to Montana. Since medical providers get no exposure to methadone use for OUDs in their training (which unfortunately is still the case today), methadone for OUD is a new concept to them. They are already familiar with methadone as used for the treatment of pain, but when treating OUD, the doses and administration is different, and many assume that we are not appropriately treating our patients. The process of educating physicians, APPs, nurses, patients, and the lay public about MOUD with methadone is long, incremental – and continuing. We have made tremendous progress over the last 10 years here in Kalispell, but we continue to fight against false impressions, misinformation, and sometimes willful ignorance and prejudice.
Moving Further into Addiction Medicine
CMS opened a total of 4 clinics in Montana over the next few years, and then 2 in ND and one in AK. George Stavros retired, and his son Nick Stavros took over running the business. Nick is not a physician, but is an army veteran, businessman, and someone with a deep personal commitment to expanding access to MOUD and helping save lives and give people back their lives that have been devastated by OUD. He worked towards standardizing policies and procedures and hiring a staff of talented and dedicated professionals (COO, CFO, CIO, QM Manager, HR Manager, Billing Manager, etc.). He was able to expand the business and by the end of 2020 CMS had over 40 clinics operating in 9 states, with a total treatment population of over 16,000 patients.
Rick Christensen retired in 2107 and I was fortunate to be offered the position of Chief Medical Officer. Since we cover so many states, we are used to using video conferencing and computer technology, so I was able to serve as the CMO and stay in Kalispell. I see patients at the Kalispell OTP as well as at other OTPs via telehealth, and also have numerous administrative duties as Chief Medical Officer for CMS. In this capacity I am in a position to set policies, deliver lectures and grand rounds, teach ASAM courses, supervise other physicians and APPs, and participate in the operational functions as far as they affect medical care.
Going forward I hope to be able to continue my work as CMO, as well as helping develop more capability in Addiction Medicine at Logan Health in Kalispell. I feel honored to be able to serve our patients and continue our mission, vision, and values.
- Robert Sherrick, MD, FASAM, President