A St. Albans pediatrician helps young addicts do the “hard homework” of getting clean
Katie Tanner, Dr. Fred Holmes, and Nicky Hayden, LPN
Katie Tanner says she was always terrible at math, but she has great recall for numbers. She remembers 54-543, the number imprinted on a little white pill called Roxicet, which contains 5 milligrams of the powerful and highly addictive painkiller oxycodone. “Used to be my favorite number,” she admits sheepishly.
Another number that devastated the life of this 24-year-old St. Albans woman: 90. That’s how many Klonopin tablets she swallowed at age 19, along with nine methadone tabs, before ending up in the emergency room at Fletcher Allen Health Care in Burlington. In the midst of her overdose, Tanner bit off part of her tongue, which left her with a speech impediment.
Tanner’s brain was deprived of oxygen for 23 minutes on that fateful day in January 2007, she says. She died three times on the table and had to be resuscitated. She lay in a coma for two weeks before waking up from that nightmare only to begin another — her long, painful journey back from opiate addiction.
This week, Tanner has a number worth celebrating: On May 9, it’ll be four years since she got clean. Like most addicts, Tanner has had a few relapses since she got “on the program.” Nevertheless, today she is drug free, and she credits one man with helping her get there: St. Albans pediatrician Fred Holmes.
“Fred believed in me,” says Tanner. “He’s the only man in my life that I have an open and honest relationship with.”
Holmes, 69, has been a doctor in the St. Albans area since 1972. His medical practice, Mousetrap Pediatrics — named for the old expression “Build a better mousetrap, and the world will beat a path to your door” — has grown to eight physicians and four satellite offices, in Enosburg Falls, Milton, Swanton and Alburgh.
Since 2006, patients and families throughout Franklin and Grand Isle counties have beaten a path to Holmes’ door. In the last four and a half years, his office has received more than 4000 phone calls from Vermonters seeking his help to get their kids, or themselves, off drugs. Today, one-third of Holmes’ patients — or about 65 young people — are in recovery from substance abuse.
Why Holmes? For one thing, he’s the only pediatrician in the state who prescribes Suboxone, a brand name of the drug combo buprenorphine and naloxone, which is used for treating long-term opiate dependency. But there’s a more compelling reason, say many people who’ve been going to Mousetrap for years: Holmes takes the time to get to know his patients personally.
“He’s opened the door. There aren’t a lot of physicians who’ve opened the door to youth on addiction issues,” says Mary Pickener, the Vermont Department of Health’s substance abuse prevention consultant for Franklin and Grand Isle counties. “When youth say, ‘My life is a mess. I have nothing. I can’t go on,’ Fred has been one of those people who says, ‘Tell me your story.’ That’s been an incredible gift to this community.”
“It’s huge and very labor intensive,” Holmes explains, in the soft-spoken, matter-of-fact tone of a country doc. “When I’m treating pneumonia or an ear infection, it’s all very preprogrammed and logical and not very complicated. But folks who are struggling with addiction come with a lot of baggage. It takes a lot of conversations and a lot of time and work to build those relationships.”
Holmes has discovered that those conversations have real therapeutic value, and it’s one reason he wants to share them with a wider audience. Recently, Holmes and a group of his patients teamed up with award-winning documentary filmmaker Bess O’Brien, cofounder of Kingdom County Productions, to launch a new community film project about teens and opiate abuse in St. Albans.
Their goal: to encourage young addicts and their families to tell their stories, in their own words, so other Vermonters see people such as Katie Tanner as more than just numbers on a page.
“Numbers are sterile. They lack emotional content,” Holmes says. “If you could have been with us on a [recent] Friday morning with a 19-year-old young lady who had just spent three days doing intense intravenous drugs … It’s bad.”
Holmes can’t say whether opiate addiction is a worse problem in St. Albans, or Franklin County, than elsewhere in Vermont. “All I know,” he says, “is that what we see in this town and this office is more than we can handle.”
Better Fred Than Dead
Past the reception desk, in a windowless cubicle, Holmes — most patients just call him “Fred” — sits at a table with Tanner. She’s a friendly young woman with a round, smiling face, black glasses and long, black hair, which she repeatedly pulls in and out of a ponytail. She furiously kneads a lump of lime-green modeling clay. “I have a bunch of these at home,” she says.
