Transcription of Dr. Mary Dowd for the show Impacted by Addiction #283
Speaker 1: You ae listening to Love Maine Radio, hosted by Dr. Lisa Belisle, recorded at the studios of Maine Magazine in Portland. Dr. Lisa Belisle is a writer and physician who practices family medicine and acupuncture in Brunswick, Maine. Show summaries are available at lovemaineradio.com. Here are some highlights from this week’s program.
Dr. Mary Dowd: Not until I started working at the jail I didn’t have any sense how much addiction was affecting our population, and I started working at the jail in maybe 2008, I can’t remember, maybe 2005. I realized everybody was there, not everybody, maybe 90%, because of addiction, because of something crazy they had done while they were intoxicated or high or something crazy they had done in order to get money to get intoxicated or high.
Kate Bowley: He’s like, oh, yeah, he filled this prescription this week. I saw him. What a gift from the universe that that information was revealed to me. That started off a series of events where I discovered just how terrible it was. He actually had returned to work that day and came home and was completely high out of his mind, I could tell, I could see it.
Lisa Belisle: This is Dr. Lisa Belisle, and you are listening to Love Maine Radio, show number 283, Impacted by Addiction. Airing for the first time on Sunday, February 19, 2017. Addiction to both recreational and prescribed substances has become an epidemic in our state. We are all impacted. Today we speak with family physician Dr. Mary Dowd, medical director of the detoxification program at Milestone in Portland, about her experience treating addiction. We also speak with Kate Bowley, whose former husband died of an overdose after a work-related injury began his three year struggle with this problem. We know that this is a difficult topic and one that must be approached with care, so we appreciate your joining us.
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Lisa Belisle: It’s my great pleasure to interview today an individual I’ve really known for decades. This is Dr. Mary Dowd, who is formerly a family doctor and is now a medical director of the detoxification program at Milestone Foundation in Portland. Dr. Dowd also works for Catholic Charities in its substance use treatment program and at Discovery House in South Portland. Discovery house is a methadone clinic. It’s nice to have you in today.
Dr. Mary Dowd: Thank you Lisa. It’s nice to be here.
Lisa Belisle: You are in interesting person for me because I think it’s one of these situations where you can know someone for a really long time, and then, really, they continue to evolve as a person and you think, wow, I never knew that about them. I didn’t realize these were interests that she had. You and I both have spent time working in the Cumberland County Jail.
Dr. Mary Dowd: True.
Lisa Belisle: You have also, I believe, you were at, before when it was Pineland, when we were caring still for patients that had developmental disabilities and severe delays. I think you were the medical director over there.
Dr. Mary Dowd: I was, yes. When Pineland closed, I ran a clinic for them for many years.
Lisa Belisle: On top of that now you’re doing the work that you’re doing with Catholic Charities and also Discovery House. You’re a woman who looks for a challenge.
Dr. Mary Dowd: I like to do a lot of different things. Really, I go to what I like. I’m not looking for challenges. I’m just following what I enjoy.
Lisa Belisle: Tell me what is it about the work that you are doing now that you enjoy? This is difficult work.
Dr. Mary Dowd: I think what makes it so difficult is that there are so few services you can offer a patient with an addiction in Maine. Most of the patients, especially the heroin addicts, have lost everything. They’ve lost their homes, they’ve lost their cars, they’ve lost their families. Their families don’t want anything to do with them anymore. They can’t work so they’ve lost everything, and yet they don’t have insurance or any way to pay for services. We see that over and over again, and that’s what makes it so difficult.
Lisa Belisle: It’s clear that this is a challenge, but you told me that you go towards work that you enjoy. What does one enjoy about this type of thing?
Dr. Mary Dowd: I really enjoy the patients. I find them to be full of life. They’re survivors. They’re incredibly resilient. They survive against enormous odds. Things that you or I would not be able to fathom, like being homeless for years on end, not knowing where your next meal is coming from. No money. They make it. They make it through these days. They have a lot of creativity.
Lisa Belisle: You worked as a family doctor for quite a while in Yarmouth, a suburb where you and I both live, and I wonder if you ever had any intersections with the patients that you are dealing with now when you were in private practice?
