When The New York Times, the Washington Post and news agencies across Maine have needed to understand the opioid epidemic and the policies emerging in response to it, they have often turned to a specialist in addiction medicine working in Portland, Dr. Mark Publicker. Unafraid to criticize redundant task forces and barriers to treatment, his advocacy led to better policy and saved lives, said those who learned of his impending retirement online.
As the pandemic complicates the more hidden challenge of addiction, Publicker, 70, will retire from his private practice at the end of the year, after 40 years in medicine. He recently spoke about his career and the changing upheavals of the opioid crisis. Today, synthetic opioids, including fentanyl, are the most common drugs involved in drug overdose deaths in the United States.
While people in Maine may have heard of drug dealers mixing deadly fentanyl with heroin, the public may not know that dealers are also increasingly mixing fentanyl with cocaine and fentanyl with methamphetamine — and that methamphetamine use is rising, said Publicker, who is the past president of the Northern New England Society of Addiction Medicine. Given fentanyl’s potency, the drug combinations may be contributing to Maine’s increasing number of overdoses.
Indeed, deaths involving cocaine and methamphetamine have increased in the past few years, according to state figures. The vast majority of those deaths have also involved opioids such as fentanyl.
It complicates the crisis, Publicker said. It also makes expanding access to treatment and educating medical providers about addiction as important as it’s ever been, said Publicker, who is also a fellow of the American Society of Addiction Medicine and a diplomate of the American Board of Addiction Medicine.
The following is a transcript of a telephone interview with Publicker, of Gorham, on Monday, Oct. 5, which has been edited for length and clarity.
Erin Rhoda, BDN: I remember being in a community meeting several years ago. Someone had a question relating to addiction treatment, and someone else spoke up and said, “Well, Maine has a top expert in that. Talk to Dr. Mark Publicker.” How did you come to be an expert in addiction medicine?
Mark Publicker: I started my career as a family physician in a nonprofit HMO in Pittsburgh. It was in a community of steelworkers, and they had a whole range of medical signs and symptoms. They had evidence of liver disease. They had blood pressure that was hard to control, gout. And my thinking was it was evidence of industrial poisoning that nobody else had identified. I was quite excited by this. And somebody loaned me a book about alcoholism in doctors. I woke up after reading it, slapped my forehead and said, “Oh my God, half my patients are alcoholic. Now what do I do?” It just so happened the doctor who wrote the book was one of the country’s first addiction psychiatrists, and he was practicing in Pittsburgh. So I went to see him.
He told me I should go to [Alcoholics Anonymous] meetings, which was hard for me being a non-alcoholic doctor. I went, and I started to recognize and understand more about alcoholism. I started to talk with my patients about my concerns and encourage them to go to meetings themselves, and initially I would go to meetings with them, which is something I wouldn’t recommend doctors to do now. About six months later I started to get “God bless you” letters from patients and their families. I went, “Wow, diabetics never sent you ‘God bless you’ letters.”
That was that. I began to study, got involved in the country’s foremost addiction medicine society, developed an addiction treatment program for this HMO, got certified in addiction medicine and was recruited from Pittsburgh to Washington, D.C., to develop Kaiser Permanente’s addiction treatment program. I was there for 10 years. Mercy Hospital recruited me here.
Even though I’m in Portland, the vast majority of my patients are from midcoast or Down East, and I can name every single little town on the midcoast where I have a patient coming from. I have got some people coming as far away as Machias. They’re lobstermen, and they’re oystermen, and they’re blood wormers, clammers. And then land-based patients, roof and carpentry.
My patients’ recovery just belies with what people’s beliefs are about people with addictive histories. These guys go out in the middle of the Gulf in January to fish. If the lobsters aren’t there, they’re roofing. And if they’re not roofing, they’re doing carpentry. If they’re not doing carpentry, they’re doing hardscaping.
We’ve [my wife and I] lived in a lot of places — we figure 10 places in our marriage. I’ve never seen a work ethic like this. I have these frankly wonderful patients, and it’s hard now for me to be starting this process of saying goodbye to them.
ER: As a doctor at a family medicine practice in Pittsburgh in the 1980s, how did addiction manifest itself then compared with today?
MP: What happened in Pittsburgh is instructive because the steel industry collapsed, and, along with that, communities collapsed, and drugs came in. When communities and cultures are wounded, drugs are more likely to come in.
What we’ve seen is a trend from primarily alcohol dependence in the country, to cocaine and prescription opiates, followed by intravenous heroin, supplanted by intravenous fentanyl.