Tanner’s nervous energy dates to her childhood. She was “always the bad kid,” she explains. “I was out of control, hyper all the time, an insomniac.”
There are no easy answers why Tanner turned to drugs. She has ADHD, which went undiagnosed for years. As a teen she suffered physical and emotional abuse at the hands of boyfriends, including one, an addict, who was more than twice her age. But even those factors are just pieces of the puzzle.
When Tanner returned to St. Albans following her overdose, she was placed in a group home for people with mental illness.
“That just put me over the edge,” Holmes says. “Katie no more has mental illness than you or I.”
Holmes later got Tanner a psychiatric evaluation and discovered she was “brilliant,” he says. She now volunteers at the Mousetrap Pediatrics office several days a week. Last year, Tanner wrote a questionnaire and then surveyed about 40 of Holmes’ drug-addicted patients. Their responses offered the doctor insights into their lives, including the age at which most addicts started using, which drugs they preferred, how and where they obtained them, and where those addicts are today.
Holmes discovered that many of his patients started snorting crushed pills when they were just 13 or 14 years old. “We see them now, on average, when they’re 19,” he says. “So, they’ve lost four or five years of critical developmental adolescent processes.”
Today, Holmes is considered an authority on adolescent addiction in St. Albans, but it wasn’t always that way. When he first hung out a shingle 39 years ago, Holmes had no idea his practice would evolve in this direction. In fact, even five years ago, he admits, he didn’t know the first thing about substance abuse or how to treat it.
The first person to “flip [him] into a ditch,” as he puts it, was an 18-year-old man who came to him in October 2006. Holmes already knew the teen’s full medical history; he’d been seeing the youth and his siblings since they were born. He also attended the boy’s special-education meetings regularly at Bellows Free Academy in St. Albans.
“So, he walks into my office after graduation and says, ‘I need something because I’m doing pills,’” Holmes says. “I didn’t have the faintest idea what he was talking about. I was clueless. Totally off the radar screen. It didn’t even exist in my professional experience.”
That’s not surprising. Holmes, a native of Great Neck, N.Y., attended medical school at the University of Kentucky, then did his pediatric training at the University of Vermont. In those years, substance abuse wasn’t considered relevant to a pediatric residency.
The irony, Holmes says, is that virtually all the kids he’s treated for opiate addiction were patients of Mousetrap Pediatrics all along. When he reviews their charts, he says, in retrospect he recognizes clues, including learning disabilities, behavioral problems and past traumas. How did he not connect the dots?
“Oh, I didn’t even realize there were dots to connect,” Holmes says. “None of us in this practice ever realized that this subset of the population might wind up getting into trouble with addiction to opiates.”
So, like any good doctor faced with a previously unknown diagnosis, Holmes educated himself. At first, he went back to the continuing-education literature looking for journal articles on pediatric drug abuse. He found “almost zero.”
He also approached Todd Mandell, medical director of the treatment unit at the Vermont Department of Health. Together, they set up grand rounds at Northwestern Medical Center in St. Albans to focus on pediatric addiction.
“Even then I was clueless,” Holmes says. As he explains, learning to treat young people with opiate dependencies changed all the rules. Why? When teens have been using for that long, they develop life skills that don’t exactly promote healthy doctor/patient relationships.
“If we give somebody a prescription for pneumonia, they go out and fill it, come back in 10 days, and usually they’re better,” Holmes says. “They don’t misrepresent the story or go sell their antibiotics. And they don’t come back and tell us something false when we ask them how they’re doing. That’s the nature of addiction.”
As Holmes tells his story, another patient, 25-year-old Alexis Gabree, nods knowingly.
“I know I’ve come in here and lied to you before,” Gabree says. “It wasn’t necessarily that I was drug seeking. It just depends upon where you’re at in your recovery and whether you’re ready to be honest with yourself.”
Gabree is typical of many of Holmes’ patients: She grew up in St. Albans and was a patient at Mousetrap since infancy. She was also exposed to drugs in the home from an early age. Her father is a recovering drug addict and alcoholic; her sister is an alcoholic. Her brother was hooked on opiates for years. “I guess you can say it ran in the family,” she says.
