It would seem the ultimate “teachable moment.”

A patient comes into the emergency department with the telltale signs of a heroin overdose: pinpoint pupils and respiratory failure. As an emergency physician, if they reach me in time, I can fix this, at least for now.

Counteracting the heroin and reviving the patient, though, is the easy part. It’s the conversation that follows that’s hard.

You almost died, I say. You need help, I say. Next time you may not be so lucky.

And almost always – more than 95 percent of the time – I get some version of “I’m OK. I just need to get out of here.” They’re not thinking about how death hangs over them. They’re not trying to figure out how they can get help. They just need their next fix.


We are in the midst of an opioid abuse and addiction crisis in this state. The anecdotal evidence splashes across the headlines nearly every day. The state Office of Substance Abuse says overdose deaths in Maine rose 34 percent between 2013 and 2014. No one expects 2015 to be any better.

From my position as an emergency physician, I see a problem that has no single solution. Much has been made of the scarcity of treatment options for people suffering from addiction who want help. Indeed, the headlines suggest the lack of available resources to treat these people is a real problem – one that is beyond the means of the health care community.

But I see a still bigger problem in trying to help those caught in this death grip who don’t want help. The people I see – and arguably, if they are coming to the emergency department overdosed, they are the most at risk – don’t seem ready to be treated.

That speaks to a much bigger challenge than quelling cravings. My personal view is that this is much more a societal problem with some medical overtones than the other way around. We can revive people who are overdosing. We can treat the physical cravings. Those are relatively easy things to do, medically speaking.

But addressing the psychological and social needs of an addict, that’s the heavy work. And unfortunately, it’s not at all clear where we as a state can find the resources to pay for it.

This problem touches people across the socioeconomic spectrum.

I recall a woman I treated within the last year with dyed blond hair, multiple piercings and tattoos. It took two doses of a very powerful antidote to revive her. When she awoke, she denied using despite the track marks on her arms. Told how close she had come to dying, she responded that she was anxious to get back on the streets with her “boyfriend.” I had the impression of a person who had lost all sense of self-worth and was stuck in poverty and abuse.

By contrast, another patient I saw, a young man, clearly had a prominent and supportive family around him. He had been to rehab several times – and that could not have been cheap – but he kept falling back into addiction. Not even his severe medical complications could jolt him to a place where he could find his way back to sobriety.

And still another case I remember involved a young college student, a few credits from graduating, holding down a job and maintaining all appearances of a happy and productive life. Except that she ended up in the emergency department nearly dead of an overdose. She seemed to have the self-awareness of someone who knew she had to change course. And yet, she found an excuse not to address her addiction, saying that perhaps after she finishes up her final semester she’ll tackle it.

In each of these cases, the common theme is that their problem wasn’t just about physical addiction but, rather, about their life circumstances and the absence of that readiness factor so critical in recovery.


How did we get here? Maine is not alone, but the problem seems to have caught us all off guard. When I began practicing here more than 25 years ago, heroin was in the community, and rarely would we see a narcotic overdose victim. This is on a different scale, and the victims of this epidemic seem more stuck in an ugly cycle, if that’s possible.

Some of this problem has to be owned by the medical community. It is true that a movement to treat pain as “the fifth vital sign” several years ago led practitioners across the country to begin prescribing opioid pain medications more often. It became clear, however, that these medicines were not appropriate for treating chronic pain, and prescribing habits have changed. Some patients, unable to wean themselves from these medications, have turned to street drugs, either illegally obtained painkillers or heroin.

While this makes for a socially acceptable explanation as to why someone might today be addicted, I’m not at all convinced it is the core driver of this epidemic. Economic dislocation – the disappearance of good-paying jobs for the moderately skilled and educated – has fostered despair. And even the educated are at times overwhelmed by the pace of change in the economic landscape.

And we cannot discount the impact of a ready supply of cheap and powerful heroin in our communities as an important driver of this crisis. People are using narcotics not so much to treat their pain, but to get relief from their suffering, regardless of the cause of that suffering.

If we only needed to find better ways to wean patients from painkillers, this would be a much easier problem to solve. Instead, it is deeply embedded in our society, and that’s not a simple fix.


The good news in this story – if there is any – is that there is a gathering consensus that we need to do something to address the problem. The bad news is that not only is there no consensus on how to address it, but advocates for various approaches have become factionalized.

Within the MaineHealth system, we have started to take stock of our collective response and better define the role an integrated health care system should play in this crisis. Bluntly, we lack the resources to provide all the needed services to a population that is largely poor and lacking health insurance.

Our commitment to offer our services regardless of ability to pay means we have to be certain we can identify resources that will allow services to be sustainable. As it is already, at Maine Medical Center, 48 percent of the patients showing up in the emergency department with substance abuse issues lack any form of insurance.

While this is challenging, we know we must do our part, and we are working to develop innovative solutions. In the coastal region, for instance, our MaineHealth partners are coming together to create a care continuum ranging from intense inpatient care at Pen Bay Medical Center in Rockland, to rigorous outpatient treatment through the Mid Coast Hospital Addiction Resource Center in Damariscotta, to ongoing support through Maine Behavioral Healthcare in Rockland. By carefully leveraging some new resources, we hope to increase by 100 the number of people who can be treated through these organizations.

And last year, Maine Medical Center announced a new pilot program that has addiction specialists seeing patients through the Maine Medical Partners primary care network. That plan also provided training to 10 doctors in that network so they could treat patients in recovery.

In coming weeks we’ll be taking an inventory of all that is being done to treat people with opioid addictions across our system, and then we’ll work to identify opportunities for our members to do more with these resources.

One of the tough conversations taking place not only within MaineHealth but also within our communities is the role that replacement therapies should play. Some practitioners are passionate advocates for making Suboxone and other drugs that can treat opioid addiction more widely available. Others – and I count myself among them – are cautious because these replacement drugs can be diverted and sold on the street or abused in combination with street drugs.

And while the medical community has an important role to play in preventing and treating this disease, even if we had unlimited resources we could not solve it on our own. Addressing poverty and the economic turmoil felt by so many is vital. It is also important that law enforcement do what it can to limit the supply of illegal drugs, but without vilifying those who are the victims of this crisis.

In the meantime, those of us on the front lines are left to pick up the pieces. Sadly, not every overdose victim gets to us in time, and when that happens I know that it wasn’t so much a medical failure that caused this person to die as it was a societal one.

And that is a teachable moment for the rest of us.

Dr. Mark Fourre is chief health affairs officer for MaineHealth, the state’s largest health care organization. In addition, he is chief medical officer at LincolnHealth, a MaineHealth member serving Boothbay Harbor and Damariscotta. An emergency physician by training, he practices in emergency departments within the MaineHealth system on a regular basis.

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