Opioid partial agonists may hold the key to recovery for many people who are dependent on opioids.
By Daniel Oppenheimer
Editor, Texas Health Journal
Dr. Jennifer Potter began a recent public presentation on the opioid crisis with a picture of “Max,” a young man who died of an overdose. Potter didn’t know or treat Max, but she uses his picture and his story for two reasons. One is to put an individual face to the tens of thousands of Americans dying every year from opioid overdoses (63,000 in 2016). The other is the complexity of his life and death, and how it’s a reflection of this multifaceted crisis.
“Max started in recovery,” says Potter, a professor of psychiatry and the director of the Opioid, Pain & Addiction Laboratory (OPAL) at UT Health San Antonio’s Joe R. & Teresa Lozano Long School of Medicine.
Before his last, fatal relapse with opioids, Max had been doing well on the drug Suboxone, which is an opioid partial agonist—a kind of opioid-lite—that allows people to manage their opioid dependence more safely. He was managing his substance use and his prospects looked good. Then he was in a car accident.
“He needed to have surgery,” says Potter. “Max’s dad is a doctor, and he and the surgeon were good friends. They agonized over what to do. If they didn’t treat Max’s pain adequately, there was a real risk he would seek opioids elsewhere, without any medical supervision. Ultimately, they decided the least bad option was to start Max on an opioid medication for the very real pain he had after surgery. Unfortunately, he was triggered by that event. He had a relapse, and that relapse ended in his death. They did the best they could. The research doesn’t tell us the right thing to do in that situation.”
Max’s case isn’t necessarily typical, says Potter. What’s typical is people with opioid problems, and their health care providers, facing scenarios and choices that don’t have clear answers. The majority of people who use opioids to treat pain, for instance, will never develop a dependence on them. For these people, opioids may be the most effective and humane treatment for their pain. For those predisposed to addiction, an opioid prescription may be the first step on the road to addiction and even death from overdose.
“The problem is we don’t know in advance who is or is not at risk,” says Potter. “So how do we serve both of these communities, both of whom deserve good, high-quality pain care?”
Other complexities abound. Opioid addiction isn’t one problem, but a family of overlapping and intersecting problems. It matters, in terms of treatment, whether the addiction is to a prescription opioid like Vicodin or to illicit heroin. It matters whether heroin users inject or smoke or snort. It matters whether a patient has chronic pain or not. Co-occurring substance use problems or mental health issues change the picture. A patient’s history of substance use dependence is important, as is the family and community support they have or don’t have.
Each factor changes the profile of the person struggling with dependence. Even two people whose profiles look roughly the same have different genetic and epigenetic profiles. In an ideal world, the science would be able to indicate precisely the right treatment for each person and we would have the resources to provide these tailored treatments. In the real world, the research is far less precise and resources are constrained.
Much of Potter’s work, for the last 15 years, has been dedicated to advancing the research half of that equation. Among other work, she has served as a leader of the Texas arm of the National Drug Abuse Treatment Clinical Trials Network (CTN), and was for years the national project director for the Prescription Opioid Addiction Treatment Study (POATS), the largest multi-site clinical trial ever conducted to examine treatment of prescription opioid dependence in individuals with and without co-occurring chronic pain. She has also done a great deal of work helping to build a basic foundation for how to do high-quality research in this field.
Her long-term goal is to better understand the many different factors that can affect addiction, response to treatment, and outcomes. She has looked at gender differences in what kinds of opioids people use, how they become addicted and how they respond to treatment. She has examined ways to keep young people in treatment. She is currently conducting a study with the military health system to assess the feasibility of implementing a prescription drug monitoring program. She has published guidelines for clinicians on how to treat pain while being sensitive to the potential for misuse of opioids.
Her most significant work has been on the POATS project, which followed 653 people who were seeking treatment for addiction to non-heroin opioids. The participants were first given a four-week course of Suboxone treatment, then taken off the medication. They were then followed for eight weeks. If they did not respond to the treatment, they were offered an additional three months on Suboxone before being tapered off. A follow-up study tracked outcomes for another three and a half years.
A very clear pattern emerged, says Potter. Over 90 percent of people offered only a four week treatment—basically a detox—failed to respond. In contrast, almost half the participants responded well to staying on the medication for longer. Over time, the number of people who responded to medication increased.
“For many people, drugs like Suboxone are an essential part of recovery,” said Potter. “That can be difficult to accept both for the patients and their families. But this is a deadly, deadly disorder, and we can’t help people get to a path of recovery if they are not alive.”
Potter compares the regular use of medications like Suboxone to using medications for other chronic diseases, like diabetes and hypertension.
“When somebody has diabetes, and you give them insulin and they do well, we keep prescribing it to them,” she said. “We don’t suddenly take them off of it. For some people with substance use disorders, it’s the same thing. They need their medication to stay healthy and address the disease. We shouldn’t judge someone with substance use disorder, just because it has behavioral components, when we don’t judge hypertension sufferers for taking their medication. There are behavioral components to hypertension as well.”
For Potter, the need for more compassionate, more evidence-based treatment isn’t just a clinical concern. It’s also personal. She has addiction in the family. Often she tells her own family’s story, along with Max’s, because tragedy is not the only outcome of opioid dependence. There is also recovery and hope.
“I believe that in human relationships we give gifts, and one of the gifts I have to give, to people who have someone in their life who is struggling with a substance use disorder, is my honesty about my own family’s struggle. And the message to not give up.”