Gabree started smoking marijuana with her older brother when she was 11, in part to self-medicate. As a child, she was diagnosed with anxiety and depression. By age 12, Gabree was having full-blown panic attacks that felt to her like heart attacks. Smoking pot, she says, made her feel better instantly.
“School, to be honest with you, was a blur,” Gabree recalls. “I don’t like to look back on it. I hated it, and I was using the whole time.”
At 14, Gabree’s world collapsed when her brother died of an overdose. Though such a tragedy might serve as a wake-up call to some teens, it only accelerated Gabree’s downward spiral.
“That’s when a lot of my really bad habits set me up for what I became,” she says. “I really halted any progression for many years.”
At 18, Gabree found out she was pregnant and quit using that day. She says she stayed clean throughout her pregnancy and felt the healthiest she had ever been in her life.
Still, the stress of her untreated anxiety and depression took its toll on her and her unborn child. Gabree’s son, Cole, was born a month early and weighed less than five pounds. Three months later, shortly after her 19th birthday, Gabree tried intravenous drugs for the first time.
The needle, she says, was her “line in the sand.” Once she crossed it, she knew there was no going back.
“Now I knew I was even worse than a piece of shit for doing it,” she says. “There’s a label that comes with [being an IV drug user], and I couldn’t escape it. That’s tied to the end of your name forever.”
When Gabree was finally ready to face up to her addiction, she turned to someone she trusted and could talk to without fear of judgment: her pediatrician.
Holmes started Gabree on Suboxone. It’s been five years now, and she admits it’s been a rocky road. Quitting the ritual of “booting up” with a needle was nearly as hard as quitting the opiates themselves, she explains. Later, when Gabree began treatment for hepatitis C, which she contracted from her IV drug use, she had to give herself injections again.
“How ironic is that? This thing that made me sick, now I have to use to make me feel better,” she says. “That was a real mind fuck.”
Gabree has had other setbacks, including a heroin overdose two years ago. Since then, however, she has been clean and now lives with her son and boyfriend and holds down a steady job.
“It’s like learning to live in a new way all over again,” Gabree says. Through it all, she adds, “Fred was always there in the background.”
In a sense, that’s true. When an addict starts taking Suboxone, he or she becomes dependent on the buprenorphine and will experience withdrawal symptoms if the drug is suddenly removed.
Moreover, Suboxone isn’t regulated the same way as methadone, an older drug used for treating opiate dependency. Unlike methadone, which is administered at a hospital, clinic or drug-rehab facility, Suboxone is a take-home prescription that is filled at a pharmacy. As such, it’s more prone to abuse.
Today, Suboxone is one of the most common street drugs in Vermont, and is regularly used and abused in the state’s correctional system. Anecdotally, Holmes has heard that an 8-milligram dose, which costs $8 at a pharmacy and $10 to $15 on the street, sells for about $100 behind bars. In fact, a 2005 case study on Vermont by the federal Substance Abuse and Mental Health Services Administration reported that “buprenorphine is widely available in the state’s correctional facilities,” though it’s unclear whether inmates use the drug more to get high or get clean.
While Holmes readily acknowledges that street use of Suboxone is problematic, “About a third of the kids I’ve taken care of have come to me already having treated their own addiction to some other opiate, like OxyContin ... by buying Suboxone on the street.
“Is that good or bad? Technically, it’s illegal and inappropriate,” he adds. “But if there’s not adequate numbers of providers to take care of these kids, then they’re taking care of themselves.”
When Holmes started writing prescriptions for Suboxone almost five years ago, he was only the second doctor in the state doing so. Today, at least six other physicians in the St. Albans area alone are prescribing it. Holmes believes more treatment options are needed, and he emphasizes that Suboxone is no magic bullet. The kids still have to “do the hard homework” to get clean.
“Suboxone doesn’t fix anything. It’s a tool,” Holmes says. “What’s happening is, you’re buying time. You’re buying a day, or a week, or a month, or a year. And you come off it when you’re brave enough.”
Why don’t more pediatricians in Vermont prescribe Suboxone for adolescent addicts?
“Part of it is, many docs don’t want to get involved,” Holmes suggests. “Or they don’t want to have to take care of ‘those kids.’”
