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Join physician Jill Becker as we delve into the world of medication-assisted therapy (MAT) for opioid use disorder. Discover why MAT is crucial, the challenges patients face, and how Jill’s compassionate approach sets her apart from the norm in the medical field.

Jill Becker is a physician.

She discusses the KevinMD article, “A doctor’s genuine approach to medication-assisted therapy patients.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, get CME for this episode by clicking on the CME link in the show notes. Today we welcome Jill Becker. She’s an addiction medicine physician. Today’s KevinMD article is “A doctor’s genuine approach to medication-assisted therapy patients.” Jill, welcome to the show.

Jill Becker: Thank you very much, I’m excited to be here.

Kevin Pho: So we’ll talk about your article in a little bit. First off, briefly share your story and journey.

Jill Becker: OK. I have what I think is an unusual story, in that I was training in OB/GYN way back when, and I requested a leave of absence after I was pregnant with my daughter, after I had my daughter, but that was declined. And so I left medicine for about 20 years, oddly enough, and decided I wanted to get back into medicine once my daughter was grown. But there really is not much of a way to do that, so I opted to get a master’s degree in psychology. So in addition to my MD I also have a master’s in psychology and expressive arts.

And all of that came together in addiction medicine for me without even realizing it. I ended up in addiction medicine and found my calling, found a group of patients that I adore, I love working with. And I just started my own practice at 58 years of age, and I’m excited about that.

Kevin Pho: All right, tell us what your day would look like as an addiction medicine specialist. Tell me the typical cases you see, the type of people you meet.

Jill Becker: Everybody. Adults, I don’t see children, but I see adults. And people often have a picture of what an addict would look like, but there is no one group or one type of person who’s addicted to opioids. I have patients ranging from 20 years old to, I think my oldest patient is probably in her 70s or 80s. And I see most of them weekly, and we develop a wonderful relationship that’s based on, I think, mutual trust and understanding. I rely more on my patients than I do on labs or tests, even though we do obviously need to get labs and tests. I have found that that’s been a great way to connect with people.

I like to think that they appreciate me in the same way. I’ve gotten feedback in that manner, or to that idea. I think the bottom line is I really love my patient population and my patients. I got very lucky.

Kevin Pho: All right, and we’ll talk more about that in your KevinMD article, “A doctor’s genuine approach to medication-assisted therapy patients.” So before we talk about your article, the term medication-assisted therapy is not something everyone may know. So talk more about that definition first, and then we’ll talk about your article.

Jill Becker: OK, so folks who have been addicted, particularly to opioids, and have had changes in their brains, in order to really get off of the opioids in a way that’s not horribly painful for them, they can use something called medication-assisted therapy. Typically buprenorphine is a medication that we use. There’s also methadone. There are a variety of preparations of buprenorphine, including Suboxone, Sublocade, there’s Subutex, a few injectables that are fairly new. And that is what we do, that’s what I do. I help people get off of the need to use street opioids in this manner.

Kevin Pho: All right, and talk about your KevinMD article.

Jill Becker: One day there was a mom and son who came into the office. Their physician had just closed the doors on them, had not told them they were closing the doors, they just closed the doors. They were panic-stricken, because the medications used for medication-assisted therapy need to be tapered, you can’t just stop them. And they were panic-stricken, they had no idea what they were going to do. They called our office, they were seen that day, and we developed a lovely relationship.

One day I was speaking to this particular patient, and I told her what an honor it was to participate in her care. And she said, nobody says that. And that’s a theme I’ve learned across the board. Most of the folks involved in the addiction community have had really terrible experiences. They’ve been ostracized, humiliated, made to wait hours to see a physician or to get their treatment.

When she said that it really hit home to me. I said, what do you mean? She said, well, nobody thinks it’s a, I think I said privilege, a privilege to participate in their care. I said, but it is. And she said, well, you’re just different, you’re just different than other doctors. And I said, well, I shouldn’t be. All doctors should feel this way, and they’re missing the point of doctoring. And that was that, and that’s what made me think about writing the article that I wrote, just to get across to other physicians that this patient population really needs a little bit of extra love and care.

I would say the majority of patients, I consider them to be trauma survivors rather than, I hate the word addicts, but rather than addicts. They’re people who have had some trauma, they’re trying to survive just like anybody else. They’ve either chosen a way or been led down a way that is maladaptive, and they need care, and they need compassion, and they need someone who can understand that.

We wouldn’t treat somebody with diabetes who went out and ate a pint of ice cream poorly, but we treat somebody who has an addiction, who uses, poorly. And it’s just not fair. It’s not fair to the patients, and again, we’re missing an entire patient population that really just needs a little bit of extra TLC.

Kevin Pho: Now, you talk about that stigma that this patient population has, even among the medical profession. Can you speculate some of the reasons why that is?

Jill Becker: Yes, I can. Just like we have often thought of obesity as an issue of willpower, I think we look at folks with addiction in the same way. We’re not really looking at the neurobiology or the neurophysiology of someone who’s become addicted to opioids. Their receptors have been upregulated. In order for them to just stop is actually extremely painful, it’s not the same as just not taking a medication. They’re actually physically in pain. And I think we look at folks with addiction, again, as it being an issue of willpower as opposed to it being a disease.

In addition to the medical profession, I see my patients, they come in and they say, the pharmacy staff is terrible to me, as soon as they hear the medication I’m on they treat me like a criminal. They wouldn’t do that if it was insulin or a cardiac medication. It shouldn’t be that way for addiction medications.

