Addiction Doc: Dr. Nick Gallagher

Lisa Belisle: Hello, I am Dr. Lisa Belisle and you are watching or listening to our video podcast Radio Maine, where we celebrate creativity and the human spirit. We are sponsored by the Portland Art Gallery in Portland, Maine. Today, to help us celebrate more the human spirit, but also a very creative individual in his own right, is Dr. Nick Gallagher, who is the medical director of Addiction Medicine at a local Maine Health organization. He is currently there helping with some of our Mainers in substance use disorder. So thanks for coming in and talking with me today.

Nick Gallagher: Thank you, Lisa. It's a pleasure to be here. Happy to be here.

Lisa Belisle: I should say that Nick is one of my favorite people in the world, and that he and I used to work closely together when I also was employed by this health system. I've missed you very much. So not only am I happy that you're here to talk about this topic, but it's really good to see you again.

Nick Gallagher: Same to you. And I would say the same about you, Lisa. One of my favorites.

Lisa Belisle: What's fun about you and I both is that we're both from Maine. We both kind of grew up and stayed in the community, went away, came back. But you have an interesting backstory with our health system, and that is that you actually worked there long before you became the medical director of this service line. And in fact, did you also have family that worked there?

Nick Gallagher: Yeah, I did. I grew up in Winslow, a small town in Maine, and being from that area, the health system there was a major employer of many people living in that area. I did have generations of my family that worked there, including my grandmothers. And then my mom actually worked for them for 40-ish years or so as well. I started working at the hospital when I was about 15 or 16. I started in environmental services cleaning, essentially doing floors and emptying trash cans and things like that, and worked my way through high school doing that. Then when I got into college, I started at University of Maine in Augusta, and stayed in the area and lived off campus and worked to support myself through college, and stayed with the hospital, which I really enjoyed.

It's a great community there. After college, I did my med school in Maine as well. So I spent most of my life in Maine. Following med school, I did my emergency medicine residency in New York, and then got interested in the practice of addiction medicine there. Then I went to Brown in Rhode Island for my addiction fellowship. To be honest, I wasn't definitely planning to come back to Maine, but everything sort of aligned at the time when I was trying to find the right place for myself and my family and what job I was going to do. The stars just aligned and I ended up coming back here, which I'm very happy about.

Lisa Belisle: And I think you have the distinction of probably being the only physician on staff who used to be the one emptying the trash and making sure the floors were clean. So you really know the place inside out, up and down. You've connected with a lot of people who work at MaineGeneral, but also you've been really connected to the people in the community for a very, very long time.

Nick Gallagher: Yes, and I'll tell you a quick funny story. When I first started here, my first boss was somebody whose office I used to clean when I was in high school. So it was kind of a funny situation when I first came and found out who I was going to be reporting to as a physician, and it happened to be one of the doctors whose office I used to clean. So it was a funny story between he and I initially.

Lisa Belisle: And hopefully he didn't create too much work on the cleaning side for you.

Nick Gallagher: No. He was one of the low maintenance ones.

Lisa Belisle: That's good to know. And you also, for a while I believe, wasn't your brother also in law enforcement in the local area for many years?

Nick Gallagher: Yeah, so my brother actually worked for the same healthcare system as well, doing sort of the same work when he was in high school, and then went off to college and came back and started his family here in the area. And he was a cop as well in the community for three or four years. He recently moved to Florida to take on a different job, and his family moved recently. But yeah, we've been part of this area for our whole lives really.

Lisa Belisle: When I think about emergency medicine and substance use disorder, which is still being called within the field addiction medicine, but we acknowledge that it's called substance use disorder. Those two service lines, both of which I was very actively involved in at that organization when I worked there with you, they're somewhat stressful. They're stressful. Their patients are coming in at a moment in their lives, or their family members' lives, where it's really high need, where they really identify that there are changes that need to be made. Whether you're in the emergency department and there's something happening acutely, or in the case of substance use disorder, you've recognized you're at a place where you need to do things differently moving forward. And somehow that attracted you. So talk to me about that. That is not something that attracts every person.

Nick Gallagher: Before I went to medical school, I did go with the goal of being an emergency medicine doctor. I can't actually remember where that interest first came to me, but I know I've always been somebody who likes to multitask. I like to be up and around, moving around and doing many different things. So I think naturally I gravitated towards that. But really I got introduced to the environment of emergency medicine when I was working for the hospital, not as a physician. When I was spending time there, I was like, this place is really interesting. There's this energy here. There's a lot going on. Just being an observer of that, I saw a lot of interesting things and I was like, I really want to know what's going on here. So I found myself attracted to that environment.