Holmes emphasizes that he doesn’t mean to be critical of other pediatricians. But the truth is, he says, many Vermont pediatricians are probably as much in the dark as he was on teen drug use five years ago.
How Big a Problem?
Holmes recalls one striking aspect of that conference: “Franklin County was the poster child for everything that’s gone wrong in Vermont.” Indeed, there’s a widely held perception that opiate abuse is more common there than elsewhere in the state.
Recent statistics don’t bear out that conclusion. The Department of Health’s most current Youth Risk Behavior Survey, from 2009, found that one in five high school seniors in Franklin County reported having taken a prescription painkiller, such as OxyContin, that wasn’t prescribed to them. That 20 percent figure is higher than the statewide average of 18 percent, but nine other Vermont counties had rates of abuse equal to or higher than Franklin County’s. Moreover, the incidence of prescription-pill abuse among Franklin County teens is virtually identical to the national average.
So, why is Franklin County perceived as having a bigger problem?
“I think the philosophy in St. Albans has been, let’s talk about it and get it out in the open,” suggests Loli Berard, the school and community coordinator for the Franklin Central Supervisory Union.
Berard, who has worked in Franklin County schools for 12 years, says this self-examination is a relatively recent phenomenon. In 2007, St. Albans experienced a rash of violent, drug-related crimes that landed on the front pages of Vermont’s daily newspapers.
“St. Albans was being touted as a very scary place, and living there, quite frankly, it was a little scary,” Berard recalls. “I don’t think anyone ever predicted that opiates would turn into such a monster.”
Admittedly, St. Albans’ self-awareness about its teen drug use has also been patchy. Last fall, for example, Charles Johnson, the Vermont Department of Education’s safe-schools coordinator, drove three hours from southern Vermont to St. Albans to attend a community meeting on teen drug problems. When he arrived, the room was empty. Confused, Johnson called Holmes to ask if the meeting had been canceled. No, Holmes informed him. No one had bothered to show up.
Since Johnson was in town anyway, Holmes asked him to stop by the office. He wanted to introduce him to one of his patients: Katie Tanner. It was Johnson who later introduced her to filmmaker Bess O’Brien.
Stories to Tell
O’Brien knew nothing about the subject before she started, any more than she did when she made films such as Journey Into Courage (1993), about sexual abuse and domestic violence, and Here Today (2002), about heroin addiction in the Northeast Kingdom. She uses a process she calls “AVA,” or “arts, voices, action,” to interview her subjects extensively, and then allows their stories to drive the narrative.
When a film is complete, O’Brien and her subjects take it on the road — “like a religious revival,” she says — speaking to audiences all over New England.
“For me, it’s all about the process,” O’Brien, 51, says. “I didn’t know anything about heroin addiction. I didn’t know anything about domestic violence. I didn’t know anything about foster care. I just knew I wanted to hear the stories of a lot of diverse people in those worlds. And, if you do it compassionately and really listen to people, then whatever comes out is the truth.”
Seated in the audience beside Fred Holmes — who footed the bill for the St. Albans premiere — are Tanner and Gabree. He asked both women to attend the screening so they could see the impact it can have, both on its subjects and on a community.
In the film, one foster child after another speaks about the anger, abandonment, distrust, guilt, shame, trauma and self-destructive behavior they endured in their lives. As Tanner and Gabree watch, both have tears in their eyes.
Afterward, each expresses mixed emotions about what it’ll be like to tell their own stories on camera for O’Brien’s next film.
“I think it’s great, to see these guys really put it out there,” says Gabree. “That’s the part that’s really getting me right now, because that could have been my child.”
Tanner seems more conflicted.
“I’m hoping this project will prevent my sisters and other people’s kids from doing the same things I did,” she says. “I had goals. I had a five-year plan; I wanted to be a writer. Now I can’t even pick up a pen without…”
Tanner breaks off, and takes a deep breath as another wave of emotions washes over her. When she was in a coma for two weeks, she’s told me, her family initially ignored her DNR (do not resuscitate) order. Thirty minutes before they were supposed to pull the plug, she woke up. Some people might regard this as a miracle. For Tanner, determined as she is now to survive addiction with Holmes’ help, it was a harsh awakening.
“This is not where I wanted to end up,” she says. “When I died, I lost so much.”