Dr. Mary Dowd: I remember having one or two patients who had addiction problems, opiate addiction problems in private practice. I had a few alcoholics, but I’m sure I probably had many more alcoholics I didn’t know about.
Lisa Belisle: The reason I ask this question is, I remember early on in private practice myself that there were, I had the same kinds of numbers you’re describing, and now, being employed by Central Maine Medical Center but working in private practice, I have a fair number of patients who are coming through our doors who are being impacted either themselves or family situations by addiction.
Dr. Mary Dowd: Yeah. It’s huge.
Lisa Belisle: Did you have a sense that this was coming?
Dr. Mary Dowd: Not until I started working at the jail, I didn’t have any sense how much addiction was affecting our population. Then I started working at the jail in maybe 2008, I can’t remember. Maybe 2005. I realized everybody was there, not everybody, maybe 90%, because of addiction. Because of something crazy they had done while intoxicated or high, or something crazy they had done in order to get money to get intoxicated or high.
Lisa Belisle: Right now we don’t have a lot of great methods of actually helping people to get away from addiction and stay away from addiction.
Dr. Mary Dowd: We do. We don’t have the money to make it happen. It’s just not funded.
Lisa Belisle: Talk to me about this. If you have a patient that comes to see you at Catholic Charities or at the Discovery House, run me through what would be a typical scenario. How would you interview, how would you treat them?
Dr. Mary Dowd: Those are the lucky patients. Those are the ones that have insurance and can get treatment. They come and they do an intake with one of the counselors there to make sure they are appropriate for services. They see me. I do a history and physical and decide whether they are a candidate for suboxone or possibly vivitrol and then I start treating them. Those people have insurance, they often have family support. They do well. I’d say 90% of my patients who have insurance can do well either with suboxone or vivitrol or methadone.
Lisa Belisle: What is usually the lead time as far as coming in for treatment? How long does it usually take before someone hits that rock bottom place that you describe?
Dr. Mary Dowd: If they have insurance they can get into treatment pretty quickly. It’s the people that don’t have insurance that really can’t get anything. Once in a while there’s a scholarship spot in one of the programs. I think Grace Street has them, Catholic Charities has them. Other than that they can’t get anything.
Lisa Belisle: Insurance usually will cover treatment?
Dr. Mary Dowd: Yeah, insurance will cover treatment. MaineCare will cover treatment and other insurances. One thing that insurance doesn’t cover and that’s why we lost a lot of services in Maine was, private insurances decided a few years ago they wouldn’t cover detox or opiates anymore, the theory being that it’s not life threatening so people don’t need to be in the hospital for it. They don’t have any other recourse. They don’t have family doctors that can see them through it. They don’t have homes they can go to and be sick in and their mother will take care of them. They can’t detox on the streets.
Lisa Belisle: Describe that clinically. What does it look like when someone is trying to detox from opiates?
Dr. Mary Dowd: They’re very sick. It’s like the worst flu you ever had. Sweats, chills, nausea, vomiting, diarrhea, muscle aches, restlessness, they want to jump out of their skin, incredibly anxious. They know they can fix it. They can get something that will make it all go away.
Lisa Belisle: How long does it usually take to go through that?
Dr. Mary Dowd: It takes maybe five to seven days for the physical symptoms to go away, but what doesn’t go away is the craving for opiates. That can be lifelong.
Lisa Belisle: What are the differences between the different treatment options that you’ve just talked about?
Dr. Mary Dowd: Methadone, you have to go to a federally licensed clinic every day and get a dose of methadone. That has some obstacles to treatment, especially people can’t get there or they have jobs that conflict with getting there. Suboxone you can get at a doctor’s office, you can get it by prescription. It can be called in. None of those things are true for methadone treatment for opiates. Vivitrol or a naltrexone, which is the oral form of vivitrol, is a monthly shot or a daily pill.
Lisa Belisle: I know that in our group of physician colleagues in the state, more and more are getting licensed to offer suboxone in their clinics, but we still don’t have enough spots because you’re only allowed to prescribe to so many people. Is that true?
Dr. Mary Dowd: It was 30 the first year, then 100, but now it’s gone up to 275 if you’ve been in practice, I think for maybe a year.
Lisa Belisle: How is it that some doctors will decide to get a suboxone prescribing credential and other doctors won’t?
