Oct. 15, 2021
The evidence is clear: The pandemic worsened the existing opioid crisis, and substance use disorders are on the rise. Plus, the treatment and research that could help those patients were, in some places, limited and put on hold by COVID-19.
But not at Virginia Commonwealth University’s Multidisciplinary Outpatient Addiction Treatment (MOTIVATE) Clinic.
Since opening in April 2017, MOTIVATE has provided integrated care to patients with substance use disorders, treating over 400 patients a month with medication and counseling, addressing the medical and environmental causes of the patient’s disease. MOTIVATE’s association with the university and health system means that treatment comes with clinician-researchers who integrate the latest, most effective addiction research into their practice and give patients access to options like clinical trials and studies.
The past few years have brought more providers from a range of disciplines to MOTIVATE, and research has expanded to meet the growing needs.
“Not many academic medical centers have a dedicated addiction medicine clinic like we do,” said Caitlin Martin, M.D., an obstetrician-gynecologist at VCU Health and an assistant professor at VCU School of Medicine. “The idea of it being integrated within a health system, let alone an academic health system, let alone a health system where there's a number of specialties, where we all can work together under one roof, was a huge draw to me.”
And the interdisciplinary, research-infused care at MOTIVATE has never been more necessary. According to recent data from the Centers for Disease Control and Prevention, Virginia saw a dramatic, 41.6% increase in overdose deaths in 2020, compared to 2019. The CDC’s figures confirm local data from last year showing an alarming surge in opioid overdoses during the pandemic at VCU Medical Center.
Bench to bedside: Seeing impact with clinical trials, studies
For Phoebe Dacha, M.D., MOTIVATE was a place to appreciate the real impact of her laboratory research on patients.
The postdoctoral fellow at the VCU School of Medicine Department of Pharmacology and Toxicology was doing “bench work,” testing the effect of morphine or oxycodone on gut bacteria in the lab, showing how tolerance to opioids develops.
But as a medical resident seeing patients, she struggled to connect the research to practice. At MOTIVATE, where she now works twice a week, Dacha helps run clinical studies and helps recruit volunteers into them. [View Image]Phoebe Dacha, M.D., and Caitlin Martin, M.D., outside the MOTIVATE Clinic in the Jackson Ward neighborhood of Richmond. Both are clinician-researchers who treat patients for substance use disorders and integrate addiction research into their care. (Kevin Morley, University Marketing)
“Patients elsewhere often ask how to get involved in studies,” said Dacha. “MOTIVATE gives patients the opportunity to build a trust relationship with their provider and have immediate access to safe, [National Institutes of Health]-funded trials and studies.”
One current study is assessing safe medication storage practices among parenting patients who come to MOTIVATE. Patients using medication to treat an addiction often struggle to keep that medication safe — from young kids, from partners. The study tests a simple question: Does sending patients home with a lockbox help?
“When I tell them about the study, honestly, most of the patients light up. They say, ‘oh my gosh, I’ve been hiding my medicine in the underwear drawer.’ So you’re giving them a tool that’s actually going to be helpful for them,” Dacha said.
Another study is testing a drug used to treat insomnia, lemborexant, in conjunction with buprenorphine, which is used to treat opioid use disorder. The latter drug has a side effect of sleep disturbance, and the phase two clinical trial hopes to see if adding lemborexant reduces not only insomnia, but anxiety and cravings for opioids.
And a third study in the works harkens back to Dacha’s bench work on the gut microbiome: studying the effect of chronic opioid use on that collection of bacteria in people’s guts.
Through research, there are better treatments than ever
For many years, addiction research funding focused more on the basic science of addictions. But within the past 10 to 15 years, spurred by the opioid epidemic, funders have ramped up efforts to support clinical research.
“What lagged behind was taking that science and actually using it to improve treatment out in the community,” said F. Gerard Moeller, M.D., a professor and division chair of addiction psychiatry at the VCU School of Medicine. “Because the community historically had said, 'Addictions are a weakness. It's a criminal behavior. Just say no.'”
The only treatments available were counseling, group therapy or residential treatment. [View Image]F. Gerard Moeller, M.D., is the director of the VCU C. Kenneth and Dianne Wright Center for Clinical and Translational Research and the VCU Institute for Drug and Alcohol Studies.
