In this Think Science program, TPR is thankful to partner with UT Health San Antonio for a discussion about substance use disorder, addiction, and Be Well Texas, a program from UT Health designed to provide statewide access to high-quality, evidence-based substance use disorder treatment that’s grounded in compassion, built on science and improved by technology. Three special guests from UT Health share some of their research and current work, and then the floor opens for a Q&A session.
TPR thanks SAWS and Lifetime Recovery for their sponsorship of “Think Science: Let’s Talk About Addiction.”
In 2021, the statewide drug poisoning death rate in Texas was 15.8 deaths per 100,000 residents, almost double the 2017 rate of 9.4 deaths per 100,000 residents. In 2022, five people a day in Texas died from fentanyl poisoning. In 2022, Bexar County was in the top three counties in the state for drug-poisoning related deaths, mostly from methamphetamine, heroin and fentanyl. We are in the midst of a crisis involving both illegal and prescription drugs. In 2023, UT Health San Antonio launched Be Well Texas in an effort to address these sobering statistics.
Our three panelists from UT Health are:
Dr. Jennifer Sharpe Potter, vice president for research, director of the Be Well Institute on Substance Use and Related Disorders and professor of psychiatry and behavioral sciences at UT Health San Antonio.
Dr. Brett Ginsburg, professor in the Department of Psychiatry and Behavioral Sciences and director of the Biological Psychiatry Analytic Laboratory.
Dr. Van King, professor of psychiatry and behavioral sciences, medical director of the Behavioral Wellness Clinic and medical director of the Texas Medication for Opioid Use Disorder program.
Below is an edited transcription of the discussion. Audio is available using the player at the top of this page (apologies for initial microphone issues with Dr. King’s lapel mic from 6.00 to 10.00 in the audio).
Dr. Brett Ginsburg: I’m happy to be here and glad to see the turnout. Thanks for coming everyone. I've been doing basic research in the substance use disorder related space for about 30 years now. I've done work in cannabinoids, stimulants, opioids. What I'd like to tell you about just briefly right now, though, involves alcohol use disorder, and while that wasn't mentioned, I just want to point out that this is another very problematic substance that people fall into a lot of problems with. So one of the things that I do in my laboratory is we measure biologic samples for medications or other chemicals that might be present. And so one of the things we've been working on is a biomarker, recently or not. Now, some of you may appreciate that we sort of already have that, and you know that police officers use that quite often if someone's had a drink recently and they take a breath sample or a blood sample, we can see alcohol in their blood, but the problem is, it goes away very fast, and so we've identified a chemical that is present after someone drinks and stays around for a few weeks. This gives us a longer period where we can see if someone's been drinking or not. And so two projects that we're applying this to that we're really excited about, one of them is in collaboration with Washington State University, and in that project, we're actually paying people not to drink. And that may be a little surprising, but it actually works really well.
If you take a breath sample that would tell you if they haven't been drinking in the last several hours. But we need to know longer-term. And so we can measure this biomarker for recent drinking, and if, over the course of several weeks, it starts to go down, we know that they've at least drank less, and we can reward them for drinking less. Hopefully, over time, they learn new habits, new behaviors, new outlets, and that can be a sustained reduction in drinking. A second project that we're really excited about, that we're doing all here at UT Health, in collaboration with both the Be Well clinic and with the imaging institute here on campus, we've just been awarded a large award to study a very new and exciting method for trying to help people reduce their alcohol use, and that is transcranial magnetic stimulation, only, non-invasive. We can place an electrode near the side of the person's head, not even touching it, and we can stimulate specific parts of their brain that we think are involved in the addiction problem, and we can then watch their drinking using this biomarker to see if we're actually helping them to drink less over time.
In addition to that, one thing we're also really excited about is we think we may have an idea for how we could use brain imaging as a non-invasive biomarker for you might call it craving, or a desire to return to drug use. And so we'll be studying whether that might be a useful way to sort of predict whether someone might be more or less vulnerable to relapse, and then we can bring other forces to bear to help prevent that. So those are a couple of the projects that I'm working on. I think you'll see the common theme here is that we like to work with groups of areas of expertise, because only by bringing in a bunch of different areas of expertise are we really going to tackle this really complicated problem.
Dr. Van King: Hello, everybody. So my name is Van King. I'm a professor here. I've been involved in treatment services, researching serious and chronic substance use disorders for over 30 years. I moved down to UT San Antonio basically to bring some treatment services back into the department, and through my great fortune, as it turns out, Dr. Potter started this initiative, which now has turned into the Institute for Substance Use Related disorders, and it has really generated this incredible new range of services that is statewide and that we continue to develop. So I just want to tell you about our Be Well clinic, and what's available now and what we see being available in the near future. We treat all types of drug and alcohol problems in an outpatient setting, and we have sufficient resources so that if people need more intensive services, say inpatient, we could readily link them to that here. As we said before, it's a low-barrier, evidence-based comprehensive clinic.
So by low-barrier, we mean having the fewest difficulties accessing care. So this is everything from funding to help those that don't have health insurance and are financially limited so they can have doctor and therapist visits, medications, lab work, and even transportation to and from their appointments. Low-barrier in that we want to get people to appointments as soon as possible. So this would include our relationship with the San Antonio Fire Department. People get overdose reversal, and they're rapidly referred to us for initiating treatment within a few days. And you know, this goes for the emergency room and the inpatient unit at the hospital as well, for similar reasons. And also low-barrier, because we use a lot of telemedicine, so allowing people to access care that's just not available to them where they live in Texas, or for people that have very tight schedules, where it’s difficult for them to get into immersive treatments and so that they can meet with professionals.
