One of Gov. Janet Mills’ early initiatives was creating a position to combat Maine’s opioid epidemic and naming Gordon Smith, executive vice president of the Maine Medical Association, as Director of Opioid Response.
As a follow-up to our Born to Drugs: Maine’s Most Innocent Victims series, Pine Tree Watch interviewed Smith multiple times this spring, asking about his strategies to help Maine’s infants and children affected by the opioid crisis. Over the past five years in Maine, 1,630 people have died from drug overdoses, and nearly 5,000 babies have been born drug affected.
A Maine native, Smith, 67, is a graduate of the University of Maine and Boston College Law School. He began working as general counsel for the MMA in 1981. Since his appointment this winter, he has traveled the state to meet with medical experts and community coalitions.
The interviews with Smith have been edited for length and clarity:
Pine Tree Watch: Since taking on this new role, what have you learned that may help reduce the state’s high number of opioid-affected babies?
Gordon Smith: I think our work in that space is really in its infancy. We’re still really learning about the problem. It’s good news that the number of drug-affected babies in Maine is down for the third year in a row. It’s gone from 1,024 in 2016, to 952 in 2017, to 905 in 2018.
But that’s still a lot of babies. It’s still 7 percent of our births, so we know this is one of the most important things we have to look at.
There are two incredibly important pieces of these drug-affected babies. One is to take care of the immediate medical needs of the baby, to get them withdrawn from whatever substance mom may be passing on.
But equally important are the social aspects of sending that baby home. And that’s where our public health nurses come in and child protective services. Some of the babies get to go home with mom, and some of them don’t.
We need more resources in the public health nursing area, so that we can help that mom. We like the baby to go home with mom, but not if it’s going to put the baby at risk. That was the traditional role of public health nursing – go into the home and evaluate what was needed.
And when all these cuts to public health nursing came, in my opinion, it affected the state’s ability to do what needs to be done. There is an effort now by the (Maine Center for Disease Control and Prevention) to hire more, but they are facing a very difficult job market.
PTW: The state’s infant mortality rate also rose as the opioid epidemic surged in Maine. Do you believe there is a connection between the two?
Smith: In truth, this is my 12th week, and a lot of the initial work was spent doing the things we knew we could do quickly, and that we knew would make a difference and save lives – like getting Narcan and naloxone (overdose antidotes) out to places that needed it.
(Analyzing the infant mortality rate) this takes a much deeper dive. We suspect opioids have a role in all that.
We want to examine this in conjunction with the maternal and child-health people at CDC; they are the experts. They’ve been starved for resources for the last eight years.
There is an infant death and serious injury and prevention panel that has not been as robust as it needs to be. At a time when the maternal and child death review panel should have been meeting more frequently and more resources should have been devoted to it, it has not been meeting virtually at all. So that’s one reason we don’t know the answers to these questions.
There has been some work done on how many of those infant deaths are the result of unsafe sleep conditions. Is the child sleeping on the couch because mom and dad are actively injecting heroin in the next room? We don’t know that. We clearly need more data.
When our new (Department of Health and Human Services) Commissioner Jeanne Lambrew fills out her team at the CDC, then at some point, we can really take a look at this issue.
PTW: After the state’s public health nurses were cut from 50 when Gov. Paul LePage took office in 2011 to less than 15 by the end of 2017, Maine created CradleMe, a new referral system for handling home visit requests to new parents and their babies. Doctors and nurses have been critical of CradleMe. They say they have no idea what happens after they request a home visit to a drug-affected baby who may be at risk. What have you learned about this program’s effectiveness?
Smith: At a time when the state should have been investing more resources into this problem, they were actually cutting services, and that’s had a negative effect on the issue.
It used to be every baby born in Maine got a visit from a public health nurse, but that program was cut in half, and then the CradleMe program came in.
I find it completely unacceptable that physicians who make referrals to CradleMe, who are asking to be kept in the loop as to how and whether that visit has been done, are not being advised of the outcome.
As you know, if a baby is born drug affected and goes home, it has a higher risk of complications and death. We’re going to fix this referral system, and the state is working very hard to hire a sufficient number of public health nurses to build that program back up.
Public health nursing on the CDC side has been working closely with DHHS’ child-protection staff. But their caseloads are unmanageable. They’re completely overwhelmed, and there’s a lot of turnover in staff. Gov. Mills’ administration and Commissioner Lambrew are very committed to stabilizing that situation. If state government isn’t protecting our children, then what are we doing? It should be our highest priority.
PTW: How is Gov. Mills’ approach on combating the opioid epidemic different from her predecessor?
Smith: It’s the difference between day and night. In her first few months, Gov. Mills expanded Medicaid and distributed 35,000 doses of Narcan and naloxone all over the state. We’re also having treatment in the prisons and jails. We’re recruiting and training more recovery coaches, getting treatment in every emergency department.
And we’re trying to create a dashboard (online) to share information, so citizens can know how many are struggling with substance abuse. How many getting treatment, how many treatment facilities do we have. How many are dying. Other states have a dashboard. Why can’t we?