Dr. Mary Dowd: I think the doctors who see opiate addicts in their practice, maybe they’re family doctors and maybe one of the sons or daughters of a family that they’re taking care of has a problem, I think that would be an inspiration to get a license so you could take care of them. Other than that I think that doctors feel like it’s too much to do in the office. You do need a lot of structure to do a good job at it. You have to know they’re going to counseling. That’s really important. Just a pill or a shot is not going to change the way people behave. It’s very important to treat cravings, but they really need help changing behaviors as well. You need to be able to be set up to do urine dips and have a good lab that’ll interpret urine results for you. It’s not all that simple in terms of the practical aspects of it.
Lisa Belisle: I guess I’m wondering, backing up to why you’re choosing to do this, you originally came from Massachusetts, and you didn’t jump immediately into being a doctor. You had another life before this.
Dr. Mary Dowd: Right. I was a medievalist. I was in medieval studies. Yeah.
Lisa Belisle: You were a medievalist and I know you have children. You’re married to a man who is a writer, I believe.
Dr. Mary Dowd: Yeah. A teacher.
Lisa Belisle: That’s a pretty, it seems like it would be a little bit of a less messy life to be able to work in literature, but you decided to make this strong right turn into medicine. What prompted you to do that?
Dr. Mary Dowd: Having a child prompted me to do that. Not that I enjoyed labor and delivery, but it made me, it woke me up to our vulnerability and fragility, so that’s why I decided to change what I was doing.
Lisa Belisle: What was that like to try to go through an entirely new training process and take on an entirely new challenge and also be having a child around while you’re doing it?
Dr. Mary Dowd: It was a lot of work, but my husband helped me a lot, and it took a long time.
Lisa Belisle: Once you got out, you decided to set up private practice at a time when a lot of doctors were being absorbed into bigger systems. You set out and you had your own shingle in Yarmouth for a number of years.
Dr. Mary Dowd: Yeah.
Lisa Belisle: What was the decision making there?
Dr. Mary Dowd: I always liked, I think because had four kids, I always liked just being able to do what I needed to do both at home and at work. It was better for me to be my own boss.
Lisa Belisle: I had asked you a question earlier about the lead time on people who are going through treatment. You said that people can get into treatment pretty quickly. What I wonder about is what’s the lead time in a life? How long does it usually take someone, and maybe this is a question I can answer or not, before they finally get to the place that they realize that there’s nothing left. There’s no other option but to go into treatment?
Dr. Mary Dowd: Let me just back up a little bit on that question. People who have insurance and support can get into treatment pretty quickly. The patients that I see at Milestone, it’s years, years, and years before they can get any treatment. As far as lead time overall on addicts getting into treatment, it’s usually about 20 years between the time an alcoholic realizes he has a problem with alcohol and he seeks treatment. With an opiate addict, that time’s getting shorter. I think it was thought to be maybe 7-10 years. I’d say people are realizing now probably earlier on that they need help.
Lisa Belisle: This means that if you’ve got 7-10 years and you’re treating people of all ages, but they tend to be on the younger side.
Dr. Mary Dowd: The opiate addicts, yeah, are younger.
Lisa Belisle: This means they’re starting really young.
Dr. Mary Dowd: Yeah. They’re starting 18, 19, 20, earlier. Some of the patients we see at Milestone start when they’re 13, 14 trying opiates. They come from generations of alcohol and opiate abuse. It’s what their families do, it’s what they know. In other instances, people get it for twisted knee, for tooth extractions, for pelvic pain, they get opiates and then they like the way they make them feel and they keep using them.
Lisa Belisle: One of the things I noticed 20 years ago when I was going through training was that they had made pain one of the vital signs.
Dr. Mary Dowd: Oh yeah.
Lisa Belisle: We have since learned that there was a pharmaceutical push behind that because the idea was, we treat people with narcotics if they have pain. I felt really conflicted about that at the time. It really worried me, but there was a lot of push, a lot of peer pressure almost, an institutional pressure to provide narcotics for people. Now we’re in the place where we’ve done that. Doctors are now being blamed for a lot of the opiate abuse. What is your, how did you feel about this when we first were being told pain was a vital sign, and we needed to give more medication?