Evidence-based is another thing we say about our clinic. This means using research, proven approaches to treatment that have the highest likelihood of success training our psychotherapists [inaudible], helping build their recovery skills and insights. And our physicians and nurse practitioners prescribing food and medicines, but also giving supportive care to the patients and peer coaches, a growing new profession of individuals with lived experience that are helping people, encouraging them, taking more practical kinds of coaches, perhaps, to help them on their recovery journey. Just to also mention that we're expanding our services even now, it seems to be happening all the time, but we're going to be opening up an adolescent and young adult service here in the fall, with a faculty member that we recruited from a Harvard program just here recently, and this is a very under-resourced population everywhere, really, but in San Antonio as well. And one of the nice things is that we've got a great collaborative relationship with our general psychiatry department. So if some of these adolescents have more serious kinds of dual-diagnosis problems, then we can work collaboratively with them as well.
And I think another thing that I'd like to mention, to echo Dr. Ginsburg, is taking this sort of comprehensive approach, you know, integrating our services and other components to maximize the response to care. And so there's some other components that I think are very important as well. This year, we've got two Addiction Medicine trainees. These are physicians that are going to learn with us the subspecialty this is important, because teaching helps keep the faculty on top of the latest developments, and we also teach residents and medical students, and also have rotations through the clinic with us. We also keep our patients informed about research that's conducted in the clinic. This is important, because this is where we're learning, you know, all the forward thinking, new things that are going on in the field. Patients that are interested, they can participate in these studies. But it also keeps the faculty and the other staff on top of, you know, what's new in substance use treatment and we can give that to our patients as well. So I see our clinic really as a great example of an academic clinic where you're eating the best of all of these different aspects of the university together to provide the best care.
Dr. Jennifer Potter: It’s nice to see peer recovery support mentioned with the inside joke on that was, I said, make sure you mention recovery, because it's an important concept. And hopefully we can have a chance later in the conversation to talk about why recovery is such an important word. And folks like me, who spent a lot of time talking about substance use have been on a journey of learning to understand why recovery is such an important word when we talk about substance use disorder. So I'm Jennifer, I'm one of the luckiest people in the world, because I've had a journey of being able to see people who struggle with mental health and substance use disorders, but who have also recovered from that, and I also get to work at a university like UT Health San Antonio.
Universities have three missions: research, education and service, and at a university like ours, our service is largely clinical service, and now with our new School of Public Health, we also get to do public health service. I consider myself now, I'm trained as a psychologist, but I really think of myself now as a public health practitioner, and that's where it comes and intersects with Be Well. About five years ago, I was pretty discouraged, because I work in a field where we know a lot of things that are the solutions to address substance use and substance use disorder. Yes, we need more research, but there are a lot of things that work. What we fail to do is implement those. And it was really discouraging when we know that there are evidence-based practices. We have robust science built on decades of work that people like me and Dr. Ginsburg and Dr. King and some people in the audience here have spent a lot of time and our government has invested in and yet it wasn't translating. So for example, you heard Dr. Ginsburg talk about paying people for work related to alcohol use. That's a phenomena called contingency management. It's an evidence based practice that you heard Dr. King talk about, and I know from our data where we're using contingency management that it can work, and yet it does not get out into the community in ways that help people with a life threatening disorder like substance use disorder, and so that is extremely frustrating.
If you've ever heard me speak, it felt like, to me—I used to be an actor—that I got a call to go on Broadway at the last minute and go on the show. And it was like that because your state government, my state government, Health and Human Services called us and asked us to help them with a challenge, and the challenge was bringing evidence based solutions to Texas. It is not perfect. It is a lot of work, but because of the investment be well, Texas got a chance to bring more evidence based practices with UT Health, San Antonio, seeing what we're doing and naming us an institute, it gives us a platform to continue to invest, to elevate science, education like you heard us talking about, and clinical service and public health practice, to begin to continue to push and elevate this work that's so important in San Antonio, and not just San Antonio, to elevate San Antonio as a leader in the state of Texas and the nation and how we can do this work, because it is life work. It's life-saving work that we do, and that's why we do what we do here. So there's a saying that UT System has called #utinservicetotexas. And I see that as a fourth mission that a university has. It's one of the entities in a community that can serve, and that's really what I think is the other reason why I think we have some of the luckiest jobs in the world at UT Health San Antonio is we can also be part of serving our community, and that's what I think we do every day here.
Nathan Cone: Thank you, Dr. Potter, I'd like to start the conversation… we'll get into the science, and what y'all are working on here. But just kind of as I like a baseline, can you just very what is the exact term mean substance use disorders for those who are on the outside, perhaps listening in to this later on, but give me the what, how you all define it.
Dr. Van King: Well, I think this simple definition would be, when a person is using any kind of substance, typically, we're talking about drugs, alcohol, things like that, but that it's causing some kind of problem in their personal life, in their work life, in their family life. So that, I think, is the simplest definition. I mean, you can use the DSM criteria and severe, moderate, whatever, but if it's causing a problem and it's interfering with those things, then…
Nathan Cone: They cannot control it…
"If people are in recovery for a month, they're likely to be in recovery at three months, and if they're in recovery at three months, they're likely to be in recovery at a year. And if they're in recovery at a year, they're likely to maintain sustained recovery."Dr. Van King
Dr. Van King: Exactly. Yeah, there's some aspect to it where it's out of their control.
Dr. Jennifer Potter: One of the things you'll notice, though, is that we're not typically using the word “addiction” anymore. If a person chooses to identify themselves as having an addiction that's up to them, and that's entirely appropriate, and some people in the medical community continue to use that term. We've made a choice not to use that term, because there's stigma that comes along with that, and we make an intentional choice to be stigma free in the way that we operate, because stigma is one of the major barriers and reasons why people don't talk about substance use disorder and why people don't come forward. We said, “let's talk about addiction,” even in the promotion for this [event] because we wanted it to be accessible and for people to notice it. And we're happy to discuss it, but we talk about substance use and substance use disorder because there's a tremendous amount of stigma in our culture.