You walk in there and there's like a buzz to it. It's different than walking around other areas of the hospital. And luckily I met somebody who I still consider to be a mentor of mine, one of my closest people in my life, and he's an ER doc, and he would actually let me follow him around. I would come in when I wasn't working and he would let me follow him around. He would show me around and let me see some cases. He would introduce me as a pre-medical student, even though I was in college and actually went to music school for college. So I was not even doing a science at the time. The trajectory was a little uncommon, I would say. But he would introduce me as a pre-medical student and allowed me to see some interesting cases with him.

And I still remember some of them. This was maybe 10, 12, 15 years ago. I still remember some specific cases. It had a really big impact on me. I did waiver a little bit in medical school, as you probably remember. You kind of go in with this thought about what it's going to be like, or what any specialty is going to be like, and there's the ability to create some glamor about what you think it's going to be like. And then the nice thing about med school when you do your rotations is you get to go and try everything out. There were certain times when I was like, maybe I want to do this or maybe I want to do that. But really at the end of the day I stuck with emergency medicine and was lucky enough to do my residency training in a really, really good program.

But throughout the course of that, this was in 2015 when I started. And I say that because of the timeline of where things have gone with substance use disorder. In the late nineties, we started to see a lot of the issues with prescriptions of opioids and the changing environment on what is pain, and what should anybody have to deal with, and what medication should be prescribed. In the early 2000s things were getting really bad, but I was in high school and I didn't really have any experience with it myself. Luckily, I didn't have any severe injury at that time. But my first real exposure to it in the real world was in residency. All of a sudden we started seeing all these people coming in, at the time mostly heroin and prescription pain medicine, and people were just suffering and really not doing well, from all different walks of life too.

That's one thing I learned pretty quickly, is that you can't really lump this sort of disorder or disease process into a certain population of people. It hits everybody and anybody. Some people are just lucky that it didn't hit them. So I learned that there, and we were seeing it so much. To me, I thought it was unique to that area because it was my own personal experience. I'd never seen it before. And I'm like, this area has a real big problem. And come to find out everybody has a really big problem. So I got interested in the disease process and what was causing it and why this was happening to so many people. And I did find that from the emergency department, we were able to create some processes and procedures, myself and a couple of other residents who were interested in it, to help streamline the process of assessing.

Particularly what I'm speaking of is acute opioid withdrawal, which is usually what we would see more than anything else. We created some processes to be able to manage that and take care of folks quickly, and then also get them connected to an outpatient place so they could leave our ER and go there. I saw that the impact of that was huge, and it was different than the impact that I felt as an ER doc who would patch things up and move on. I would find myself getting a little more involved in these cases and wanting to know what happened to them and where they went. More long-term things that I never thought would be part of my medical practice. So it kind of found me in a way. And then we quickly found out that we didn't have enough resources in the community to care for all the people that we were seeing in the ER.

So that was another issue. Then I started working at the local practice that we were sending people to from the ED, and I would see them outside of the ER. So that's how I got this continuity of care piece that I wasn't getting from the ER either. Just being able to be involved and help folks in the little way that I could, and see a huge impact that just having a little bit of help made for them in their life, was very impactful for me and sparked my interest to do this more regularly.

Lisa Belisle: One of the things that I know you and I have talked quite a bit about is the importance of moving beyond bias. Because I do think that when you think about addiction, people still will use terms like addict and alcoholic, as if that is their identity. And what you're describing is this is an individual who is using substances and is disordered in the way that they use substances. I think that's truly important, because it's very similar to, say, somebody who is a diabetic. It's actually a person who has diabetes. I think we need to be thinking about the fact that these are people, like all of us are people, and they happen to have this specific type of disease process. If we keep thinking about them as somehow separate from us, and being biased toward this idea that they are addicts and alcoholics, that othering of them isn't really productive for them, it's not productive for our society, and it doesn't enable them to get the help they need.

