Understanding and addressing addiction
A new universit y initiative brings clinical care, research, education and community engagement under a comprehensive framework to address substance use, addiction and related conditions
By Claire Kowalick
For a health condition as complex as substance use disorder, there are no simple solutions. But the possibilities for addressing the vexing health crisis stemming from substance use and addiction substantially increase when an intentional strategic model for a system of care is applied to create a scaffold of interlinking functional practices.
That’s the aim of the Be Well Institute on Substance Use and Related Disorders, a pioneering initiative established earlier this year at The University of Texas Health Science Center at San Antonio. The novel approach to advance research, education and evidence-based treatments for substance use and addiction was created by Jennifer Sharpe Potter, PhD, MPH, the institute’s founding director.
Potter also serves as the university’s vice president for research and is a professor in the Department of Psychiatry and Behavioral Sciences. She notes that the health science center has long had a robust track record of innovative research and clinical work in the field of substance use disorder. The Be Well Institute aligns the science emerging from the university with a public health approach to address substance use across Texas.
“As a state university, it is our responsibility to use the science and intellectual gains at the health science center to improve the lives of our fellow Texans,” Potter said.
She started working with the Texas Department of Health and Human Services in 2018 to bring evidencebased practices to assist in the statewide opioid use disorder crisis. After that effort, the Centers for Disease Control and Prevention funding aided the Waiver Texas program that increased the number of providers in the state that could prescribe buprenorphine, an opioid agonist used to treat opioid use disorder.
Now, with more than $50 million in National Institutes of Health, state and other federal funding annually, the Be Well Institute operates as a highly integrated and collaborative center of excellence with national scope for research, clinical and public health programs, as well as education and community engagement to advance the field addressing addiction and related conditions.
The institute encompasses a range of projects and initiatives, including its Be Well Clinic, the physical location at the university providing patient treatment services, and Be Well Texas, a statewide in-person and telehealth program that launched prior to the establishment of the Be Well Institute and is supported by the Texas Health and Human Services Commission and other federal funding.
In addition to its in-person and telehealth clinical operation, Be Well Texas coordinates a network of more than 140 community providers treating for opioid and other substance use and providing recovery support services across the state.
Compassionate, low-barrier care
“It is about bringing compassion and treatment to everyone in a way that is low-barrier and evidencebased, and we believe that everyone deserves it,” said Tara Wright, PhD, with the Be Well Texas program and associate professor in the Department of Psychiatry and Behavioral Sciences.
Rather than trying to become a new entity that replaces established medical centers, the Be Well Institute aims to encourage a support system for established providers to help them assist their communities.
“We do not want to just come in and take over, because they know their communities the best, and they know what they need,” said Wright, who notes that substance use treatment also comes with a unique set of challenges related to governmental regulations.
“Every legislative session brings changes for substance use. It is a very fast-changing, regulatory field and we must keep up with that,” Wright said.
Individualized treatment, support
Because Texas is a large state with many rural areas, some people may not have ready access to substance use disorder treatments. The institute’s Be Well Clinic uses both in-person and videoconferencing appointments to offer life-saving services to many individuals who would not otherwise have access.
Van L. King, MD, medical director of Be Well Texas, chief of the university’s Division of Alcohol and Drug Addiction and professor in the Department of Psychiatry and Behavioral Sciences, said the clinical mission of the Be Well Institute is to be high-quality and high-impact in the San Antonio community and throughout Texas.
The Be Well Clinic does this by offering lowbarrier, evidence-based treatment incorporating medications, psychotherapies, contingency management, case management and peer coaching and support. For those who are uninsured, funding is available to supply medications and transportation to clinic appointments to minimize barriers to care.
According to King, recovery from substance use disorder involves significant lifestyle changes. Individuals ideally need a place to live that is drug and alcohol free, a stable income, options for enjoyable recreational and social activities that do not involve drugs or alcohol and access to treatment for co-occurring mental and physical illness. Along with treatment at the clinic, clinicians connect clients with programs and services that can address these other aspects so that each person has their best chance at recovery.
