As the opioid crisis challenges communities across the country, Albert Einstein College of Medicine and Montefiore Health System held a full-day conference to bring together scientists, clinicians, policymakers, and community activists to discuss promising research in the field of addiction, effective treatment models for people with opioid use disorder, and the urgent need for innovation to confront the epidemic that claimed more than 70,000 lives in the United States last year.
The event, “On the Front Lines of the Opioid Epidemic,” highlighted Einstein and Montefiore’s leadership in the field of opioid use disorder, from basic and clinical research to progressive community care and outreach services. It also marked the 50th anniversary of the Division of Substance Abuse (DoSA), which was established as an Einstein methadone treatment program and has evolved into a leading provider of comprehensive outpatient care at multiple locations for more than 3,400 adults in the Bronx as a part of Montefiore.
“The promise of today is to catalyze the development of scientific solutions to arguably one of the most important public health crises that we’re facing,” said Gordon F. Tomaselli, M.D., the Marilyn and Stanley M. Katz Dean at Einstein and Executive Vice President and Chief Academic Officer at Montefiore Medicine, as he welcomed more than 150 people to the conference opening at Einstein’s Robbins Auditorium. “We’re energized by the growing ranks of faculty, staff, and trainees, as well as community partners in the Bronx, Westchester, and Hudson Valley, who are deeply committed to progress on the front lines of this pervasive challenge to human health and wellbeing.”
Steven Safyer, M.D., president and CEO, Montefiore Medicine, noted the success in fighting the opioid crisis but acknowledged the need to keep advancing in the face of changes to the epidemic, including the recent proliferation and use of synthetic drugs like fentanyl: “We have the right tools—now we have to make them work.”
The Brain’s Role in Addiction
The opening keynote address was delivered by Michael Botticelli, M.Ed., the former director of the Office of National Drug Control Policy (ONDCP) under President Obama and the current executive director of the Grayken Center for Addiction at Boston Medical Center. The first director of the ONDCP to be in recovery for substance use, Mr. Botticelli discussed how the country’s public policy has changed over time in response to the opioid epidemic and how the epidemic itself is evolving and growing to include other drugs, including synthetics and stimulants.
During the first of four conference panels, Einstein researchers discussed recent discoveries on the brain’s structures and mechanisms that control reward-seeking behavior, including addiction. While acknowledging that addiction is a complex disease, Jonathan Alpert, M.D., Ph.D., professor and chair of psychiatry and behavioral sciences at Einstein and Montefiore, noted: “It’s never just about the brain, but it’s always at least in part about the brain. Whether we’re talking about risk for addiction, risk for relapse, trust or mistrust, treatment, stigma or non-judgmental approach to addiction…one way or another, the brain is a critical organ.”
Saleem Nicola, Ph.D., associate professor of neuroscience and of psychiatry and behavioral sciences at Einstein, explained neuroscience research that focuses on how drugs highjack the brain’s reward center. His lab is exploring the effect of binges, when large quantities of drugs are taken in a short period of time, on the brains of rats. Drug binges facilitate brain plasticity and can therefore “stamp in” risky drug-taking behavior.
“The more bingeing and drugs you take, the more it becomes habitual kind of behavior,” said Dr. Nicola. In one of his recent studies, he and colleagues injected cocaine directly into two areas of rats’ brains, the nucleus accumbens and the ventral tegmental area (VTA). The results indicated the VTA is likely responsible for muffling the rats’ normal sugar-seeking behavior. Dr. Nicola suspects that cocaine suppresses the activity of VTA neurons that contain dopamine, a neurotransmitter that sends reward-seeking signals to other nerve cells.
“If we can figure out how it is that a drug of abuse like cocaine suppresses interest in alternative rewards, perhaps it can eventually lead to development of a treatment that we give to people to reduce drug intake during binges.”