Nick Gallagher: It's pretty staggering if you look at the amount of people that have substance use disorder, or that would be diagnosed with a substance use disorder. There's a lot of studies now looking at the numbers of people, and the numbers are staggering, comparing them to other chronic diseases like diabetes or high blood pressure. The numbers are right up there in terms of how many people have substance use disorder compared to some of these other disease processes that we know of in America as the chronic diseases that we manage. And I think one of the reasons is because with substance use disorder, it affects younger people too. Heart disease and diabetes, diabetes is a little different, it's a wider age range, but cancer, heart disease and those things are more common in the older population, as opposed to substance use disorder, which is in those folks and even kids as young as 12. It's getting younger and younger.

So it's a larger population of people overall in terms of the age range that it spans. And more and more there's research, and with the advance of imaging and things, it has been really proven that it is a disease process of the brain, and it affects the body as well. So it has real identifiable physiologic changes like other diseases. The thing that really solidified to me the chronic disease model of addiction is, and it's still to this day, every time I sit down with somebody and I hear what happened. If you sit down with somebody who is an alcoholic or an addict, or whatever you want to say about it, and you talk to them about what happened, how did this happen, you're going to find that some of the stuff that leads to the development of a substance use disorder is just awful.

People growing up in families where they really didn't have a chance, a lot of them are exposed to this at an early age. There's always that nature versus nurture, environment versus genetics discussion with most diseases. But if you look at even diabetes, if you have parents with diabetes, you're way more likely to have it. But that's just one little piece. If you grow up in a family with parents who are diabetics, how does that also affect the food that's in the home? The thoughts about exercise and physical activity? What is the socioeconomic status? Are people actually able to buy fruits and vegetables? There's this whole big thing underneath. Any person that has any kind of medical condition, there's a big picture underneath. And I think maybe substance use disorder and the carnage that it's caused is really disturbing.

And sometimes it's easier to separate ourselves from that, where we don't identify them as people who have gone through a lot of stuff that led them to this. When I'm sitting across my desk from somebody, I often have the thought that if I had gone through that, I would be on the other side of the desk right now. So it's just by luck that I'm not over there. I've learned that, and it's really impacted how I interact with folks that I see. It has given me a greater understanding of the disease process. And I think that's really lacking in society as a whole, not because I think people don't care in general, it's just a developing philosophy. It's a new philosophy, whereas even 10, 20 years ago, it was like a moral failing, a weakness, that sort of thing. What's wrong with them? Why can't they just pull themselves up? But the more we dig into this, the more we can see that it's just a big picture thing, and this is a symptom of a lot of things that have happened to people in their life to get them there.

Lisa Belisle: I like the idea that you're calling it a developing philosophy, because then we're not necessarily saying to people who have had a different philosophy in the past, oh, you're wrong and you're bad for having that, because then you're just othering that group of people for that understanding at that time. We have new information, we're developing a new understanding, we're moving forward with this new understanding, and everybody's going to adopt this new understanding at different times. I think the other thing that you have said more than once that captures my interest is the fact that this really not only can happen to anyone, it does happen to everyone across every socioeconomic stratification. Yes, it may be more likely to happen with people who are adversely impacted by specific social determinants of health and trauma. And also it impacts people who grew up in relatively straightforward homes with not as much trauma.

And these are people that work alongside us. These are our brothers and sisters and our aunts and uncles and our grandparents. It's just that they end up being kind of rendered invisible, because maybe we can't see them. Maybe we don't want to see them, maybe they don't want us to see them, because there's such shame associated with this. So for me, that's the thing that chills me when I think about it, this idea that somebody feels so much shame around having this specific diagnosis that they wouldn't want me to know about it as a family member or a friend or a colleague.

Nick Gallagher: That's the term right there, is shame. I have this conversation quite frequently with many of the patients that I see, and I'm just in awe of people that I have the pleasure of taking care of. But really they're doing all the hard work. What I do is the easy stuff, they're doing all the hard stuff. They leave and then they have to go and be in the world. And the amount of determination and will and just dedication that I see in these patients, it is just overwhelming. I'm constantly in awe of what they do. If you just think about any behavior change that you've ever tried to make. I'm going to be less annoyed. That's hard. Even just driving down the road, my goal today is I'm just not going to get mad at anybody who's driving five miles an hour under the speed limit.

