The Future of Research Leadership
Lessons Learned from the Opioid Crisis
While medical research brings remarkable discoveries to the clinic, occasionally health care providers find themselves in the uncomfortable position of addressing health care challenges for which health care itself may be contributing. Opioid overdose and opioid use disorder continue to be a major public health challenge. More people die from opioid overdoses than from auto accidents every year.
“One early contributor to high rates of opioid-related morbidity and mortality we experience in the United States is the proliferation of opioid analgesics, particularly the acceptance of long-term use of opioids for chronic nonmalignant pain management,” said Jennifer Sharpe Potter, Ph.D., M.P.H., vice dean for research at the Joe R. and Teresa Lozano Long School of Medicine. “This sets off a cascade of events contributing to where we find ourselves today.”
“The early warning signs failed us,” Dr. Potter said. “The medical community accepted the long-term use of opioids for many types of chronic pain with insufficient supporting scientific evidence. While opioids do provide pain relief for some people, the abuse liability remains a significant concern requiring careful monitoring. Unfortunately, many of the very patients we sought to help were harmed by our failure to evaluate the evidence, and we traded one problem for another.”
Today, misuse and abuse of opioids remain unacceptably high although heroin and illicit synthetic opioids such as fentanyl feature more promptly. More people have died from an opioid-related event than deaths at the height of the AIDS epidemic. Dr. Potter states the solution is for medicine to accept the dual challenge of ensuring safe, effective and appropriate treatment for pain (including opioids for those who benefit) and assuming responsibility for the treatment of substance use disorder.
For too long substance use disorder treatment has been in the shadows of health care and not fully integrated in to medicine. The public and medical profession too often sees substance use disorder as a weakness or moral failure. “We have to come to terms with our own prejudices and biases. Opioid addiction, what I prefer to call substance use disorder, is a treatable condition. We have failed to provide sufficient access to evidence-based care,” Dr. Potter said.
“More than the shame this imposes on individuals and their families, this stigmatizing view impacts outcomes. Too many people do not seek treatment for fear of judgment and recrimination. And while the opioid use disorder crisis gets the most attention because of the epidemic of overdose deaths, stigma is a barrier to treatment for substance use disorders. Alcohol, for example, continues to be our major substance use disorder in the United States.”
To mitigate the crisis, there are excellent treatments for opioid use disorder that are available for any physician to use, yet many physicians do not treat. “Physicians as a group like to see their patients get better. Buprenorphine and extended-release naltrexone work well and are available for use in primary care with an excellent success rate. Contrary to the perception, this is a disease where there is solid hope of recovery. Primary care physicians could play an important role in reducing overdose deaths if they embraced this lifesaving, effective treatment.”
Unfortunately, failure to incorporate simple but effective therapies for many diseases is fairly common in medicine. There are many examples of this, including the low use of hydroxyurea to prevent sickle cell anemia crises and the reduced use of effective and non-toxic therapies for elderly cancer patients simply because of their age.
Dr. Potter said that it often takes 10 to 20 years for effective interventions of public health diseases to become widely used by the medical community. The current attention on implementation science, the study of how to systematically improve uptake of evidence-based medicine, reflects an effort to reduce the latency between effective treatment and uptake in general practice.
Research leadership in a population health crisis is distinct from classic medical school research leadership, which is mainly focused on laboratory space, increasing grants and contracts, and improving core facilities. While Dr. Potter also works toward the above goals like any other research dean, she said there are some unique tools she needed to implement to make progress addressing this epidemic.
Words matter: “We need to think about the impact of our words. For example, support person-first language, such as person with a substance use disorder, rather than addict,” says Dr. Potter. “Imagine the physician who learns one of his or her patients died from an overdose and realizing the individual never asked for help because the patient feared the doctor’s judgment.” Through her research and programmatic efforts, Dr. Potter envisions treatment for substance use in the mainstream of medicine, such that any health care provider can recognize and ensure treatment for any patient with these disorders. This includes providing that care in primary practice.
Be solution focused: Dr. Potter pointed out that she rarely talks about the failures that led to the crisis, but rather emphasizes ways around the current barriers to treatment, both from a patient and physician perspective. One key is to communicate clearly the pathways around these barriers. Thus, she offers low-barrier access to medical education on substance use disorder, including training on medication for opioid use disorder throughout Texas through TxMOUD, the Texas Medication for Opioid Use Disorder training and technical assistance center.
Cast a broad vision of recovery: These patients are often mired in shame and stigma, which prevents them from seeking treatment. Casting a vision to these patients of what their life could be without opioid use is the first step to successful treatment. Providing a specific and hopeful vision of the future is part of Dr. Potter’s leadership. “A crucial realization for both physicians and patients is that the data is quite good that this is a disease that can be treated effectively in many cases,” she said. She contrasted opioid use disorder treatment with a new cancer treatment that cured patients at the same rate. Every patient would be clamoring for the new cancer treatment, and no physician would think of not participating.
Use systemic solutions: This is a widespread population-based epidemic that requires systems engineering to solve. Every step of each process must be analyzed for how it affects other steps and other processes. For example, it does little good to reduce the public stigma of such patients seeking care if there are no physicians that will treat them. Thus, Dr. Potter is a leader in the Texas Targeted Opioid Response of the Texas Health and Human Services. TxMOUD expands access to compassionate, evidence-based treatment throughout the state. “This is a great example of how two state entities can partner to execute treatment delivery. We are able to offer the oversight and activities that a health care system can provide using science-based approaches. We are able to support their public health mission on a statewide basis,” she said. “And, this all supports UT Health’s mission of making lives better.”
Traditional medical school research leadership is focused on the individual superstar laboratory principle investigator. Addressing the opioid crisis requires a team-based approach in order to deal with a wide variety of socioeconomic and psychological issues that permit this disease. Dr. Potter states that leading teams is distinct from leading individuals. “Teams have personalities too, and putting the right people in the right team is a skill that requires just as much time as leading individuals.” Dr. Potter stated that her role was to create a team of teams, made up of team leaders addressing this crisis throughout the state, in order to better coordinate efforts and share best practices.
Dr. Potter combines her public health activities with her NIH research as a principal investigator of her U01 funded grant from the National Institute on Drug Abuse (NIDA) Clinical Trials Network.
Prior to the COVID-19 pandemic, the opioid use disorder crisis was the greatest public health crisis of our generation. Unfortunately, COVID-19 has made the opioid use disorder crisis worse, Dr. Potter said. “Deaths from opioid overdose are up 20 percent over this time last year. This is likely from the increased isolation and disruption of the substance use treatment infrastructure, the repurposing of so many health care resources to COVID-19, and the lack of attention on addiction given that COVID-19 dominates public health discussions.”
One of the added complications of the COVID-19 pandemic is the harm it has brought to patients with other diseases who have not received appropriate and timely care. “This is a health care cost that we will be paying for decades,” Dr. Potter explained.
Dr. Potter said her overarching goal as research dean is to support all faculty members in performing their own research while fulfilling the larger mission the institution has of making every life better. “We must balance data-driven decision-making while never forgetting our compassion and our colleagues. My perspective is we want data to provide support for decision-making, but at the end of the day it is about our people and their talents. With a finite set of resources, we can enrich the work environment as much as possible. We must set up faculty for success.
“I believe the philosophy that the whole is greater than the sum of its parts. As a leader, that is the message I want to share. Together, we can make a huge difference throughout Texas, the U.S. and beyond.”