Nathan Cone: The other baseline kind of to get at is shared a few statistics at the top of the program this evening. And I'm wondering. We're based in San Antonio, but in y'all research, how do you see us right here, in this place where we live, as compared to other communities, statewide or perhaps even outside of Texas? How is the problem in San Antonio and versus other communities?
Dr. Jennifer Potter: We're tracking pretty typically with national trends. I mean, what we are seeing right now throughout the state of Texas, is fentanyl, as you mentioned at the beginning, is something that we're concerned with. In the state of Texas, we do not have the ability to test our drug supply in the way that we can in some other states. There's the presumption, based on poisoning reports and overdose mortality data that we have from poison control and from coroner reports, that there is fentanyl that is resulting in overdose deaths. So we assume that there is a significant amount of fentanyl in the drug supply. It's a reason why for anyone who might be using illicit drugs to be very aware that if you are using substances, you should be aware that you may be using fentanyl, and it's very important to test your drugs if you have access to those supplies. It is not currently legal to test drugs in the state of Texas. In the last legislative session, there was bipartisan support for that, but at the current time, it is not legal to test, so we don't know how much fentanyl is out there. We also know in the city of San Antonio, Methamphetamine is a significant issue. We know that from the fire department that responds to these calls. We know that from the coroner's office and recently, the city of San Antonio noted that in their declaration of an overdose crisis. So those are the drugs. But as Dr. Ginsburg mentioned, alcohol continues to be a significant issue always, and we're also seeing a fair amount of marijuana, which, again, is something to be concerned about. It's not necessarily always the case that marijuana, despite perceptions, is a safe substance to use. It does come with concerns and issues related to it as well.
Nathan Cone: And it's a far different marijuana today than it was 30, 50, years ago, as I read about too.
Dr. Jennifer Potter: Dr. Ginsburg could comment quite extensively on that.
Dr. Brett Ginsburg: Yeah, sure, the producers of drugs are very clever, and that's true across the spectrum, but it's certainly been the case in the in the world of cannabis that there's really been an unbridled explosion of genetic knowledge about these plants and how to get them to maximally produce the effective substance. We know it as THC Delta 9 tetrahydrocannabinol. And so these plants now can produce much, much, much more of this chemical than they could 50 years ago. It's also the case that we have a proliferation of semi-synthetic cannabinoids that I'm sure many people have seen in the community. These are not natural products, not completely. Typically, these are cannabidiol-based products. It's not really a substance that we are concerned about for abuse, but really clever chemists can take that cannabidiol and convert it into tetrahydrocannabinol, which is psychoactive, and that's what you're seeing being sold. And people have gotten themselves into some trouble with some of those products.
Nathan Cone: People don't know what it is, because they think, oh, you can buy it at Circle K…
Dr. Brett Ginsburg: That's right. And there's a presumption of safety with something that's being sold across a counter in pretty packaging. And I'll just share an anecdote. During COVID, I was bored, as we all were, and I went into shops just to kind of see what they have, you know? I always would tell people in public spaces to make sure that if you're going to pick one of these up, that you find one that's been tested by an independent laboratory.
Don't take the person who's selling you a product's word for what's in there and what it can do to you. I checked one of the products, just picked one at random and took a little picture of the QR code. And that analysis had been done 16 months prior, so the relationship between that independent lab test and the product sitting on the shelf is probably [inaudible], so even then, it can be really challenging to know what you're getting and what's in the product.
Nathan Cone: How does Be Well Texas interface with other agencies that are addressing this, like the Texas Department of Health and Human Services, for example, which also tracks drug poisoning and is presumably working to reduce injury and harm as well.
Dr. Jennifer Potter: So the vast majority of our funding right now is actually Texas Health and Human Services funding, and so we interface with them quite a lot. They are our funder. They interact with us on a probably, it feels like a daily basis in a lot of different ways. A lot of the funds that Texas receives to support the infrastructure, and I see some folks that are peer recovery support specialists in the in the audience, and a lot of the funding that we have, it's important to note all of the work that we do the program Be Well Texas is successful because of the work that well over 100 community agencies do out in the cities and communities in Texas. And so part of the job that we have is the honor to provide resources to groups throughout Texas, and the funds for that come from the federal government. So Texas Health and Human Services receives from a variety of mechanisms at the federal level, funds, and our job is to be responsible for shepherding those dollars and responsibly navigating those out into community resources. So that's a chunk of the funds that we do, and we're responsible for making sure those funds are obligated, that they're navigated, that we provide technical assistance to those groups and that they are available to our communities. And that's how a lot of our peer recovery network is done. So it's very important to recognize that that's not just UT Health San Antonio. That's a lot of community organizations here in San Antonio and everywhere. There are a lot here, right here in the city, as well as other places. The other thing that we do is we have—and Dr. King is the medical director—is this clinic, the Be Well clinic, but to describe it as a clinic sort of reduces it to a relatively small footprint. That clinic actually serves all 254 counties in Texas because it's a virtual clinic. So people can come to the clinic right here in San Antonio, but on any given day, our physicians, our nurse practitioners, our physician assistant and all of the staff there, the therapists, the case managers, the social workers, they can be serving somebody anywhere in the state of Texas. And it's a pretty extraordinary thing that that can be happening, and it's a 24 hour program now, because we have peer recovery support specialists that answer the phones 24 hours a day. So if someone calls us at 3 a.m. wanting just to learn more, there's going to be a peer on the other end of that phone who can also provide services that is experienced, they're trained, they're in recovery, they have a very particular and unique, special set of skills to meet someone where they're at and provide them with engagement, even if it's 3 in the morning. It's a pretty special program in that way.