Dr. Mary Dowd: I think we were already doing addictions when that happened, when JCAHO made that push. I think the state medical boards were also in on that. They were feeling that people should be using more opiates. I was dismayed by it.
Lisa Belisle: How did you deal with it in your own practice?
Dr. Mary Dowd: I think at that time I was just doing addiction anyway. I think in my own practice when I was doing private practice I had very few patients who were on chronic opiates. I had maybe two or three. At that time, it was still felt opiates are for cancer pain, extreme end of life pain, and people were doing all right. There are other ways to treat pain. It turns out that something that I don’t think most doctors realized is opiates in the long run make you more sensitive to pain. Often times when people get off opiates, they may have less pain and they certainly have a better quality of life. They can do more.
Lisa Belisle: Do you think that doctors and other health care providers have some responsibility for this what we’re now calling a crisis?
Dr. Mary Dowd: I would pin a lot of the problem on the big pharmaceutical companies who made the push to make this seem like a really great idea.
Lisa Belisle: Do you think that the pharmaceutical companies are now taking responsibility?
Dr. Mary Dowd: No.
Lisa Belisle: Would you like them to?
Dr. Mary Dowd: Yes, I would. I’d like there to be some class action suites. I’d like them to fund addiction treatment.
Lisa Belisle: Isn’t that interesting that we’ve now been through tobacco money being offered back to the states because we came to realize that this was a very damaging product that, marketed successfully, was going to lead to things like illness and death, and now here’s another product that we have yet to understand how to use fully, and we haven’t gotten to the place where anybody’s helping to pay to clean up the mess.
Dr. Mary Dowd: Right. It’s destroying people’s lives and their ability to work, their ability to support themselves, it’s destroying their families. Much more than chronic cigarette use does. People still work, they have a full life. Doesn’t destroy all their relationships.
Lisa Belisle: What is it specifically about opiates that makes them so destructive?
Dr. Mary Dowd: All drugs of abuse take over the reward pathways of your brain, but opiates seem to do it best. They seem to really get a grip on you, and I think they’re so rewarding and then after a little while they’re not rewarding at all, people keep using to try and feel the pleasure they felt it begin with or try to medicate the anxiety and the pain they were having to begin with while they turned to them in the first place.
After a not too long period of time, some people get addicted within a month or two, they’re taking them because they feel bad, because they’re withdrawing all the time and they’re taking them because their own hormones that the drugs increase have really been depleted, those people are not enjoying anything. They’re not getting pleasure out of any aspect of their life. It’s only possible taking the drug, and then even pretty soon even the drug’s not doing it either, and they’re just taking to not be in withdrawal, so they can function. They’re taking it to feel normal so they can get out of bed and go and do something.
Lisa Belisle: How do people get to the place where they feel such despair that they decide that they want to take the ultimate path and not live anymore?
Dr. Mary Dowd: When something that seems extraneous like a drink or a drug takes control of your life and you feel like you have no control over it, you can’t stop craving alcohol, you can’t stop craving cocaine or opiates, you feel, even though you try over and over again, like a total failure, like you have no hope. That’s how you get to that place.
Lisa Belisle: There are a lot of situations where we call something an overdoes, but maybe we think of it more as an accidental overdose. That maybe there’s a question. Maybe it’s not so accidental after all? Have you witnessed any of these or been party to any of these?
Dr. Mary Dowd: My patients will say to me, you have a choice every day to seek your drug and take it, and you’re hoping you’ll overdose or if you don’t overdose you feel like the walking dead.
Lisa Belisle: Then the third choice is to become a patient and if you can, if you can actually get into a program.
Dr. Mary Dowd: If you can get into a program.
Lisa Belisle: If you have insurance. It sounds like access right now isn’t limited so much by the number of providers that we have, at least not in this part of the state. It’s more limited by the ability to pay for the services themselves.
Dr. Mary Dowd: Yes. It’s very limited by the ability to pay for the services. The ancillary services like counseling. People need sober houses. Most sober houses don’t allow patients to be on suboxone. I think the number throughout the state is there’s 25,000-35,000 of people who need treatment aren’t getting it. I think there’s about 10,000 in treatment.
