Reduce the stigma. These are normal people like you and I; it’s just that their brains are wired a little differently. Understand that these behaviors (that are so baffling) are the behaviors of a sick person. With the right amount of help, they can return to normal function. I’ve seen it. It can happen.
As a part of my series about “Heroes Of The Addiction Crisis” I had the pleasure of interviewing Mark deClouet.
Mark deClouet is a nurse practitioner whose focus in treatment is psychiatry/behavioral health and how it intersects with addiction. He is a strident advocate for increasing access to care, and he is the owner of Axis Behavioral Health and Recovery, an outpatient psychiatric and addiction clinic with two offices in Louisiana (Alexandria and Lafayette), employing six psychiatric nurse practitioners and two psychiatrists, one of whom is also board certified in addiction medicine.
Mark deClouet is a psychiatric nurse practitioner with a graduate degree from McNeese State University and post-graduate training from Arizona State University. He is board certified through the ANCC in psychiatry, and focuses his practice in addiction and geriatrics. Mr. deClouet has served on the board of the Alzheimer’s Association in Arizona and Louisiana, and has been a guest lecturer on the management of behavioral disturbances in dementia, while authoring the chapter on the management of dementia in APEA Clinical Guidelines for Primary Care. He has also lectured on the intercept between psychiatry and addiction, with a focus on opioid use disorder.
Mr. deClouet is the founder of Axis Behavioral Health and Recovery, an outpatient psychiatry and substance use disorder clinic with offices in Alexandria and Lafayette, Louisiana. Axis also provides psychiatry and substance use treatment to clinics in rural Louisiana through telehealth. Mr. deClouet is a staff clinician at Longleaf Behavioral Hospital in Alexandria, LA, where he treats patients with acute psychiatric and/or substance use disorders. He serves on the board of the Louisiana Association of Nurse Practitioners as the Health Policy Chair.
Thank you so much for doing this with us! Can you tell us a bit of your backstory?
Approximately five years ago my family and I returned to my hometown, Lafayette, Louisiana. I began Acadiana Psychiatric Solutions, which is now known as Axis Behavioral Health and Recovery (2018). I had continued to focus on developing a practice that centered around geriatric psychiatry, which is what my focus was from 2011 to 2015, when I resided in Tucson, Arizona. Networking in Lafayette is difficult. The laws governing how nurse practitioners practice are very restricting, much more so than in Arizona. This led to me becoming a staff clinician at Longleaf Hospital in Alexandria, Louisiana; which is where I met Dr. Christopher Rodgman, who is now a partner at Axis. Dr. Rodgman turned me on to the treatment of substance-use disorders, and at Longleaf Hospital I began to dip my toe in the waters of what is the crisis of our generation — the opioid epidemic.
Is there a particular story or incident that inspired you to get involved in your work with opioid and drug addiction?
Three years ago, I began stabilizing patients who came in to Longleaf who were in acute withdrawal, by prescribing buprenorphine, stabilizing them and referring them to one of “waivered” physicians in the community. I began to notice that a handful of these patients would return shortly thereafter, back in the same condition. When asked what happened to the plan that we had created for them, often the response was that they could not afford the clinical visit to continue the medication (buprenorphine) that was keeping them functional (outpatient office visits varied between 250 dollars and 300 dollars per month, with no one in central or north Louisiana accepting private insurance, Medicare or Medicaid). Dr. Rodgman and I were perplexed at the number of patients cycling back into the system. One day in early 2019, an old high school buddy of mine ended up in Longleaf because she could not afford the MAT visits and that was the straw that broke the camel’s back for me. Dr. Rodgman and I decided to begin treating opioid use disorder (OUD) with buprenorphine in our outpatient clinic (Axis). We accepted all forms of insurance (Medicaid and Medicare included). I believe it is safe to say that we have one of the largest outpatient MAT treatment for OUD in the state.
Can you explain what brought us to this place? Where did this epidemic come from?
In the 1980s “pain” became a problem to be adequately treated. Intractable pain treatment regulation passed in US states protected physicians from prosecution for treating pain aggressively with controlled substances. In 1995, the American Pain Society designated pain as a fifth vital sign, to be monitored along with respirations, temperature, blood pressure, pulse.
Based on a letter to the editor that was published in the New England Journal of Medicine, the idea that people who were in physical pain could not become addicted was transformed into an accepted truth. The false belief that only recreational use caused addiction took hold in the medical community. Everyone believed opioids to be safe for the treatment of pain.
Opioid prescribing increased throughout the 1980s and 1990s with short-acting opioids. In the mid-90s, Purdue Pharma created Oxycontin, a long-acting opioid. Purdue and other drug companies heavily promoted Oxycontin and other long-acting opioids.