Nathan Cone: So that is the first step that somebody who has a peer support, person, in other words, as you describe it, who has been through that, so to speak, you know,
Dr. Jennifer Potter: So, so there's no wrong door to recovery. A lot of people quit using substances on their own every day. They may or may not need treatment. They may or may not want to utilize peer recovery support services. Some people don't even know what that is. This is a relatively new concept, although they've been available in different places for a long time. Some people stop on their own. Some people don't. There is no wrong door to how you choose to manage your issue with substances. For those individuals who find themselves struggling as they go along that journey, when they decide that they need help, what the help they need and how they find that help is up to them. When they come for a treatment engagement, we will work with them to find that treatment plan that works for them. Does that make sense? So some people would disagree with me, but I really think that it's important to understand that the person who is struggling has to be part of the decision to enter treatment or to engage with a peer. Having said that, from my perspective, when there are individuals who meet criteria, now, I'm flipping into this medical world for a substance use disorder, particularly opioid use disorder—and I think Dr. King, you should comment on this as well—opioid use disorder, and some of the more severe substance use disorders, there are treatments that work well, that are most likely in a population to provide a successful outcome for that substance use disorder. Do you want to mention anything about that? Because you may disagree with me.
Dr. Van King: No, you're absolutely right, especially for the more serious, chronic kinds of substance use problems, and if we want to use opioids as [an example], so, fentanyl, heroin, things like that. There was a time many years ago when they tried to have everybody come off of opioids, and they'd send them away for months at a time, they come back to their neighborhoods, and they quickly start using substances again. And so they found that really medications in combination with psychosocial help to get people heading in a different, more positive direction in their lives, really works the best. And for most people that have these chronic problems, really some kind of medication, an opiate like methadone, buprenorphine, or perhaps a blocker like naltrexone, really are an important part at least for the beginning of people, you know, getting their lives turned around, and, you know, on a different kind of path. Especially nowadays, since it is, there was always a great risk for overdose, and, you know, and dying using these kinds of substances. But it's even much more acute now that the supply of opiates is just so powerful. And I might even mention too, folks may have heard this before, but you have no idea what it is. You get these nice little tablets. They look like valiums, they look like Percocets. You get some powder, you think it's methamphetamine, and it's really got fentanyl in it. And you know that can be a deadly combination for people, and it happens all the time, so it's just much, much more dangerous out there.
Nathan Cone: Talking about testing drugs and things like that makes me think of how in some cities, there's this kind of idea of harm reduction, right? Where we're going to give you a safe place, where you can use until you, you know, get on your track to recovery. What's your opinion on that? Do things like that work, or does that just extend the addiction, the disorder?
Dr. Van King: Oh, boy....!
Nathan Cone: There's your can of worms for the evening!
Dr. Jennifer Potter: Let's start with what harm reduction is, because harm reduction is more than—just for fairness, harm reduction is more than what was just described, with all due respect. So what I think you were describing is consumption sites, right? Yes. So a consumption site is a place where—and by the way, there are places where this is done quite commonly—a consumption site is an area, a place where someone can go who is using drugs, typically an opioid, and they use the drug there. When they use the drug there, they are observed so that they do not die. They use the drug there so they do not die, because, Dr. King cannot treat somebody who is dead, right? So that is a very extreme example of this continuum that is harm reduction. So let's, let's step back. Dr. King, in your practice, do you consider yourself to do things that would be within this continuum of harm reduction?
Dr. Van King: Some people, philosophically or whatever, think, “Well, you know, you're giving you're giving people methadone to help control their heroin use. You're giving people Suboxone.” So these are opiates themselves. You know, wouldn't it be best if they could just get off all of these drugs, and, you know, have that control over their life? Well, unfortunately, many people can't, and they keep on falling back into using these drugs, which [leads to a] high risk for terrible things happening to them. So that's a form of harm reduction as well. You don't want to insist on what you think might be the best for a person or… has the least… I think in this case, the least risk is using these medications in such a way as to keep people alive so that you can work with them. And even though, you see these, you know, consumption sites and things on the TV, and it's like, oh my goodness, but there are a lot of people there that are trying to engage these folks in reducing their use and living their lives in a somewhat different way so they're not at such risk. So there's a lot of that kind of stuff going on around these kinds of very sort of extreme sort of visuals.
Dr. Jennifer Potter: So let's jump in a little bit more. So for example, a fentanyl test strip allows an individual who's going to use drugs to be able to test in certain circumstances whether something that might kill them is in that drug. This is an individual who is going to use the drug… unless, what if they decided they might do a different thing if they knew there was fentanyl in the drug? Would they make a different choice? And what if, when they got the test strip, they also found out about a program like Be Well Texas for the moment when they were ready for treatment? Or what if, when they got that test strip they found out about, or the peer recovery support specialist who is someone in recovery and who is trained, who is supervised, who is in a community of other folks who are like-minded, who is resourced, who has funds, hopefully, to be able to help with transportation, who has resources, is also present. And what if the data told us that when somebody is provided with this information and these resources, it actually increases the likelihood, over time, that that person will engage in treatment, and the data told us it prevents mortality. Then we start to unpack this term harm reduction and go, wait a minute, maybe there's more there than just these words that say we're giving people, we're giving people drugs, and we're just causing a problem, because it's actually on a backbone of a whole lot of evidence that actually started with HIV and how we were working to overcome some of the spread of HIV. And it turns out, when you give people information and you protect them and you give them tools to keep themselves safe, there's a lot more that goes on that actually might prevent harm.
Dr. Brett Ginsburg: I just wanted to say that, you know, in the context of medical supervised medications, we do this all the time with all sorts of medications. You know, it would be ridiculous if someone with the potential for heart failure goes into their physician and says, “Well, you just need to exercise more and eat better,” and expect that, you know, abstinence from those sedentary lifestyle and you know the delicious food that we have all around us all the time would be sufficient. Often, we put people on medications, and then we manage that medication over time. We don't just give them the medication and let them go out into the world. They check in, and you check their vitals, and you make sure that things are improving or stable, at least. And we do this even with psychoactive and potentially abused drugs all the time for various other mental health conditions. So we can do this safely. We can do this effectively. And I think this gets right back to the point Dr. Potter made about stigma. You know, this idea that methadone and methadone maintenance is stigmatized because it's an opioid in an opioid-dependent person, and we need to change our thinking on that and think about it more like any other medical condition, like hypertension or gout, or anything else you could come up with that we treat with medications chronically.
