Tackling the opioid crisis in a rural community
One death a day in Maine is caused by an opioid overdose. Bridgton family practice physician Craig Smith, M.D., a member of the Bridgton Hospital medical staff, is on the front line in the battle against the crisis that is harming people of all ages and all walks of life – not just in Maine but in communities large and small across the country.
A Bridgton substance abuse counselor, Catherine Bell, nearly a decade ago approached Smith about prescribing Suboxone, an opiate withdrawal medication, to treat patients with opioid use disorder (OUD). If he did, she would provide counseling to those patients.
Smith was reluctant to do so until he realized the OUD crisis had reached his tiny community of 5,000 residents and could not be ignored. Four of his patients died of overdoses in one month, including a 34-year-old mom of two small children.
“I was totally unaware they were using it,” he says. “It was a wakeup call that we had an enormous problem and I was sticking my head in the sand.”
With the support of Bridgton Hospital CEO David Frum, Smith partnered with Bell, director of Crooked River Counseling, to set up medication-assisted treatment – or MAT – to treat OUD in his primary care practice. MAT pairs nondrug therapies, such as counseling or cognitive behavioral therapy, with a Food and Drug Administration-approved medication, like Suboxone, to treat patients suffering from OUD.
Before the program began in 2009, the only other OUD treatment option was a methadone clinic, which was an hour and 45 minute drive away in Portland.
“We got overwhelming support from the hospital,” says Smith. “I was amazed when David and our leadership said, ‘if you are telling us this is a significant problem in our community, we will standby you and do whatever we need to do to care for these patients.’”
As part of the program, the 25-bed critical access hospital provides comprehensive maternity care to women with OUD during their pregnancy.
Frum says, “It has been a joy as a CEO to see our medical staff identify a major problem – and here in western Maine it is a significant problem – and figure out a creative way to address it.”
The practitioners who are implementing MAT view it as the standard of care for treating OUD. They say it saves lives while increasing the chances patients remain in treatment and learn the skills necessary for long-term recovery.
Smith, three other physicians – including his wife, Jennifer Smith, M.D., also a member of the hospital’s medical staff – and two nurse practitioners, prescribe the medication. Crooked River Counseling provides intensive outpatient counseling and group therapy for the patients. About 200 patients are enrolled in the program.
Appointments at Smith’s North Bridgton Family Practice are coordinated with patients’ counseling sessions at Crooked River Counseling, just five miles down the road. Crooked River Counseling is located on the hospital’s campus, which the partners say leads to better coordination of the treatment and services.
“That interconnectedness of services has served us well in putting these pieces together so it is holistically balanced for our patients,” Frum says.
“We have constant communication with our providers and we talk about cases all the time,” Bell says. “We tell our clients that the doctor and I are going to do that so we can give you the best possible care.”
The program seeks to remove the stigma associated with the disorder.
“Often it is the first time they really tell somebody how severe their use is,” Bell says. “It takes courage to walk through that door.”
Smith talks to patients about the stigma. “I tell them that I can’t undo the prejudices some people may have about you, but you can hold your head high and know you are doing the right thing.”
Bell notes that more than 90% of her clients “started out with a legitimate medical need to take a prescription,” but at some point lost control. “Recovery is about rebuilding relationships and being a productive member of the community and society,” she says. “They start building recovery-based relationships the moment they walk through our doors.”
The program supports pregnant OUD mothers in a net of integrated care that keeps their babies close to home. Despite its modest size, Bridgton Hospital six years ago began delivering babies born to local mothers on Suboxone.
Before the hospital adopted the maternity care program, Jennifer Smith observes that “our obstetric nurses were caring for these women their entire pregnancy, then sending them to larger hospitals to deliver their babies. All of our [obstetrics] nurses are now trained in Neonatal Abstinence Syndrome scoring, which is a withdrawal scoring system for newborns exposed to opioids or [Suboxone].”
She says “Bridgton Hospital is one of only a few rural hospitals in the state providing this level of care for opioid-dependent mothers and I am proud to be a part of it.”
Craig Smith adds: “We are a community hospital and I wasn’t sure how that would go over. But we got tremendous support from the hospital and multiple departments to make sure we could take care of moms who needed to be here and care for their babies.”
Smith has watched patients turn their lives around, go back to work, reconnect with their families and dramatically reduce their risk of dying from an overdose.
“We can’t do it alone,” he says. “The police can’t do it alone. But we can come together as a team when the community says this is a problem and we need to fix it.”
Too few treatment facilities, qualified personnel and limited insurance coverage are barriers to widespread adoption of MAT programs like the model implemented in Bridgton.
But hospital CEO Frum said his small rural community’s experience in tackling the OUD epidemic demonstrates that where there is the will there is a way to overcome those barriers.
“There are barriers, but that is what led us to create this integrated, creative local solution that has saved people,” he says. “They otherwise would have been lost and that is why we do it.”