The payment structure in the U.S. promoted physician practice of increased patient volume and opioid prescribing. Insurance paid for opioids, but not for physical therapy. Patients were getting excess pain pills and some turned to selling them on the street. This problem was finally recognized. After 2010, we saw a decrease in opioid prescriptions and an increase in heroin use. A few years later drug dealers started adding Fentanyl to heroin.
Deweerdt, S. (2019). Tracing the US opioid crisis to its roots. Nature, 573(7773). doi:10.1038/d41586–019–02686–2
The Netflix series, “The Pharmacist” is an excellent documentary on how this played out in New Orleans 9th Ward.
Can you describe how your work is making an impact battling this epidemic?
The challenge in treating people with opioid use disorder (OUD) is that there is no one-size-fits-all treatment strategy. It’s not as simple as say, diagnosing pneumonia and then selecting the correct antibiotic. There are multiple treatment strategies for all stages of the treatment of this disease:
(1) managing opioid withdrawals
(2) approaches to the management of rehabilitation
(3) approaches to management of maintenance, with each strategy having its own set of risks and rewards.
Prescribing a treatment strategy that is specific to the individual (meeting them where they are in their recovery) is a central tenant in this space, but in order to do so effectively you have to be able to have access to all of the various types of treatment.
In Louisiana, access to the most effective treatment reducing overdoses and serious acute care events is only available to those that can afford it. Getting an appointment with a clinician who can prescribe buprenorphine costs upwards of 350 dollars /initial appointment and 250 dollars/follow-up appointments, cash (insurance isn’t accepted). Families on the margins are having to choose between keeping the lights on versus being able to see a physician who will prescribe them buprenorphine, the most effective treatment in reducing cravings.
For those following along, it’s the cravings that lead to relapse, which leads to overdose and serious acute care related events.
Without sharing real names, can you tell us a story about a particular individual who was impacted by your initiative?
The story that does it for me happened about a month before Dr. Rodgman and I decided to focus a major part of Axis’ mission to treating those with opioid use disorder. Without getting into the specifics, an old friend of mine had ended up on my inpatient unit at the hospital. She was there following relapse after four months of sobriety with buprenorphine. Life was finally being pieced back together when her husband had his hours cut due to the slowdown in oilfield work, and they had to choose between her 250 dollars visit to a clinician for buprenorphine or keeping enough food on the table for their three beautiful kids. The kids came first, and mom relapsed on heroin to keep the cravings down. Little did she know that the heroine had fentanyl in it, and she overdosed. Fortunately, she made it and ended up in our hospital where we started her back on buprenorphine and she became one of the first buprenorphine patients at Axis. I have countless stories like this. The lack of access to care of those suffering from opioid use disorder in Louisiana is mind boggling to me, but that’s why we’re having this conversation today. BTW, she is nearly two years sober today, and killing it in the recovery world.
Can you share something about your work that makes you most proud? Is there a particular story or incident that you found most uplifting?
Every clinician at Axis would marvel you with stories of courage, resilience and fortitude. The amount of trauma that has been endured by those with substance use disorders is overwhelming. And they have been let go by friends and family at every turn, but they’re here. They’re still trying to heal. They’re finding the courage to put themselves out there and give it a go. However, we’re finding that as we provide access to buprenorphine (a medication that decreases cravings) the treatment in group therapy becomes more meaningful much quicker, and they are staying vested longer. Periods of sobriety are going from weeks to months, and cycles of sobriety are reducing in number. Group work is becoming more meaningful as life is becoming more meaningful, and our patients are being welcomed back into all forms of community (family, work and social).
It needs to be said that the treatment of those with substance use disorder can be extremely challenging. The reasons for this are many, but by-in-large they are the result of failed policies of management that stigmatized those who suffered from these disorders, contributing to a culture that marginalized these groups of individuals…and in doing so, created a culture in which these individuals often times don’t believe in themselves. It is when that belief starts to build back that they begin to show true glimpses of who they are, and that small window of transition from feeling marginalized to feeling recognized is one of the purest moments in healthcare that I’ve experienced.
Can you share three things that the community and society can do to help you address the root of this problem? Can you give some examples?
- Reduce the stigma. These are normal people like you and I; it’s just that their brains are wired a little differently. Understand that these behaviors (that are so baffling) are the behaviors of a sick person. With the right amount of help, they can return to normal function. I’ve seen it. It can happen.
- Reduce the barriers to treatment (i.e. increase access to care). Help educate the community on what treatment is available and where; and then streamline the process to accessing those programs. Public health programs exist for needle exchanges, buprenorphine access, inpatient rehabilitation, intensive outpatient programs, safe shelters for habitation and supporting organizations for health care access.