Dr. Jennifer Potter: One other thing that you may not realize is you are in the only county in Texas that actually is practicing one particular form of harm reduction, which is syringe services. And that's been going on for some time now in our community, it was a bipartisan effort, and right now, because of that, there is the ability for an individual to have access to a needle that is not infected. It is not because anyone particularly wants someone to use drugs, but if they are going to use drugs, we want them to have access to a needle that will not infect them. It's a safety issue, not just for that individual. It's a safety issue for their family members, for our community, for our law enforcement, for our first responders, and it's been going on for quite some time and again, I know it's scary when we hear about other communities that are having difficulties, but it's being managed in San Antonio, and it's not in the news all the time, the skies have not grayed over, and we're managing to do this in a way that's allowing lives to be saved, and the world hasn't ended, and it's harm reduction. So I think it's really important. I'm so glad you asked that question to speak to there's lots of different ways to do that.
Nathan Cone: Absolutely. Quick technical question about the way Be Well, Texas works. I also read that it's not available, at least yet, I guess, for those under 18. Is that something that is...
Dr. Jennifer Potter: I want to thank University Hospital that made the initial funding for this possible. There's an issue with adolescent substance use in our community, if you weren't aware of that, that is true is not unique to San Antonio, but we were bound and determined to find a unicorn, which is an individual who specializes in treating adolescent addiction medicine, but we wouldn't have been able to do this without University Hospital and some baseline funding to make this possible. So…
Dr. Van King: We had a person who called us, he's getting out of a fellowship in addiction medicine for adolescents at Harvard, up in children's and in Boston, and he's going to come and join us in the fall, and he's going to be spearheading this. And, you know, I think this is great. We hear from people, you know, the community, friends, family, neighbors, like, oh, where can we, get some help for this teenager? And there's just very little out there. It's very difficult. Usually it's like, oh, send them away someplace, you know, like to another city or whatever. But then, like, what are they going to do when they get back into town and they're starting to live their life over again? Are they going to have sufficient professional treatment and other kinds of treatment resources? So it's great. Another thing that I forgot in my little synopsis at the beginning here is that we also got some funding for a mobile medical team that is going to be focused on the unhoused in central San Antonio. And that's also possible with some grant funding.
Dr. Jennifer Potter: And that was the vision of another one of our colleagues, Dr. Wright, who really envisioned that. So we're in, hopefully in contracting with that right now to bring that to vision. But the piece about the adolescents that was so important is that it's important for people and families not to have to send a young person out of town for care like this. It's also important that in addition to the great work, one of the local community resources, Rise Recovery, is one of the areas in the programs that does a lot of this work, we want to complement what Rise is doing by providing this specialized treatment to complement the support and the recovery work that Rise is doing. So that's great. It's really a service that will allow not just that individual's psychiatry, the addiction medicine care, but also the therapy, the family work that needs to go along with supporting that individual. So more to come on that.
Nathan Cone: I'd like to open it up for questions. I'll ask one more while folks are wandering to the microphone. Another technical question about Be Well, Texas. And as we know, class means access sometimes. And so how do you reach, especially with something that is based on, you know, virtual appointments and things like that. How do you reach folks that may not otherwise have access on a regular basis for things like, “Oh, I got to do a virtual doctor visit,” and things like this. How does, how does Be Well, Texas work for that.
Dr. Van King: Well, I think typically, what you know, people can either sort of reach us over the telephone. They can reach us over our website. It's, it's a very nice, user friendly website where we can get back to them. Are you talking about if people don't have…
Nathan Cone: Yeah, I think about some of those who are really in need and don't regularly have access to the tools, perhaps in order to access the program itself. The phone is there, of course. But then how do you follow up and continue on a regular basis with someone that, someone like that?
Dr. Jennifer Potter: So people can call us at 888-85-BEWELL, and we can meet you where they're at. It's important to note. About 50% of the people that we see don't have health insurance, and we're funded to see them, so we can see anyone in the state if you don't have the ability to pay. We go through a financial need calculator, and we can cover your cost of your care. That includes the cost of medication. This is all paid for. It includes the cost of labs and other issues like that, so we can take care of that. We even have the ability to use Lyft Health to be able to provide those individuals with transportation to visits. So the system is not perfect.
Nathan Cone: That's kind of what I'm getting at because you mentioned mobile ability…
Dr. Van King: I will say we, we've done visits with people who access computers at libraries like in Abilene and places. Actually this mobile medical team is part of that. These are individuals that don't have telephones and things like that. So we're sort of going where they are to help them with medical problems, but also, many of them have substance use problems and bring that to them. We've also been talking about other… still working on this, but it's a bit more of a challenge… Is finding, you know, various locations in rural areas where people might be able to sort of go there, libraries, I guess there's these agricultural kinds of community centers, yeah, where people might be so that's a work in progress, but, you know, we have done some of that.
Dr. Jennifer Potter: I think Nathan, you're highlighting a major issue, though, which is access points. We have explored a lot of different vehicles, trying to identify ways to get laptops. And we can do a visit on a smartphone, but not everybody has a smartphone. So if anyone knows anyone who's donating smartphones, we'd love to talk with them, but these the access point issue is a very real issue, and individuals who don't necessarily have Wi Fi access, or individuals who don't have a smartphone, and how do you keep that phone on? Because sometimes people will have the phone, and then the bill comes due and they're not able to pay and they lose the access. So figuring out ways to keep it active is so important, and that's one of the reasons why we were interested to Dr. King's point about the mobile service, because how do you actually create these access points in ways that feel safe and comfortable for individuals? So we reach out to a lot of different groups. There's a really important organization in San Antonio called Corazon, [and] Corazon is another one of those groups that goes out, they don't stay in their offices, they go out into the field. So how do we actually break down barriers and go to people? Don't expect people to always come to us. And that's part of what we're trying to do, but that's that it's often easier said than done. And so how do we do this work without walls?