There’s all kind of information that should have been put out to the public in the past, like on the prescription monitoring program. That is one tiny example of how there was a lack of transparency in the previous administration.
PTW: What efforts are being made to treat women of childbearing age who have opioid-use disorders?
Smith: It is a vulnerable population. And a population of great interest to us because of these numbers of drug-affected babies.
We have to have an objective assessment: Is everything being done for these potential moms that needs to be done? They should be a high priority for interventions, so they’re not using and have treatment and contraception opportunities before they have a child. We need to know what is the most effective intervention that we can do before the mom becomes pregnant, during the pregnancy, after the birth, after the baby gets home to give support to mom and the baby.
I have talked from time to time with obstetricians and family planning about, well, if mom is coming in again and delivering her second or third baby under these circumstances, do we have a good opportunity to talk to that mom about long-acting reversible contraception? So well-informed, patient-consented contraception needs to be part of the discussion.
We also have to examine why mom is using drugs. Unless we address the root causes of addiction in this state, we’re just rearranging the proverbial chairs on the Titanic. You have to get in there and examine why is mom misusing substances in the first place.
PTW: You’ve talked about your frustration with the lack of communication between several Maine agencies that are tasked with drug prevention and treatment. Can you share more details about this?
Smith: Maine is a data-rich state, but all the data sit in silos and isn’t integrated in a way that helps inform opioid policy in the state. We are going to have a data workgroup that takes look at this issue.
My job is to advise the governor, report to her every week on how we are doing, and to break down some of these silos. So that we have an opioid response that’s strategic and takes the resources that the state has and that the federal government gives us and puts them in the place that can do most good. It’s pretty obvious that hasn’t been done in the past.
There are a tremendous amount of good things going on around the state, but nobody knows what anybody else is doing.
PTW: Maine’s rural counties have high rates of opioid abuse along with a surge in infant mortality rates. What can be done to help these families and babies at risk?
Smith: We’re not at the point yet where we have good data to tell us where the resources need to be, but I think we’re only a few months away from that. We know in general that we need to have more recovery community centers with counseling, recovery coaches, treatment resources.
We also don’t have recovery housing in six or seven counties. While we have 102 sober houses, they only exist in half the counties.
Even if we get a mother into treatment, if she is going back to the same apartment where her partner is trafficking in drugs, it’s just not going to work. The solution to the opioid problem in our rural counties and in the state has to be very comprehensive with people working together.
PTW: Your job as Maine’s opioid director encompasses a wide swath of problems, from drug-affected babies to overdoses. What has been the response from communities and families that you have met during your public forums?
Smith: I so enjoy working for this governor, who allows me to go from one end of the state to another delivering her message of hope and recovery, but we have a tremendous amount of work to do. We’ve got two and three generations of addiction frequently to deal with. We have a lot stigma; there is a lot of shame involved with the disease. I’m just learning so much.
I’m not an expert in prevention; I’m not a clinical person. Every public audience I talk to I say, ‘I’m just a health lawyer and I need to know from you what we need to do in this community. How can we help? How can the state be a better partner to you?’
That message really resonates with people, partly because, frankly, the bar is pretty low. They haven’t heard this message in quite a while.
PTW: There is so much to be done in your job. What’s keeping you awake at night?
Smith: That we’re not doing enough fast enough.
We need more treatment; we need to break down some of the stigma. We need more incentives for doctors to provide medical-assisted treatment, increase the reimbursements and make it more lucrative, which we’ve done for methadone.
I also worry about the variability of treatment. Substance abuse and mental health has always been more difficult to treat than physical illnesses. I am concerned about people being sent off for treatment and not having a good program.
They aren’t many residences in the state where a mom in treatment and her infant can go. I believe we have five now. We’re increasing those, but that’s what keeps me awake at night.
PTW: Gov. Mills has scheduled an Opioid Response Summit on July 15 at the Augusta Civic Center. “Turning the Tide: Maine’s Path Forward in Addressing the Opioid Crisis” will feature talks from health providers, experts, law enforcement, families and individuals affected by opioids. What are your hopes for this summit?
Smith: We’re very excited about it. We know that the journalist Sam Quinones, who wrote “Dreamland” about the nation’s drug crisis, and Michael Botticelli, President Obama’s director of National Drug Control Policy, will draw a big crowd.
But in addition to getting people focused on where things are now in the nation with the opioid crisis, we have workshops on prevention, harm reduction, community coalitions, and voices of people in recovery.
We want to showcase what we’re doing, but also allow people the opportunity in those breakout sessions to react and let us know what we’re missing. We know there will be hundreds of people there from families who have lost loved ones, as well as people in recovery. Those are people we really want to ask, ‘Are we doing the right stuff? Are we putting our resources in the right places?’
And just as importantly, we want to use the summit as a springboard to launch our volunteer brigade. We don’t want it to be just a one-off event. We want everyone leaving that civic center – and we think there could be 500 to 800 of them − to know they have a role to play in helping us and to give them a to-do list for when they get back to their community.
There is quite a bit we are trying to accomplish.