Kevin Pho: So if patients come to your office for the first time and they tell you the story like you just told, about how they were treated by their prior clinicians, by the pharmacy, take us into your exam room. What would be an interaction in terms of your approach, and what are some of the things that you do and say?

Jill Becker: I hear often when people walk into our office, they just say, oh, this place is different. Immediately they feel that it’s different. They are seen by appointment, not just sitting waiting for hours. They are treated with respect. Generally we’ll offer them a cup of coffee or a glass of water. We have a staff that’s very welcoming, caring.

I explain to them, I don’t just give them medicines, I explain to them why the medications might work, how we’re going to use them. Oftentimes patients who have been on let’s say buprenorphine for a long time, when I go through with them how to take their medication in particular, most often I hear, no one ever told me that before. And I’ve heard it so many times that I believe it to be true. It’s not a medication that you just swallow, it’s a medication that you need to put under your tongue and do in a particular way, and there are things that can influence it.

It’s gotten to the point now where a lot of my patients will bring in lab results from other physicians, or they’ll come in and say, someone recently said to me, I have what they call an aneurysm in my belly, I don’t know what that means. And so I sat down with him and drew a picture for him and explained to him what an aortic aneurysm was.

And it’s a level of trust, I think, that’s been established over time. We do see our patients weekly at the beginning until they’re sober, and then we’ll go biweekly and then monthly. And so when you see somebody that frequently, they know me, I know them. I don’t bring my personal things into the office, but they know who I am, and I know who they are. I even know their kids, they bring photographs. It’s an honor. It’s an unusual place to be, and it’s an honored place to be.

Kevin Pho: What are some of the things that we can do to relieve some of that stigma outside of the addiction medicine community, and make primary care offices as welcoming as your office to this population?

Jill Becker: I’ve been thinking about this since they removed the X waiver for folks to be able to prescribe buprenorphine, Suboxone. I’ve been hearing a lot of primary care docs say, well, I don’t want those people in my office, or, they’ll upset the patients. I think seeing the patient as a human being rather than as a statistic would be really important.

Kevin Pho: What kind of training is involved? What kind of education does one need in order to comfortably prescribe buprenorphine?

Jill Becker: That’s a great question. Currently there’s a requirement that, I believe it was last year, put in place by the federal government. Each physician now has to take an eight-hour class in order to prescribe buprenorphine. There are also lots of organizations, ASAM, the American Society of Addiction Medicine, SAMHSA. They all have addiction education conferences. There’s plenty of places to read about addiction.

There’s a mentoring location which is actually through BMC, I believe, called MCSTAP, where they mentor you weekly. There are addiction medicine fellowships. I would like to be able to take one, unfortunately I can’t, because of the fact that I left my residency.

Kevin Pho: And for patients looking for addiction medicine specialists, how difficult is it to find one?

Jill Becker: It’s really not difficult to find one. I don’t think it’s difficult to find one who is trauma-informed and as individualized as I think we are. There are a lot of facilities that folks can go to, inpatient, outpatient. You can go through the SAMHSA website, and there are addiction medicine physicians listed everywhere.

I would encourage patients to, I know this may sound silly, but interview their physician. Find out if they connect with the physician, how they feel. They’re entitled to feel a connection, just like any other field. They’re entitled to feel respected. And unfortunately for the most part they’ve been made to feel that they have to take what they can get.

Kevin Pho: Can you share a success story, or a case study, where someone came to your office perhaps from a primary care doctor and you really moved the needle for them?

Jill Becker: Thank you, I appreciate that question. A number of people come to mind, but the first one, we’ll call him Daniel. He was already on buprenorphine when I met him, but he was still using IV drugs. And he said he just didn’t feel right, he just didn’t feel good, he just didn’t feel right.

And unfortunately the physicians who were seeing him before, the way they used to prescribe the medicine was, the maximum amount anybody would need was 16 milligrams of buprenorphine. Well, with fentanyl that’s a whole different ball game, but the old information was still out there. I had been reading and listening and was more new to the field, and so I’d been doing a lot of education, and was learning that with fentanyl in particular a lot of people actually need more than they’re getting.

And so the first thing we did was we switched him to a different medication that was more tolerable for him, and then we did increase his dose. And that was over two years ago. And when he sees me he’s like, Doc, you saved my life. One thing he says to me is, I never thought I could do this, I never thought I could do this. He’ll say, I couldn’t have done it without you. And I always say that’s absolutely untrue, you did the hard work, I got to be part of it, and I’m grateful. I get to reap the benefits of being part of that, and I just reflect back to you who you are. That’s what I do.

So that’s one success story. There are a whole bunch, but that’s one. Really, I could see his face in my head right now, smiling.

Kevin Pho: We’re talking to Jill Becker. She’s an addiction medicine physician. Today’s KevinMD article is “A doctor’s genuine approach to medication-assisted therapy patients.” Jill, let’s end with some of your take-home messages that you’d like to leave with the KevinMD audience.

Jill Becker: OK. People are people. All people deserve respect, all people deserve love. Some people just need understanding. If you realize that the person sitting in front of you is sitting in front of you because they have been traumatized and they’re trying to survive, understand that they’re doing the best they can at this moment. As Maya Angelou said, when they know better they will do better. Give them the tools to do so, and give them the respect that they deserve.

Kevin Pho: Jill, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Jill Becker: Thanks for having me.