Nathan Cone: Yeah, and to keep it continuous.
Dr. Jennifer Potter: Yeah, exactly.
Audience question: I got my masters at UTSA. And so I'm not sure if you guys know Paul Rad, so he's part of the Open Cloud Institute there at UTSA, so they do a lot of cyber data stuff. I know there is a professor here that did research on autism students, and so I coded the video cameras that collected that data, and they were trying to extract facial expressions to understand autistic patterns and kind of track their behavioral associations based off of their facial patterns. Now I'm going back for a PhD, and so I'm going to kind of build upon that. But I know you mentioned, like, the need of cell phones. There's a lot of IT infrastructure needs that I think work hand in hand. I'm not sure if you guys seen there's a TED talk a gentleman, it's called “The Birth of a Word” by Deb Roy, but he pretty much collects video footage of his household, and his son eventually ends up saying the word “water,” but they collect all that audio. But I guess to what extent do you guys see, like AI infrastructure, IT kind of playing a role in, kind of helping to elevate human experiences. I take technology kind of AI, but I know there's, I think there's a unique exchange, and especially with quantum technology coming out, which will guarantee the privacy of data, I think there's a healthy exchange that we probably have to have as far as data privacy and how we can use data enriched solutions for programs such as you're describing. Sorry, hopefully I made sense.
Dr. Brett Ginsburg: I won't speak to the cell technology, there's plenty there. I don't know if Dr. Potter has something to say about that. There are people that are investigating whether, sort of, you know, momentarily pinging someone, or geo fencing them, and seeing, are you in the vicinity of a place that we know is a problem for you and wait, stop. This could be a role for a peer, for sure. So I know those are things that are happening. And as to the other part of your question, AI, it's certainly gotten everyone's attention, for sure. It's also very much a developing concept and technology. So one of the things I mentioned at the front was this project where we're doing TMS, transcranial magnetic stimulation for alcohol use disorder. And what I didn't mention about this is that it's, it's, actually was an international consortium. We have colleagues all over the world who are doing related projects on various types of substance abuse, not limited to alcohol. And the concept is that as we collect our data, our imaging data, our TMS outcomes data, and there are other people working on this, that that will be fed into a larger data set that then can maybe help refine some of the things that we're developing. And, you know, the idea is to really supercharge this. I should mention the organization is Welcome Leap. The Welcome Fund is a philanthropy based out of the UK, but the Welcome Leap is a domestic philanthropy, and their CEO used to run Google, worked at Meta, so she has a very strong interest in sort of leveraging those kinds of concepts and bringing that to bear on improving the way we diagnose sentry substance use disorders.
Dr. Van King: I might mention just briefly that we're actually working on evaluating a couple of different digital apps in our program, one specifically for people that are early in opiate use disorder recovery, where they can put in their symptoms, and then the app will… the software learns what's going on with the person, learns what's helping them based on what the feedback is for the individual. And basically it's something that, then will give the person specific advice based on sort of cognitive behavioral principles to sort of reinforce these healthier, more positive behaviors that the individual is actually telling the software that is helping them to improve. So we're doing that, and we've got another app that's aiming to help people decide whether or not they have problems with substance use issues and whether or not… giving them some advice on what they might want to consider, to do about that,
Dr. Jennifer Potter: And that particular project is just starting, but that is using a bot. The first project is a partnership with the local business here in San Antonio. The other is a business, small business out of Colorado, in partnership with Tara Wright, who's in the audience, if you're interested, and she is working on the bot. The problem we were trying to solve with that was people contact us all the time, could we have a better level of engagement with a bot? I think that still counts as AI, although I keep learning AI is more expansive. But the goal is, is, how can we use something on the AI continuum, such as a bot to have a more authentic engagement? Actually, might they like being engaging with a bot more than doing one of my boring assessments, like answer these questions for me and tell me this? So could the bot in some ways meaningfully engage and for whom would that be useful in ways that actually enhance the experience of somebody who's coming to the web page, in ways that give us important information? Engage that individual because, particularly with substance use, you want to get them right at that moment when they're ready to talk and go “Whoa, come back. Let's talk about this right now,” and that can be hard with critical resources. The other project that we're working on is another software package that we're working on as well. WEconnect is a company out of California, and that actually is one that uses contingency management, those motivational incentives that we were talking about, and this is actually deployed right now, and that is being used, and we actually do use geo fencing in that so individuals’ behaviors—as they consent, by the way—but as they're going around in their daily lives, certain things are reinforced or incentivized, like taking their medicine or going to the doctor or doing things that are consistent behaviorally with activities of recovery. And when they do those individual things, they earn gift cards. And when they get the gift cards, those are intended to reinforce those, those behaviors that are intended to be supportive of recovery. And it we think—it's under review right now—but the data is telling us that it turns out, when you give people these incentives to support their recovery and reinforce them and congratulate them for these activities that they're doing that support that and provide them with incentives that mean something to them. They give them the ability to invest those incentives and things that are important for them. They actually do better in treatment.
Nathan Cone: It's probably better than the bot saying "You don't want to do that...you don't want to do that!"
Dr. Jennifer Potter: No, that's a little creepy! We don't want a bot like that. This is a good bot.
Nathan Cone: Yeah, the positive reinforcement, yes.
Audience question: Hi, first of all, thank you all for speaking as this is really educational. And my question, I'm curious to hear your take on the future of this issue. And I guess I'm speaking broadly as a younger person here, I'm still high school, and what I've noticed is that, you know, crises pop up, like the COVID crisis, the '07 housing crisis, they pop up and then generally they disappear, not disappear, but they get solved fairly quickly. And I'm curious to hear if you guys think that this recent uptake in drug or fentanyl crisis is something that might almost have been solved in the next decade, or if this is something that I suppose my generation would like have to put a lot of effort towards, like the climate crisis, for example, I'm just curious to hear your take on it.