Lucas Sjulson, M.D., Ph.D., assistant professor of neuroscience and of psychiatry and behavioral sciences at Einstein, discussed his research and the dearth of effective medications to treat addiction. Methadone, buprenorphine, and naloxone are available to treat opioid use disorder, but their success is the exception to the rule. Researchers have also explored non-medication treatments, including transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS), but he said both methods have had mixed results in humans, perhaps because of their inability to selectively target the two complementary pathways in the nucleus accumbens, a critical region of the brain implicated in addiction.
“These two pathways have a complex interplay we don’t fully understand but both of them are involved in initiating actions and switching between actions,” said Dr. Sjulson. “We’d like ideally to have a method where we could target these two pathways selectively in specific parts of the brain.”
Dr. Sjulson’s lab uses the neuromodulation technique known as chemogenetics, a gene therapy that can target specific neurons and coax them to express “designer” receptors on their surface. These modified neurons will then respond only to the corresponding “designer” drug, which can activate or inhibit the cells.
“It all sounds very science fiction-y but we’ve been doing this in animals routinely for over 10 years now,” he said, noting that the technique will probably be used in clinical trials for neurological disorders in the next five years. “It’s closer than you probably think.”
Kamran Khodakhah, Ph.D., professor and chair of the Dominick P. Purpura Department of Neuroscience at Einstein, speaking via a pre-recorded video message, said advances in these areas can help drive clinical care. “As Einstein and Montefiore come closer together, I believe we have an historic opportunity to join forces and more effectively tackle addiction and provide solutions that not only involve understanding brain function… but also holistically look at our patient population and provide better care and affect policy to ensure that nobody is subject to this devastating condition,” he said.
Innovation and Leadership in Clinical Care
Additional sessions highlighted how Einstein and Montefiore’s research collaboration extends from the lab to the clinic. Chinazo Cunningham, M.D., M.S., associate chief of general internal medicine at Einstein and Montefiore, noted that “our patient care has informed what we research, and that research informs the care that we deliver.” For example, she said, research found that buprenorphine treatment in Montefiore clinics improved treatment outcomes for people living with HIV and hepatitis C, as well as outcomes for their substance use disorder.
Additionally, studies about the barriers some people experience with starting buprenorphine treatment at lengthy office visits led to the development of a “toolkit” that helped patients initiate treatment at home. Dr. Cunningham and colleagues developed and implemented a program to integrate buprenorphine treatment in Montefiore’s large network of 22 primary care clinics and to educate new physicians about its use. Buprenorphine is now offered at six clinics in the network, and more than 1,000 patients with opioid use disorder have been treated.
“We cannot do business as usual,” she added. “People are dying every day. We need to be innovative and we need to expand our effort to get medications that are life-saving to people who need them.”
These efforts extend to Einstein and Montefiore’s education mission as well. “So many of these people who have learned how to provide buprenorphine treatment as part of their training [at Montefiore and Einstein] have gone on across the country to Idaho, Michigan, Oregon, Washington California, and New Mexico to start their own buprenorphine treatment programs,” added Dr. Cunningham. “That’s critically important—taking the next generation, training them to be confident to see this as part of their role.”
During a panel on models of current care, physician-researchers highlighted Montefiore’s “one-stop-shopping” approach at its opioid treatment programs, where primary care, counseling, and mental health services are available. Montefiore also incorporates medication-assisted treatment in primary care clinics and for patients at its hospitals. The physicians stressed the importance of fighting the stigma of addiction and of providing a range of treatments and services.
The promise of today is to catalyze the development of scientific solutions to arguably one of the most important public health crises that we’re facing.
Gordon F. Tomaselli, M.D.
“We do really cool things and we’ve been doing them for decades,” said Shadi Nahvi, M.D., M.S., associate professor of medicine and of psychiatry and behavioral sciences at Einstein and an internist at Montefiore. “And now the next steps are to end stigma and structural racism…to expand access to treatment both within and outside our opioid treatment programs, expand the workforce of people equipped and trained to tackle opioid use disorder and scale our model of integrated treatment to provide people with the care they need.”