But research shows that many people with substance use disorders benefit from a combination of pharmacological inventions — usually medication — and behavioral health interventions like therapy. There are medications to treat specific disorders, like alcohol or opioid use, as well as medications for depression, anxiety or other psychiatric conditions that often intersect with substance use. Behavioral health therapies, too, can include case management, social work, psychosocial support and recovery support.
“We still have a long ways to go,” said Moeller, who is also director of the VCU C. Kenneth and Dianne Wright Center for Clinical and Translational Research. “There's still some in the community who think medications aren't needed to treat addiction. But they’ve been shown, in clinical trials, to be effective. And that's where MOTIVATE really is focused — having all the tools in our toolbox available.”
The active ingredient in Suboxone, buprenorphine, was developed by understanding the scientific underpinnings of addiction in the brain. It helps stabilize the mental reward system that becomes dysfunctional with the disease of addiction — and allows patients to pursue other elements of their treatment, like therapy.
“Their brains can start healing,” Martin said. “These medications really do help. We have a lot of data for that so far, but we need more.”
Meeting patients where they are means expanded options
MOTIVATE has expanded over the years to meet the growing need for its services, bringing clinical research options to patients across central Virginia.
In 2019, Martin helped establish OB MOTIVATE, a program that specializes in gender-informed approaches to addiction medicine. Women struggling with substance use before, during and after a pregnancy come to the program for individualized care.
And the program isn’t confined to the walls of the clinic in Richmond’s Jackson Ward neighborhood. Martin and her team see patients at VCU Medical Center’s Nelson Clinic and the Henrico County Jail. OB MOTIVATE centralizes and coordinates care from a multidisciplinary, trauma-informed perspective.
“What lagged behind was taking that science and actually using it to improve treatment out in the community. Because the community historically had said, 'Addictions are a weakness. It's a criminal behavior. Just say no.'"F. Gerard Moeller, M.D.
VCU Health emergency rooms, too, are a vital link to MOTIVATE. A recent program, the Virtual Bridge Clinic, strengthened the ties between the emergency room and MOTIVATE. Extra staffing and improved telehealth capabilities work to start treatment sooner and immediately schedule patients for a follow-up visit at the clinic.
“We try to meet people where they are, outpatient or inpatient, as well as in residential and community based settings,” Martin said. “We coordinate their care centrally, especially pregnant people and post-pregnant people, as they go into the hospital at different times, to different places.”
Where research questions become answers for patients
Martin and her team have published the results of their ongoing research in peer-reviewed journals like Substance Abuse, the Journal of Addiction Medicine, the Journal of Racial and Ethnic Health Disparities and the International Review of Psychiatry.
Faculty Research at VCU
We are publishing a series of stories demonstrating the wide diversity of faculty research at VCU, where inquiry, creativity and innovation are synonymous with public impact research. On Oct. 20, President Michael Rao, Ph.D., and Vice President of Research and Innovation P. Srirama Rao, Ph.D., will discuss a bold and ambitious new research strategic plan that will serve as a framework to streamline future investments, leading to increased funding and growth, ultimately advancing excellence in research at the university. Please visit the OVPRI website for event details on how you can participate in the conversation.
Patient care at MOTIVATE is continually enhanced and improved based on what they’re learning in their studies. The research culture at MOTIVATE is an opportunity for researchers like Martin, Moeller and Dacha to continue to answer some of the many questions that remain.
Martin, for example, wants to look at patient-driven outcomes to treatments. Many patients say they want to be a better parent, have more security in their finances, or simply have a stable household. And she thinks treatment data should include patient-reported outcomes, not just positive or negative urine drug tests.
“People think you have to be completely abstinent from drugs or alcohol to be in recovery,” she said. “And that's not true. It's actually more about achieving a better quality of life as a citizen in your community.”
Martin also points to sex and gender differences as under-studied in addiction research. More data on how treatment variables work — or don’t — for men and women, both cisgender or transgendered, would be valuable, especially for integrating medication into the treatment.
In April, Martin received a five-year, $1 million grant from the National Institute on Drug Abuse, a career development award to help pursue some of these research questions at the intersection between gender-informed medicine and addiction medicine — specifically opioid use disorder and postpartum people.
“We know that everyone reaches recovery in a different way,” Martin said. “Every person is different, and everyone's road to recovery can look different. Our work will continue to illuminate that road for our patients.”
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