Nathan Cone: Will we be continually struggling more?
Dr. Jennifer Potter: So if you look in the news at San Francisco in the in the early ‘70s, you will see headlines top of fold in these little things we used to call newspapers, no internet, and what you will see is… because it's a really good question. You will see a headline, because I've looked it up that says “the heroin crisis may destroy San Francisco,” and this is in the ‘70s. So people have used drugs for a very long time, and I anticipate people will continue to use drugs, so it may look different, but unless people like you and the other people, long after I am gone, and perhaps some of the others here, continue to recognize and do things differently about how we approach these issues, I fear that we will continue to have challenges around this, but imagine a world where when someone had an issue with substances like drugs or alcohol, and they said, “I think I have a problem.” And we said, “We can help with that,” whether we're a friend, a family or the healthcare community. And imagine we did something different, and we said, “let's work on that.” And I think we're at a tipping point where we might be closer to that than we are farther away from it. So I hope that coming to things like this work on us so we can be a little bit different in how we approach it, and then we might be in a better path.
Dr. Van King: One of the things that I think might help, and this is much more of a societal thing, is that when people have productive things to do, if people have work, and stable, strong communities, I think there's more… we could start talking about ways that we could do a bit more prevention for from people getting into trouble with drugs. Fentanyl is here. I don't know how it's going to go away, or, you know, there's always a stronger drug that can come… there's always going to be an interest in using drugs and alcohol. I think prevention is something that we haven't spent much money on, quite frankly. And so I think that that is something that, from my point of view, we should be spending more time on.
Nathan Cone: Thank you very much. Dr. Ginsburg, that reminds me though you earlier on this evening, you talked about being able to almost map somebody ahead of time to find out if there have a predilection towards addiction. Is that something that is science now, science coming?
Dr. Brett Ginsburg: So, let me temper expectation on that. We're not pre-cogging people. These are people who have already developed a substance use problem, and so once they develop a substance use problem, the way they interact with the world really changes fundamentally. And you've heard this for 30 years now. This is a brain disease. And while I can quibble with [inaudible], there definitely does look like there's a change in the way that the connection within the brain, kind of functions, and how it responds to the environment. And so if we can see someone's sort of, I don't want to say aberrant brain patterns, but these, these changes that may coincide with addiction or substance use disorder and craving and these kinds of aspects that go along with the problem. We can then track it and see if it improves. This isn't to try and pull people out and put them up against the wall. The idea here is a diagnostic. Because we we'd like to pick up people who are vulnerable. This gets to Dr. King's point about prevention. You know, if someone's vulnerable, if they've already struggled with it, they've successfully engaged with in recovery, but they may be vulnerable to a relapse, it might be nice to pick those people up and focus the attention on them to try and prevent that from happening.
Nathan Cone: Yeah, and I was just thinking also of the way folks say, I found that I have the gene for breast cancer in my family, or I've got this in my family, et cetera, et cetera,
Dr. Brett Ginsburg: Right, so, I struggle a little bit with that, because there's certainly a hereditary aspect to this, there's no doubt about it, but there's also certainly an environmental, social aspect to this. I mean, every one of you knows someone who has a family history and is totally sober. Every one of you knows someone who has a totally sober family who's fallen into problems. So it's not fate. And that's the problem I sometimes have with this. Is that people say, “Well, you know, my mom drank, my dad drank, my grandparents drank, I'm going to drink.” And it sort of becomes a self-fulfilling prophecy. So I think it's important to say, even in the most severe situation like that, we do have interventions that we can help to break that, or interrupt it, and hope that people can develop alternative pathways for their lives.
Dr. Jennifer Potter: That said, if you do have parents that drank, it is generally recommended to share and be aware of that. So just as a public health awareness, when you do have a family history of drugs or alcohol, it is very useful for that to be shared with other family members. So parents, if you know that your mom and dad or family members had significant substance use, sharing that with your children, just for their awareness, is a generally recommended good practice, so that they're aware of that, because there is some heritability, particularly with alcohol, that we know exists. So there are some, like, general things that are good habits.
Audience question: I know we're running a little over. I heard you talking earlier about a maintenance drug… methadone, like for opiates or heroin. I'm wondering what type of maintenance for recovery you're doing for methamphetamine. I've heard some, not sure if I read or heard it, but I heard that Adderall was being prescribed as a maintenance kind of thing, but I thought that was kind of kind of counterintuitive, because it's an amphetamine. But I'm just wondering what, what you guys are providing for folks that are suffering from amphetamine or methamphetamine addiction, as a maintenance.
Dr. Jennifer Potter: I'll tell you a little bit about the research that's underway. The first positive randomized controlled trial, that looked for an effect was published in 2021 that identified a combination of two medications, Naltrexone and Bupropion, it's a combination, that did have a positive effect for stimulants and those two medications in combination, it was a multi-site trial, it was published by a group called the NIDA Clinical Trials Network, and so that was one of the first multi sites looking for a medication for stimulant use disorders, cocaine and methamphetamine is a top priority of the National Institutes of Health. There are multiple trials currently underway that are looking for that, that are multi-sites. That is the only one right now that has been found. There is a significant group of individuals that are very interested, particularly in the harm reduction community, and particularly in the drug user advocate community, that are interested in studies around amphetamines as treatment for meth—I'm going to hand it off to Dr. King in just a minute—but as treatment for stimulant use disorders, I do not think that those studies will happen in the United States within the next 10 years, because it is very political, for some of the reasons that we see with opioids. But I don't know your thoughts on it from a psychiatrist, from your perspective, from a physician…
Dr. Van King: So, here's a place where there's plenty of good data that contingency management works very well for stimulant use disorder, much better, really, than any medications that we found, including amphetamines or stimulants. Something that's important to know, is that there's only more people that come to the emergency rooms in our city due to methamphetamine toxicity, so using too much stimulants, becoming psychotic, ending up in the hospital for days and maybe even getting permanent damage to their brains. The issue with prescribing stimulants to people that already can't control their stimulant use is, well, why won't they take too much of that and get into trouble with that? Maybe not everyone will, but it's a risk, and so it's something that needs to be managed. So I can't say that I'm familiar enough with these potential studies of stimulant use… prescribed stimulants for stimulant use disorders. I think they need to be studied more. It probably would require also, like how much of supply you would get. So, you know, there's a lot of different things that you would need to, you know, it's not as simple as, you know, “Oh, I'll prescribe this for a month, and here you go. You're going to be better.” There's a lot of, you know, potential risk to it. Just as you wouldn't necessarily do that with other kinds of medicines without close follow up, methadone even.