The goal is for people to be able to selfmanage their condition with minimal or even no formal treatment over time, said King. To bring it into perspective, consider a person who has had a substance addiction for 10 or 20 years and how long it will take that person to restructure a life without their drug of choice, he added.
“Everyone has their own story and needs. We want to support people for as long as they need support,” he said.
Be Well Clinic patient referrals come from many different avenues. Some are referred by their primary doctor or nurse practitioner, some are self-referred, others come after a visit to the emergency room and some are referred by first responders after an overdose.
“The linkages between Be Well and hospital systems in San Antonio and throughout the state are crucial,” King said. “Health care providers can help motivate patients in crisis to establish treatment to help them on their journey of recovery. The key issue is that we can treat acute problems in the hospital and reverse overdoses in the community, but unless patients have an outpatient clinic to establish ongoing care to help change their lives in ways meaningful to them, they frequently continue pursuing high-risk drug and alcohol use.”
King said retention rates at the clinic are high, especially for those with severe opioid use problems.
“We are especially encouraged by our retention rates with patients who experience an overdose reversal referred by the San Antonio Fire Department. These results are as good or better than community efforts in other Texas cities,” he said. “We plan to continue efforts to connect with other service providers in San Antonio to better integrate services for these highly affected citizens.”
Leveraging technology
Beyond the Be Well Clinic’s use of telemedicine to connect with patients, the institute is using and researching the latest technologies to make treatment more accessible. This includes a contingency management application loaded onto a patient’s mobile device to provide positive reinforcement and encouragement to attend important treatment-related activities. Researchers at the Be Well Institute are investigating other mobile applications for effectiveness.
Potter is the primary investigator of a randomized study currently underway to evaluate the effectiveness of a mobile medical application called KIOS. The study examines people in the early recovery phase who are taking buprenorphine for medication assisted treatment for opioid use disorder. Patients log in daily, rating themselves on variables such as depression, pain, drug craving and other factors that can impact drug use.
The highly individualized, evidence-informed application software tracks changes in patient symptoms over time and encourages patients to increase recovery behaviors that are associated with improvement in symptoms and reach out for appropriate support. King said this kind of support may be beneficial between therapy sessions or at times when the patient cannot reach other support to avoid drug use. An initial study of the app demonstrated very good acceptability and usability.
Another study, led by Wright, examines an application that uses chat-bot style messaging to help the user screen for possible problems with substance use and encourage appropriate follow-up.
Comprehensive training
The capstone of the Be Well Institute is a premiere evidence-based training program — the Be Well Center for Substance Use Training and Telementoring — that provides eight learning communities relatedto specific aspects of substance use disorder.
Adrienne Lindsey, DBH, director of the training program, said the need for this training was spurred because the time between the establishment of an evidence-based practice and when it is implemented in the field can take more than 17 years. This lag is especially evident in the realm of substance use disorder.
Lindsey said a prime example of this is seen in the deployment and use of treatments for opioid use disorder. The three current medications available — methadone, buprenorphine and naltrexone — are highly efficacious. However, there is a low uptake from providers willing to prescribe the medications as well as reticence of pharmacies to dispense them. She equates the problem to failing to tell a patient with cancer about chemotherapy or radiation treatment.
“It is very similar in terms of the potential reduction in mortality. The fact that we do not offer it at the scale needed, and we are in the midst of this overdose epidemic, is a related crisis and ethical conundrum,” Lindsey said.
The training center aims to be a catalyst in the implementation of effective, evidence-based practices and helping providers get the tools they need to begin implementing these practices. The sessions are for anyone who encounters people with substance use disorders, including health care providers and public safety professionals, along with individuals who have lived experience of substance use and can serve as peer recovery-support specialists.
The training program was developed based on Project ECHO, a mentorship and training model created by the University of New Mexico’s ECHO Institute. The Be Well Institute also partners with the university’s Center for Research to Advance Community Health, which uses the ECHO model.
The goal is to build capacity throughout vast areas through a “hub and spoke” model, where the hub of experts extend knowledge to the various spokes, building capacity until the hub is no longer needed. The spokes then become the new hubs, extending knowledge further, and so on.