See how long you can go. It takes a long time and a really determined effort just to make little changes. But then you think about somebody whose whole life has been changed by this disorder, this medical condition. And I can tell you, the amount of physical symptoms that people have, you think about the worst flu you've ever had, multiply that by 10. That's how somebody feels one day into trying to make this change. Whether it's opioids or even alcohol, you take human behavior and how hard it is for anybody to make even a simple change because of habit, and then you add on this whole component of physical dependence, illness that this causes. And also over time your life becomes one that facilitates your substance use. So not only are you trying to deal with the emotional and physical aspects of things, you're also more likely to continuously be exposed to that environment where substance use is offered, is encouraged, people encouraging you to continue.

And that's where this whole shame thing that you mentioned comes into play. People in some ways don't feel like they deserve help. So they try to do it on their own, and they have to be continuously surrounded by this environment that they've been in before, because going out into the general population and saying, I have a drug use problem or I have an alcohol use problem, is not really that welcoming in our society. It's just not something that people feel welcome to do. And it hurts me to think about, because when I see some of these folks that go through so many hard things to rebuild their life, and sometimes it takes years and years of hard work and dedication and sacrifice to get to a better place and to be in recovery for the long term, and they don't even want to tell anyone. And I'm like, you are an all-star.

I can't even tell you how awesome you are and how big what you did is, and you don't even want to tell anybody. I want to get a banner and celebrate their efforts. Even after all that they've been through, which nobody will ever know, most people won't ever know, and they still feel like they have to be in hiding. When they were in substance use disorder, even in recovery, they're hiding their recovery. You know what I mean? And I think part of that is just the way it's viewed in society, that it's just not something that we recognize as an achievement. And I think that's changing. Like you said, it's developing, it's changing. With the more we talk about it, the more education there is out there, the more that's going to change and people will see that. But I get the luxury of seeing what happens after years of work and not giving up on people, riding through the ups and downs of it, and then seeing where they come out on the other side. Most people don't get to see that. So I do have sort of a biased view, in a good way, I would say. I do see that, and then I can speak about it.

Lisa Belisle: I think you're so right about being able to give people credit for remaining in recovery, because it is something that doesn't ever go away. That's the thing. It's similar to people who have HIV, that will always be with them. We've now come to a place where HIV is not in and of itself a death sentence, which is not the way it was back when it was first diagnosed, back when I first came into medicine. But substance use disorder is very similar, that this is something that will be with somebody for the rest of their life, like diabetes, like people who have diabetes who are on insulin, they will never stop taking insulin. People who have substance use disorder, who need to maybe have maintenance medication, or even if they don't need maintenance medication, they're still going to wake up and they're going to say, oh, I could go back and use the substance again. Or they might get triggered and they might really feel like they need to self-medicate. So that ability to give them credit, it feels like what we do with people who have cancer, like good job, you've made it through, this is so amazing. We do that with people who have cancer. So could we start being more open to actually supporting people similarly who have substance use disorder?

Nick Gallagher: I hope so. I would love that. It is a big achievement, and it's hard for me to describe the amount of work and time and effort that it takes. I can tell you, just being a provider, somebody who takes care of these folks, when you look at other chronic diseases like diabetes and hypertension, the treatment availability is much more robust. If you're like, oh, I have high blood pressure, saying that you have a primary care, you have the ability to get access to that, which isn't easy. I'm not saying even in this day and age it's always easy to get access to a regular provider, but if you do, you can be pretty sure that they're going to help you with those things like diabetes and hypertension.

But with substance use disorder, it's not necessarily like that. Not everybody does that. Not everybody treats it. Not everybody wants that to be part of their practice, I would say. So when you look at why the growing numbers of people with diagnosis of substance use disorder and the overdose deaths, one of the major conversations is access to care, access to care. There's just not a lot of access to care. And I can say the program that we've been developing over the last three years here in central Maine, one of the biggest challenges is because this disease really does impact everybody from every walk of life. It's really a challenge sometimes to figure out how to make policies and procedures with a program that encompasses, when you see somebody who has a car who can drive there, and then an hour later you're seeing somebody who's homeless.

So even creating policies and procedures, attendance policies or tardiness policies, or how often do I need to see people. It really is difficult because of the wide range of abilities and where people are coming from. I'm a very strong believer in individualized care, so I try to spend as much time with everybody that I see. Our philosophy is that everyone's totally different, and their disease, although the physiologic process can be explained pretty well now with all the studies that we've done and our advances in medical knowledge, we know a lot about the brain and how this process works, but that's only a little piece. The disease process in general is really an individual thing. So somebody who has a home and a car is going to be much different.