Now the scary thing that we’re facing is increases in combinations of fentanyl with cocaine, and fentanyl with methamphetamine. What the cartels are doing is combining fentanyl with cocaine. People may not be aware that they’re using fentanyl, which may be one of the reasons that can account for the increase in overdose death rate over the last year or so.
In this state we’ve been largely spared methamphetamine. But no longer. Over the last year and a half it’s flooded into the state. The drug problem is quite severe and not showing any signs of slowing. In the midst of all of this, hidden, is high rates of alcohol dependence. Attention to it has been orphaned by the prescription opiate epidemic. It definitely kills more people per year than opiates do.
ER: I hadn’t heard about the increased mix of fentanyl and methamphetamine.
MP: It’s interesting because at noontime today we just had a presentation that was given by Millennium labs, which is one of these reference labs. The September 18 issue of JAMA [the Journal of the American Medical Association] published the results of their surveys of their lab results, from not only Maine but across the country. What they’re showing are like 300 percent increases and 400 percent increases in drug screens positive for fentanyl plus methamphetamine or fentanyl plus cocaine.
The study that was done compared pre-COVID and post-COVID. So post COVID is when these rates of co-occurring drug use have exploded. It’s likely stress, unemployment, the circumstances that tend to increase drug use.
ER: When you first started treating people for their alcohol use disorder, it sounds like you weren’t formally taught how to talk to and treat people with alcoholism, and later sought out training yourself.
MP: To this day there is little to no formal education of medical personnel on addiction. It’s rare to find any real coursework in medical school. Residencies have very little, and medical schools have been resistant to introducing significant curriculum to address the deficits. If you think about what are the major causes of preventable morbidity and mortality, they’re addictions. It’s anything from nicotine to alcohol to opiates and benzos.
The most interesting thing I’m doing these days is participating in this project with the Lunder-Dineen foundation. [It] is an alliance to teach Maine health professionals on a variety of topics, everything from dental health to care for the elderly. They’d approached me about six years ago, asking me for a suggestion for a project for addiction. My proposal was to help teach medical professionals how to initiate and have conversations with their patients about their concerns about their drinking.
It’s not simply a matter of writing a prescription. How do we talk with people? If you have a concern about your patients’ alcohol, how do you approach that? This is a major project with project managers from Mass General. It’s a five-year project. It’s being piloted now in seven health centers, federally qualified centers around the state. This is all in Maine.
ER: Tell me more about how you learned to respond to people and how your initial experiences affected how you later developed addiction treatment programs.
MP: The first thing I learned is that treating people with care and respect allows patients to not respond defensively but at least to allow you to have a conversation to express your concerns. Contrary to my fear initially that if I spoke with patients about my concerns they would become angry, instead [what I found is] they might not agree, but I was able to continue expressing my concerns and, over time, get people to change.
There are a number of behavioral tools that are extremely effective in helping people become motivated to change. Not just change addictions, but it could change almost any behavior. I wish I had thought about using it with my teenagers when they were in school. It’s called motivational interviewing. The principles are expressing empathy, not arguing, avoiding confrontation, emphasizing self-efficacy.
This was contrary to the old concept of treating addictions by confronting people and causing them to feel debased in order to build up their new selves. This was a revolutionary concept. It was one of the things that I did training and ultimately taught, was the use of this technique called motivational interviewing, which is now I think regarded as central to treatment.
ER: Mercy Hospital in Portland recruited you to be the medical director of the hospital’s recovery center in 2003, and you helped develop a maternal addiction program there. You’ve called it “perhaps the most rewarding thing” in your career. What was the work like?
MP: We recognized that we were seeing a lot of pregnant women coming into our detox unit. This is opiates. We kind of asked ourselves, “Well, what are we doing? We have all these pregnant women. We need to come up with some formal way to treat them.” So a number of us got together. Twenty-four hours a day, if a woman came into the recovery center, we would admit them to our inpatient unit, assess them, give them treatment options, generally begin them on buprenorphine [a medication used to treat opioid use disorder].
[Then we’d] discharge, transition them into our partial hospital program, which was six hours a day, five days a week; then move them into our intensive outpatient treatment program, which was three hours a day, five days a week; then ultimately into a group we called the Mom’s Group that met for an hour-and-a-half every week with a counselor and a nurse, with participation of one of the three addiction doctors at the recovery center.
We would encourage women to continue in the group after they gave birth, so we had mothers breastfeeding, and we had babies crawling on the floor. We had peer support through that. It was wonderful.
My wife first started out by knitting baby outfits and then developed her own diaper bags that women still cherish. I still hear from them. It’s very gratifying. I don’t think I ever did anything that gave me as much professional satisfaction and pride as working at the mom’s program.