- Encourage the use of Medication Assisted Treatment (MAT). It is the only treatment for OUD that has measurable outcomes that save lives. In February of this year, the Journal of the American Medical Association did a retrospective comparative effectiveness study of 6 treatment pathways including no treatment, inpatient residential treatment, buprenorphine or methadone, naltrexone — which is an opioid blocker, and non-intensive behavioral health. The ONLY effective method for reducing overdose, death, and serious complications was medication assisted treatment (MAT) with buprenorphine or methadone. The study also showed that MAT was the least available option to patients. We need more clinicians prescribing buprenorphine, and we need them all to accept insurance.
Wakeman, S. E., Larochelle, M. R., Ameli, O., Chaisson, C. E., Mcpheeters, J. T., Crown, W. H., . . . Sanghavi, D. M. (2020). Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder. JAMA Network Open, 3(2). doi:10.1001/jamanetworkopen.2019.20622
A second study in JAMA February showed that residential inpatient treatment facilities are not providing patients with MAT.
If you had the power to influence legislation, which three laws would you like to see introduced that might help you in your work?
Well, for starters, all laws would have an influence on reducing unnecessary barriers to accessing health care. Regulation on access has had a negative effect on individuals, families and communities in ways that are too numerous to count.
Medicaid expansion in all 50 states or Medicare for all. Access to care is that important. I’m fortunate to work in a state that had the foresight to see the benefit in expanding Medicaid, but many are not. This is quickly becoming an issue as mass unemployment and increased illness due to COVID is plaguing the nation.
I would have legislation passed that granted advanced practice nurses full practice authority. While increasing access through expansion of Medicare/Medicaid would give people an avenue, there are not nearly enough physicians to treat the entire country. Advanced practice nurses would ease the burden in this capacity. These highly specialized clinicians should be able to practice to the fullest extent that their scope allows, without having unnecessary barriers to treat patients. While not a panacea for the limited number of clinicians’ problems, certainly a viable contributing solution that is turn-key in its’ ability to have an immediate impact from day one.
I would permanently extend the CMS benefits that have allowed for broad use of telehealth and audio visits, so that patients have continued access to care. You would be amazed at the number of patients who are filling prescriptions in Louisiana since the COVID pandemic. They no longer have to rely on a “ride” to the clinic monthly for a wellness check to get their medicines for hypertension, diabetes and depression. Phone call visits are being used widely, and treatment is being delivered more regularly. Diving into state and federal data on outcomes of this massive change in policy will be eye-opening. I’m hedging my bets on the increased benefit outweighing the shortcomings.
If I could have a fourth it would be to reduce the buprenorphine waiver restrictions on clinicians, so that more people suffering from opioid use disorder could have access to buprenorphine, the only outpatient treatment that has demonstrated itself in reducing the risk/incidence of overdose and reducing the risk/incidence of acute incidents requiring hospitalization.
I know that this is not easy work. What keeps you going?
Treating people with substance use disorder is difficult work. It’s a sprint from when the lights are turned on to when they are turned off, and then it’s a jog during off hours. The wins are few and far between; however, we’re finding that the access to care that we’re providing (buprenorphine), these wins are becoming more regular. Seeing lives turned around, seeing people regain their confidence and personality, seeing families reunited, seeing people rejoining the labor force, seeing them become a contributor to society…all of this makes it worthwhile.
Ultimately though, what we’re seeing here is a disease that has a treatment with medication that has good data backing its effectiveness. What we’re doing is not rocket science. It’s conscious-driven help-your-neighbor kind of work, and this is something we should all be advocating for. At the end of the day, what we’re doing is improving communities. What more in life can one ask for in their day-to-day 9–5?
Do you have hope that one day this leading cause of death can be defeated?
You know, I do. We will look back on this the same way we’re looking back on the difficulties in treating HIV and AIDS in the 90s, and here we are thirty years later and being diagnosed with HIV/AIDS is no longer a death sentence. It’s going to take cultural change though. There are large swaths of leaders in the field who are of the mindset that abstinence is the only way, and that Medication Assisted Treatment (MAT) is “substituting a drug for a drug”. We know that the data does not support this extremist way of thinking, but it’ll take more than publishing data to change the tide. It’ll take community, inclusiveness and patience.
How do you define “Leadership”? Can you explain what you mean or give an example?
I’m immediately taken back to a quote that I gave when I unsuccessfully ran for student council back in high school. “The task of a leader is to get people from where they are to where they’ve never been.” Looking back on that Henry Kissinger quote, I can see why I wasn’t successful in running for student council (Kissinger quote was not as memorable as my opponent citing Bill and Ted), but it brings up a notable quality that I try to emulate, which is getting to meaningful change often requires people/communities to change culture. The most effective way that I’ve found to do that is by being the change. Unless you’re out there doing the work, you’re not going to lead people to where you think they ought to be. For what we’re doing at Axis, that means seeing the patients for who they are, actual people who are trying to overcome a major life obstacle. They are no different than the person with unmanageable diabetes or hypertension. It means meeting with local and state community leaders in trying to enact programs that are accessible to the general population, not just those with means. It means supporting your colleagues when the work becomes difficult, because it is difficult work; and we cannot afford to have colleagues feel defeated because of this difficulty. It means being just as supportive to your patients when they succeed and when they fail. It means being accessible. It means showing up.