New model for needed solutions
Substance use disorders and related illnesses continue to cause devastating consequences to communities, and people are demanding new ways to address the problem, said Potter. The work the Be Well Institute does in partnership with the state helps grow the science at the university by creating an infrastructure for asking more questions and finding more solutions. In turn, the widespread provider training and scientific innovations that emerge through the Be Well Institute benefit the entire state and ensure unprecedented access to care for years to come, she added.
“My vision of the next five to 10 years is that new treatments will come out of the institute that were developed by our scientists and deployed here, and that these treatments are informed by the context of our community and what matters here.”
– Jennifer Sharpe Potter, PhD, MPH, director of Be Well Institute, and vice president for research, UT Health San Antonio
Into the Light
Statewide fentanyl awareness campaign aims to save lives, reduce stigma
Fentanyl, a powerful synthetic opioid, is 50 times more powerful than heroin and is used to treat severe pain. Illegally manufactured fentanyl, however, is especially dangerous because people may be unaware that they are taking the drug when it is added to counterfeit pills and sold as legitimate prescription drugs.
According to the Drug Enforcement Administration, the abundance of illegally manufactured synthetic opioids appears to be the primary driver of the dramatic increase in accidental drug overdose across the nation. Since 2014, fentanyl-poisoning deaths in Texas have increased sharply, with the preliminary data showing 2,293 deaths in 2023, according to the state’s Department of Health and Human Services.
For the past several years, Natalie Maples, DrPH, MA, assistant professor in the Department of Psychiatry and Behavioral Sciences, has shaped a statewide awareness campaign about illegally manufactured fentanyl.
“In our campaign, we use a variety of different platforms like social media, within schools, billboards, TV and movie theaters,” said Maples.
The campaign aims to bring the idea to the larger community that this problem exists, and that ignoring it will not make it go away. Letting people know this is everyone’s concern aids progress in reducing the stigma around substance use disorders and opening access to treatment options, she said.
Maples was chosen for this awareness project due to her expertise in training personnel across Texas and beyond in evidence-based mental health and substance use disorder care. Since 2012, she has led the Centralized Training Infrastructure for Evidence- Based Practices.
After the first year of the fentanyl awareness campaign, Maples said they saw some success and produced more impressions than they predicted. One thing that made a difference was the targeted approach based on areas of the state with comparatively higher numbers of accidental synthetic opioid deaths.
“We were able to look at that county data to target where our campaign was going to be, because Texas is enormous,” Maples said.
The project is now funded for a third year. According to Maples, they will reanalyze the data and will sharpen their approach for targeted accuracy in regions of Texas with the highest need. They will also disseminate a wider variety of videos for Spanish speakers.
In addition, research and observational evidence over the years has led to an increased focus on preventing substance use issues before they begin. Programs in schools and a training infrastructure allow for awareness of risk factors that may mean a child or young adult is at risk of substance use, said Maples.
“Identifying people at risk is one way you can help prevent substance use.”
-Natalie Maples, DrPH, MA, assistant professor in the Department of Psychiatry and Behavioral Sciences
More Services and Education
The programming and services of the Be Well Institute continue to grow, including plans to add an adolescent substance use expert to begin a treatment program in fall 2024 as well as additional training opportunities.
Training programs are essential to spreading interest in and knowledge about treating addiction, said Van L. King, MD, medical director of Be Well Texas.
“Addiction is highly stigmatized, but patients oftendo well and go on to lead happy and successful lives. For the most severe disorders, most will need professional assistance. We want to ensure that trainees working with us realize that treating these patients is very rewarding and successful,” King said.
Medical students, psychiatry and family medicine residents, and nursing students have opportunities to rotate through the Be Well Clinic. The university and the Audie L. Murphy Memorial Veterans’ Hospital now have a joint addiction medicine fellowship that provides sub-specialty training to physicians.
“New treatments and treatment approaches are occurring regularly,” King said. “It is an exciting time, and young physicians, nurse practitioners and physician assistants appreciate having this training.”