Montefiore also provides primary care services at a Harlem-based syringe exchange program operated by the New York Harm Reduction Educators, or NYRHE. “Harm reduction is a different approach but just as important for people who use drugs,” said Brianna Norton, D.O., M.P.H., assistant professor of medicine at Einstein, internist at Montefiore, and medical director of the program, which she developed and launched earlier this year. “If we can meet people where they are, we have a really good chance of getting people into health care.”
Mary Jeanne Kreek, M.D., director of the Laboratory on the Biology of Addictive Diseases at The Rockefeller University, who closed the morning session at Einstein, spoke about the history of methadone treatment as well as recent neurobiological and genetic research on addictive diseases.
Evidence-Based Treatment Paths
During the afternoon sessions at the Montefiore Wellness Center at Waters Place, speakers described ongoing Einstein and Montefiore clinical research in prevention and treatment, including initiatives to review opioid prescribing data, improve residents’ education about opioid management, and collaborate on careful and appropriate tapering for some patients with chronic pain. Speakers also discussed criminal justice policies that work against people with opioid use disorder and the idea of safe injection facilities for people who may not be ready for more “traditional” treatment programs.
Montefiore and Einstein researchers are also studying the use of medical cannabis, which is legal in 33 states and in Washington, D.C., for pain and its effect on prescription opioid use.
“This is going to the other end of the continuum, when we think about how we might prevent people from beginning to use opioids, perhaps for the treatment of chronic pain or for other reasons, and what might be an alternative treatment for people who are looking for relief,” said Julia Arnsten, M.D., M.P.H., chief of general internal medicine at Einstein and Montefiore.
At Montefiore’s primary care-based medical cannabis program, where she and other physicians see about 600 patients, a recent analysis showed that less than half of the patients who were certified to purchase medical cannabis for their pain did so. The reason, she said, is that medical cannabis remains a federally-classified Schedule 1 drug; it is not covered by insurance and must be purchased with cash. The average cost for those patients in the survey, most of whom are on Medicaid or Medicare, was between $200 and $300 a month—a notable contrast to opioids, which are covered by insurance and rarely require significant out-of-pocket expense.
A History of Care
The afternoon at Waters Place also included a luncheon, awards ceremony, and a “fireside chat” with Hillary Kunins, M.D., M.P.H., M.S., a former Einstein faculty member and the current executive deputy commissioner of mental hygiene for the New York City Department of Health and Mental Hygiene, and Marc Gourevitch, M.D., M.P.H., chair of the department of population health at NYU Langone.
Among the more than 25 people honored for decades of service at DoSA was Joyce Lowinson, M.D., professor emerita of psychiatry and behavioral sciences. Hailed as a “lone wolf” in the field who persevered in the face of opposition and a lack of resources, Dr. Lowinson created a methadone clinic that sparked the beginning of the division in 1968. She also helped secure $10 million in state funds to address the issue of heroin addiction.
DoSA staff and other experts also demonstrated how to administer the nasal spray form of naloxone to reverse an overdose and distributed dozens of easy-to-use naloxone kits. Montefiore’s opioid overdose prevention program was established in 2015 and has distributed thousands of these kits, with training, at its hospitals, clinics, and in the community in the last three years.
A patient panel, moderated by Juan Martinez, administrative director of the Montefiore Wellness Center, featured patients who shared their personal struggles with addiction, their path to discovering successful medication-assisted treatment at Montefiore, and their desire to help others overcome stigma and barriers to recovery
“I put my body through a lot of abuse so now I’m paying for it,” said Acxel Barboza, who works at NYHRE. “But I still wake up every morning. And now I get to be there for other people who are suffering and I know exactly what they’re going through. I know they’re afraid and don’t know what’s going to happen next. I got a purpose now: Get up and try to be an example to them and link them to different things and give them the same choices that I have.”
Posted on: Thursday, October 03, 2019