“By far the best period of my practice life has been in this work. And that’s not because it’s been easy or cheerful or un-challenging. On the contrary, it’s been quite challenging. “

About five years ago, William Porter, MD, decided to stop working as a primary care physician and devote his practice to medication-assisted treatment (MAT) for patients with opioid use disorder.

During a stint treating inmates at Marble Valley Regional Correctional Facility in Rutland, Dr. Porter found it satisfying to help those who struggled with addiction. Leadership at Porter Medical Center, an affiliate of University of Vermont Health Network where he practiced at the time, embraced the opportunity to expand its MAT options, Dr. Porter recalled recently.

At Bristol Primary Care, which was part of Porter Medical Center, Porter joined Emily Glick, MD, who had been offering MAT there for about a year. Together, they treated 113 patients in the practice with Suboxone, a drug that combines buprenorphine to minimize withdrawal symptoms from opioids, and naloxone, to prevent misuse or abuse of the medication.

Porter recently moved to the staff of Mountain Health Center, a federally qualified health center, designated to provide medical care and support programs to underserved populations. Its services include a dietician, behavioral health care, psychiatry, dental care and MAT. Porter said he welcomes the opportunity to provide those wraparound services to the 75 or so MAT patients he brought with him to Mountain Health, which serves as one of two “spokes” – clinics that provide MAT –  in Addison County. Porter is one of eight total providers in the county, which he considers insufficient to meet the need.

Porter recently shared his insights on treating patients with opioid use disorder.

When you decided to leave primary care, you could have done many other things. Why MAT?

I was looking for a more social-justice angle in medicine, rejuvenating my enthusiasm for the practice of medicine. By far the best period of my practice life has been in this work. And that’s not because it’s been easy or cheerful or un-challenging. On the contrary, it’s been quite challenging. But it has really positively affected me in working with people who are seeking to change their lives. It has resulted in me discovering a lot about how I want to live and frankly becoming healthier myself.

How is caring for patients with MAT similar to or different from primary care treatment?

When we treat people with Suboxone, it transitions them from whatever opiate they’re using illegally. They become dependent on Suboxone, just like they have dependency on other opiates. It makes them super-reliable patients. They don’t mess around. They show up for their appointments.

If you want to take care of someone’s health, to have them show up for appointments is essential. So it really works. If you just treat them kindly, with respect and caring, then you’ve solved a bigger problem than just treating their dependence.

What other problems can you address?

You’ve got them in the room and you can talk to them about hepatitis treatment or quitting smoking or losing weight. These folks, they’ve gotten sneered at and given the hairy eyeball by every person that represents medicine or ‘officialdom.’ So it’s a real opportunity to build trust and to deliver benefit to them through enhancing their health – and not only in addiction treatment but in general.

What was the demand for MAT when you got started?

For the first three years we had a waiting list that was interminable. We never got to the end of the waiting list until Mountain Health started doing treatment and really expanded quickly. Then, we had treatment on demand in Addison County, which was huge. [Since the time of the interview with Dr. Porter, he shared that one provider at Mountain Health has retired, and the county now has a waiting list again.]

People were lining up, and that’s not ideal. It is exactly the wrong thing to have people wait. You also can’t just open the doors and overwhelm yourself. You’re not going to be doing a good job taking care of the people you’re already responsible for.

So our case manager who was responsible for the wait list, she wouldn’t cross people off. But people would rise to the top or go to the bottom depending on: Are they pregnant? Do they have young children? Is DCF (Vermont Department of Children and Families) breathing down their neck? Are they coming out of jail? That’s a priority. You got to take those people ASAP because they are at the greatest risk for overdose.

How did Bristol Primary Care staff respond to the MAT part of the practice?

Emily had started here, and there was a sense already at this office that people were proud to be part of helping people who really needed help. So the stigma in this office was gone. It didn’t exist. From the front desk to the manager to the other providers who don’t do MAT – everybody sees it as a positive mission and feels pride in the fact that it’s being done here.

Why does stigma still exist with these patients?

Mostly the culture is of punishment and discipline. This is where you get, “What’s wrong with those people?” What’s wrong with those people is they need help. They don’t need to be told that there’s something wrong with them. They’ve been told there’s something wrong with them all along and that doesn’t help. That drives them further into isolation and the shadows. So being truly interested and being kind – not that everyone isn’t interested in being kind, but we have this reflex of (thinking that) aberrant behavior deserves punishment.

Compulsive behavior that continues in spite of negative consequences – that’s what addiction is. So it’s out of control. We can pass all kinds of moral judgements on that. (But) if punishment was going to work it would have stopped the compulsive behavior. So what works? Intervening, finding a substitute which is nonintoxicating, and giving them assistance in getting used to living life outside of that rollercoaster of punishment and reward that drug use constitutes.

Why do you treat addiction to opioids with another addictive medication?

If you polled my patients, many of them would say, “If I hadn’t gotten in this program I’d be dead.” It’s dramatic. If you could see what happens in a week to someone. They’re not sick anymore. They can function. They don’t have to be chasing after [their next fix.] It’s actually a really effective medicine. I’ve prescribed a lot of medicine in my life. This one is a good one. It does save lives.

How have you seen patients improve with MAT?

As my colleague Lynn Wilkinson said, when she started doing the Suboxone treatment, “It’s like surgery. People actually get better.” Because, you think about it: In general medicine, it’s managing people’s decline or chronic illnesses. They don’t perk up a whole lot, (or they’re) deteriorating slowly or aging. But these patients come to us from the edge of the abyss and it revolutionizes their world. They get their kids back. They pay their debts. They build trust with their families.

What do you see with the patients you treat that most people don’t understand?

It sounds like a cliché, but people with addiction problems are just like everyone else. I think there’s a general sense that there’s something that sets them apart and there isn’t, except that they’ve stumbled into this trap, this bad relationship. All of us have experience of that. We’re doing things and we don’t know why.

What makes someone a good MAT provider?

I think the trick is to let go of judgment and meet people where they are, which is the trick with anything. It’s the trick with children. It’s the trick with colleagues. Really be curious about where people are, where they’re coming from. This is a form of practice which requires a lot of that empathy and withholding judgment and finding out what will be truly helpful to people.

This story was reported by Carolyn Shapiro, with the UVM Health Network.