And in some ways the treatment regimen, and the way that we approach them, or how we set up a treatment program over the long term for somebody who has resources and family support, is going to be different than the person we see next to them who walks to our office with no shoes on in the winter. We do see that range of people on a daily basis. So individualized care. It is a difficult illness to manage. I think that is another reason why access to care is just not as readily available, because it's hard to set up programs at a primary care office that can accommodate that wide range of people's abilities and resources. So where we're at, we have the luxury of, that's what we do, that's who we take care of. So we're able to do that, and we're able to create policies that allow us to really care for each person individually and welcome people from all walks of life who have this illness.

And that's an important thing if you're trying to treat people. I don't ever want to lose anybody. I don't ever want to not have a program that is set up to help somebody because of where they're at in life. So that keeps it very interesting for us too. Every year we kind of review how we're doing things and change things here and there. Over the last three years, when we find little loopholes or things we could be doing better, we keep everybody in the practice, to welcome as many people as we can and care for as many people as we can.

Lisa Belisle: One of the other things that you've identified, there's so many challenges that you've identified, and this is a conversation you and I could have. We could have 12 shows and we could still be talking about this. But I think one of the things I want to close on is also this idea that, in addition to all the things we've mentioned, whether you're talking alcohol use disorder or opioid use disorder, we also have ones that are coming into the picture. We now have stimulant use disorder, for example, and people who have been maybe taking stimulants for treatment of their very significant ADHD or ADD, they've been appropriately using these medications, but not everybody is appropriately using these medications. We now have things like fentanyl being introduced into the street drugs that are out there. So that's the other interesting challenge that I see, that somebody like you, but really everybody in medicine, is dealing with. What we thought of when we thought about "addiction medicine," and I'm putting air quotes around it, and now calling substance use disorder, it's not even what it's going to be in 10 years, and it's not even what it was 10 years ago.

Nick Gallagher: No, and that's very, very accurate. I haven't been doing this for too long, but I've seen it change so much since 2015 after I got out of medical school and started my training. So nine years has changed a lot. Fentanyl wasn't even a thing back in 2015. And now that is the predominant substance that I see. I look at hundreds of drug screens a month, and heroin is almost non-existent. It's all fentanyl, and it's even being mixed into other drugs. So people are buying drugs not intending to use fentanyl, and they're getting exposed to it. And I've seen it cause a lot of problems too. So there's that thing we call harm reduction as well, which we approach most patients from that mindset. We're really looking at the whole picture and trying to figure out ways that we can talk to people about the risks of their behavior and minimize those risks as much as possible, while also knowing that we're not going to make them stop.

We're not going to make behavior change by forcefully trying to do that. So what you're saying is very relevant, in that it's one of those things we're always talking to people about, even those who aren't intentionally using things like opioids, that they're getting exposed to it and that's really dangerous. And you can see that in the overdose deaths. They're just astronomical. A lot of people are dying still. And it's a dangerous world out there. Not to be dramatic, but I kind of say it's a little Russian roulette when you use drugs on the street now, because you just don't know what you're getting exposed to. So that is an important aspect, in my opinion, really talking to patients about that, even if they're not using opioids in general that are going to put them at high risk for immediate overdose, but it's mixed in with the stimulants, it's mixed in with all these other things too. We do see things like cocaine and other prescription stimulants, and it's becoming a little more common, but still most of what we're seeing is the fentanyl, and that's just the most dangerous in the short term drug that people are getting exposed to. So we're trying to look at it from the big picture perspective and really try to reduce as much harm as we can.

Lisa Belisle: Well, again, I feel like we're just scratching the surface here, so maybe we'll have to have you come back again to talk about this. But I really appreciate you taking the time out of your extremely busy schedule to come all the way down here. Thanks.

Nick Gallagher: I'm so happy to do it. It's awesome. Thank you.

Lisa Belisle: I've been speaking with Dr. Nick Gallagher. He is the medical director with Addiction Medicine for one of our local health service organizations. He's somebody that I used to work with, and I really appreciate all the work that he does on a daily basis with people in our community who are suffering from substance use disorder. I'm Dr. Lisa Belisle. You've been listening to or watching our video podcast, Radio Maine, where we explore and celebrate creativity and the human spirit. I believe that Nick is somebody who also is celebrating the human spirit and doing his part to make sure that we continue to move forward in a positive direction with this really important problem that we've been dealing with. Nick, it's been great to have you here today.

Nick Gallagher: Great to be here. Thanks so much.