What are your “5 things I wish someone told me when I first started” and why. Please share a story or example for each.
- Surrounding yourself with the right people — people who not only share your vision, but can also teach and challenge you is vitally important. Cutting my own path in Lafayette was difficult. While I had support of a few colleagues, I was largely going at it alone. My experience in Alexandria has been life altering. Having access to a team who can support, teach and constructively challenge you is the difference between having a shot at changing culture versus running in quicksand.
- I am only now learning of the effectiveness of delegating appropriately. I would probably say that I am still learning to do this, and with the recent hire of our first COO (Cynthia Beverly, FNP), the pendulum is swinging towards over-delegating; however, the lesson has been intense. I might be considered a bit of a micro-manager, but I’m realizing that it may be because I have not learned how to delegate appropriately. I’m learning to be more detailed in describing why I’m delegating, and asking whether the person understands the reasoning behind the task being delegated and setting expectations for when/how the tasks are to be completed. It’s a lesson in leadership that I am not great at, but am learning quickly.
- Don’t let setbacks discourage you. Easier said than done, but it allows for a moment of pause and begs the question (1) Am I aiming too high, or (2) Am I pointing in the right direction? Angela Duckworth, PhD, is credited with this perspective. My work/life was increasingly challenging until I came across her article in mid-2018 (https://thriveglobal.com/stories/a-grit-expert-explains-how-setbacks-still-discourage-her/), about the same time that Dr. Rodgman and I kicked our grind at Axis. My perspective on setbacks changed, I stopped sweating the small things and kept my goals in perspective. Leaning on trustworthy colleagues and staff led to greater perspective of opposing viewpoints, and the stress of setbacks became less of a hindrance and more of a learning tool.
- Embrace your strengths and weaknesses. Being open with my colleagues, friends and staff about my strengths and weaknesses has made all of the difference over the past year, which is when Axis has seen immense growth. It has allowed us to pivot with the pandemic, keep our head above water with some internal credentialing issues and made for a much stronger (more resilient) team. It has taught me to constantly reevaluate who I am as a clinician and leader. One of my greatest weaknesses has been to say “yes” to any/all requests, which has nearly led to burnout on more than one occasion. Understanding the motive for why I would do that has been challenging, but it allowed me to realize a great deal about how I tick, while also making me understand that it’s ok to say “no.”
- Be open to criticism, you don’t have all the answers. See © 😉
You are a person of enormous influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
I’m a firm believer that increased access to health care can lift communities out of despair. It’s at the heart of what we’re promoting with increased access to buprenorphine. Rather than inspire a new movement, I would prefer to promote what I think is one of the leading initiatives shaping the country’s healthcare. The Future of Nursing: Campaign for Action is a strategic partnership between AARP and the Robert Wood Johnson Foundation that is empowering one of our most untapped resources, nurses, in leading the nation to lead healthier lives. Dr. Susan Hassmiller is leading a remarkable team of nurses and social workers in fostering health communities by focusing increasing access to care, promoting nursing leadership, increasing diversity in nursing and transforming nursing education. It’s something that everyone should be not only aware of but support. After all, nursing is the country’s most trusted profession. Check ’em out at https://campaignforaction.org/.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
My wife had just left for graduate school in Tucson, Arizona, and I was a year away from completing a graduate program at McNeese State. It was a trying time as we had been together since we were freshmen in undergrad, and hadn’t really experienced the world without each other. About this time, that I read The Art of Happiness by the 14th Dalai Lama, and it really changed my view on life challenges.
I am constantly pulling little morsels of knowledge from that book, and sharing it with patients. One of the takeaways in readings that followed was this quote: “Remember that sometimes not getting what you want is a wonderful stroke of luck.” I tend to always plan a few steps ahead. Often “a few steps” turns into “a dozen or so”, and I find that what was planned that far out won’t come to fruition. Rather than be disappointed, I try to see what is changing in expectations allowing me to appreciate, and how can I make the most of it. It’s not always as smooth as this sounds, but the quote is a constant reminder to be appreciative of the unexpected.
Is there a person in the world, or in the US whom you would love to have a private breakfast or lunch with, and why? He or she might just see this, especially if we tag them. 🙂
I would appreciate a cup of jo with Gabor Mate. His perspective on treatment has caused my view on the subject to change quite a bit, and I’m more at peace because of it. In the Realm of Hungry Ghosts is still as relevant today as it was when it was released in 2008, and is a constant reminder that we have a ways to go in the treatment of substance use disorders.
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