Lisa Belisle: When I think about all the young people in my practice that have enough issues just being young people in the world.
Dr. Mary Dowd: Right.
Lisa Belisle: The number of them that have drug addiction issues. I don’t have a lot of people in my practice who are in this case, but it seems as if their future has almost been cut short before it even began. I think about my own children. I think about what it would be like to raise a child and get them to a place where you finally thought they were going to go out into the world and make good choices and participate in society and what that must feel like for the parents who didn’t realize they were going in order to be working with an addict.
Dr. Mary Dowd: Yeah.
Lisa Belisle: Does this ever cross your mind as a mother of four children?
Dr. Mary Dowd: Oh sure. Yeah. It’s heartbreaking to have a child who’s an addict and you can’t really communicate with them. Some of my kids had trouble with alcohol and marijuana in high school. It’s hard.
Lisa Belisle: This leads to a question that I am still not sure I understand the answer to myself. Recently we have passed legislation to legalize marijuana.
Dr. Mary Dowd: You would ask me that.
Lisa Belisle: I’m actually interested in what you have to say because I know how I voted and I know the argument that I had with my 23 year old son about it and I’m not going to make a commitment one way or the other as to which direction I went in, but I also know I had a conversation with a fellow physician who very firmly told me that the was going to vote yes and had really good reasons for it. I’m not sure any of us really knows how to address this. This is purely an opinion coming from you.
Dr. Mary Dowd: Yeah. I really have two opinions about it as probably everybody does. I think it’s a much safer drug than alcohol. People who are out drinking are out fighting, driving, getting into domestic violence situations. On the one hand, marijuana is a much safer drug than alcohol, and alcohol’s everywhere.
On the other hand, I think that for young people who start using marijuana really early and if it’s legal, people are going in order to start using it earlier and earlier, it changes the way their brain works. Their brains aren’t mature. Teenage brains aren’t mature until they’re 25 or 27. If you’re using marijuana pretty regularly when you’re 13, 14, 15, it’s going to change things for your brain. It’s not going to be a good thing. People have more difficulties with focusing for chronic use, IQ drops about eight points, and that’s big for IQ. The difference between cognitive disability and normal intelligence is only 10 points. The other thing is it saps people’s motivation to keep moving on forward with their lives, with their goals. I think people need that to feel good about themselves.
Lisa Belisle: Do you consider it a gateway drug?
Dr. Mary Dowd: Yeah, to the same extent that alcohol is. Yeah. I think other drugs are everywhere. You don’t need to have a gateway to get opiates now. You don’t need a gateway to get anything. You can buy K2 and spice legally in head shops. Those are so much more destructive than marijuana.
Lisa Belisle: You’ve become a bit of an advocate for treatment. You’ve taken on the responsibility of writing op-eds for the local paper. You’ve spoken about this whenever anybody will listen, and yet you describe yourself as an elderly physician. You describe yourself that way. I’m not describing you that way. This is a big social cause to take on this far along in your career. Why are you doing this?
Dr. Mary Dowd: I really love the work. I love working with addicts. I love my patients. I think it’s very rewarding to be able to help somebody completely transform their lives. It is a complete transformation. Somebody going from living on the streets and having no connection with family, having their kids taken away, having their parents write them off, not being able to work, and then they get on treatment and it’s night and day. It’s very rewarding in that sense, if you can get people into treatment and if you can’t. I really love the work I do at Milestone. I just feel connecting with people and kindness and respect for people who have known so little kindness and respect is helpful to them.
Lisa Belisle: I appreciate your taking time out of your very busy schedule to come in and have a conversation with me today. I think it can be very difficult to be in health care, and it’s nice to talk to somebody who’s probably in one of the more difficult fields of health care who feels rewarded by it. I encourage you to keep doing what you’re doing because we need people like you.
Dr. Mary Dowd: Thank you, Lisa.
Lisa Belisle: I’ve been speaking with Dr. Mary Dowd, who is a family doctor and medical director of the detoxification program at the Milestone Foundation in Portland. Also, working for the Catholic Charities substance use treatment program and at Discovery House in South Portland methadone clinic. Thanks so much for coming in today.
Dr. Mary Dowd: Thanks so much, Lisa, thanks for having me.