ER: Mercy’s recovery center closed in 2015 because it was losing money. How did you feel?
MP: Everyone who was working there was, I think, heartbroken. We were sad because we had a tremendous program. We understood why Mercy did it. Nonetheless it was a major loss. I would have worked there for the rest of my career. But along with it, our mothers’ program ended. I think we all wished that had continued.
At that point I was 65 and had always worked for nonprofit organizations, and suddenly I didn’t have a job. I made the decision that I was going to go into private practice, which has been successful, but it’s not as gratifying as working with a group of people and a program.
ER: When you opened your own private practice in Portland, what did you learn about the needs of the state of Maine from your patients?
MP: Maybe 75 percent or more of my patients are uninsured. So even though MaineCare was expanded, I’ve got a population of working people who don’t have health insurance who make too little to qualify for the ACA [Affordable Care Act] and too much to qualify for MaineCare. I’ve got a lot of patients who are uninsured, which severely limits their access to treatment.
Much of the treatment in the state is based on participation in outpatient treatment programs. There are patients who have been sober for years who don’t need to be in group. For certain populations who are working people, a requirement that people participate in a group is a real impediment to access to care. If you’re a lobsterman, and in order to get your prescription you have to show up at a group on a Thursday afternoon, for example, but your captain’s going out, you’re not going to that group, and you’re not going to get your prescription. That serves as a barrier.
ER: I was looking back through some of my emails. In 2016 you wrote to me, “virtually everything that is being proposed or done is wrong” in Maine when it came to combating the opioid epidemic. One thing that you’ve fought for is the recognition of the science that medication helps people with addiction. Have you seen progress on this front?
MP: This is a significant issue. We’ve got this action plan for the state. If you read it, what you’ll see is it’s based on buprenorphine. That to me is a major error.
[Asked about it, Gordon Smith, the state’s director of opioid response, said the administration supports all types of medications. The state has increased the MaineCare reimbursement rate for methadone, for instance, he said, and is pursuing additional methadone clinics.]
ER: How do the other Food and Drug Administration-approved medications, methadone and Vivitrol, fill a gap that buprenorphine, commonly known by its brand name Suboxone, can’t?
MP: Not everybody can manage a prescription medicine. Some people do better with greater structure. Adherence rates may be better for somebody on methadone.
What can happen and what often happens is, somebody continues to use opiates or is unable to stop while on buprenorphine, and they’re discharged. There’s no understanding that there are alternatives that you can offer to people other than simply to discharge them.
We know that methadone has been proven to be effective since the ’60s. It should be part of our armamentarium. It also allows us to expand access to care. Vivitrol, which is an injectable form of the drug naltrexone, has also been shown to be very effective. All of the medications that are FDA approved should be part of our opiate response.
ER: As you know, the number of drug deaths rose in Maine as the pandemic shut everything down. What are your words of advice for what the state should do to slow the rate of death?
MP: It would be wonderful if I had the solution to this problem, which I don’t. Let me start with that earned humility. No, I don’t have an answer to this other than to recognize that our treatment programs may be so focused on opiates that we are forgetting that there are other drugs that may need to be addressed. I’ll say this in regards to alcohol as a co-factor in deaths — treatment isn’t really available.
When I say to you, “Gee, we have this tremendous increase in co-occurrence of fentanyl and methamphetamine,” your answer is, “I didn’t know that.” The knowledge that we have this problem isn’t known yet, and that knowledge needs to be expanded. The fact that we have a methamphetamine epidemic is probably still not widely known. But we do. Cocaine is still prevalent.
The problem is more difficult, more complex and more resistant to solutions. I think we ought to try to solve what we can. Effective medication management is one such way, but that needs to be expanded to all medications.
If you look at the state’s action plan, education isn’t part of it. In general, broader education of Maine health practitioners on addiction would improve our response to the epidemic. It should be included in our action plan.
[“While we have not prioritized the education of future medical professionals on addiction, both medical schools have adopted new curriculum doing just that,” said Smith, with the state. Plus, several family medicine residency programs are requiring all of their residents to get the needed approval to provide medication-assisted treatment, he said.]
ER: Maybe you could talk about why you decided to retire, and how you feel about it.
MP: I’ve been debating this now for a year and a half. While there are a lot of rewards from private practice, it also has limited my ability to do things that I enjoy such as teaching and volunteering in the community.
It’s time for me to figure out something else in addition to only practicing medicine for 40 years. I’m not giving up medicine, but I’m definitely moving to another stage in my life.