Dr. Jennifer Potter: But there are a number of trials looking for new therapeutics for methamphetamine.
Audience question: I was really excited when I heard that UT Health was coming on board with an addiction medicine program and clinic. I thought that was very progressive and forward thinking. And as somebody who struggles with weight and also who has a family member who struggles with alcohol, seeing these programs come to light, I was really excited about it, and I very much appreciate the work you are doing with underserved people of the community. I'm wondering, in reference to weight loss, I know we haven't really talked about that tonight, and that's okay, but I know that there's a lot of weight loss drugs that are out in the market right now, and a lot of people's plans aren't covering them. I have coworkers and friends who are trying to pay $500 a month, $400 a month, and even for the drugs that aren't, like the Moderna and the Ozempic, the less sexier drugs like Qsymia, that not only help with appetite suppressant, but work with triggers in the brain, and they work in a whole different way. But I'm wondering if your programs help with people who have insurance or having difficulty with that. I was disappointed to see that UT Health actually cut funding on weight loss drugs recently. I think it was with the new calendar year. But I'm just wondering if the clinic has assistance with that, or what you can tell me about that.
Dr. Jennifer Potter: So I'm happy in my role to make some connections to those programs, but that's not something that we treat in our program, although I appreciate the challenges that you're describing. Health care is expensive, and it's one of the reasons that we were excited that our program able is able to do that. But unfortunately, we really do focus on the drug and alcohol use.
Audience member: I’m wondering if maybe I'd seen something else because I had seen obesity topic with it, and maybe it's a separate clinic here that I'm confused about.
Dr. Jennifer Potter: Well, you are talking to someone who can connect you to the right place, so I'm happy to give you my card and I will connect you to wherever. I'm not sure what you're referring to, but I'm really happy to connect.
Nathan Cone: As a way to wrap up here this evening, I was wondering if each of you could maybe take just a couple of moments to look towards the future for what your hopes are for this program, as well as what your own research and studies are going to be focused on in these in these two to five years going down the road here.
Dr. Brett Ginsburg: So one of the things that kind of came up, and we didn't really get a chance to get too deep into it, was the concept of recovery, and learning how recovery can be successful and what truly challenges recovery. And so some of the research that we've done in the past we're hoping to stand back up again, funding is really challenging right now. Funding is very challenging, especially in this space, but we want to know what happens when someone engages in successful recovery, what changes and what we're learning is that it changes the way the person responds to those things that used to be as someone else called them, triggers. So those things that might have prompted a drug-seeking response or return to drug use that changes over time, and it really emphasizes an important point here, this tight junction between medication and behavioral [inaudible], because you can give someone a drug that will eliminate all of their cravings. They don't ever need to go seeking it again, because they can just go to the clinic. And yet, they haven't really learned how to be substance-free, in a sense, in the community. They really need to learn how to fill those gaps in their lives that they're filling with their substances. So for instance, if someone comes home every day and what they do is they sit in the couch, they turn on the TV and they start drinking, well, we need to find a way that they can learn how to be at home and not be drinking. What else can they do besides that damaging behavior? And so I think that really learning how to optimally apply these medications to help reduce some of the physiologic hallmarks of substance use disorders, and also how to strengthen their behavioral repertoire so that they can learn to live without the substances, or at least with a managed substance situation. That's my hope for the future, is that we get better understanding of how to improve recovery for people. We know that if people are in recovery for a month, they're likely to be in recovery at three months, and if they're in recovery at three months, they're likely to be in recovery at a year. And if they're in recovery at a year, they're likely to maintain sustained recovery. And so getting them to that first month period, that three month period, these are really critical times, and it's really challenging when people, I mean, if anyone's tried and thought, well, maybe, you know, for a New Year's resolution, I'll go work out a little bit. It's easy the first week. It's really easy the first week. But how do you get into a habit of healthy behavior? And so for me, that's what I hope we address in the future.
Nathan Cone: And that speaks to the importance of integration into society and peer support.
Dr. Van King: Well, so what I'm interested in doing here at this point is continuing to work on developing our clinic, so it's increasing capacity, increasing expertise or helping a wider variety of people, both in San Antonio and across Texas. Continuing to train individuals in some specialty, but also more generalists, because there is a mandate, I would say, to get generalists, physicians and other health practitioners to do more treatment of substance use problems. Not everybody has a very severe substance use problem. It would be great if, if general physicians and other health practitioners, we could recognize these kinds of conditions early on and help people to not develop such serious conditions. So I think those are the things that from my point of view, I'm going to be looking at working on here over the next few years, and I would say that it's important to remember that a lot of people do great! You know, they get control of their substance use problems, and live happier and more productive lives! And that's one of the things that that actually attracted me to substance use problems. You know, I'm trained as a general psychiatrist, but once I became involved in treating… and this was in a methadone maintenance program where I spent a lot of years before I came to the University of Texas. Now, people do great, you know, they get their lives back. They get their families back, and I think that that is the appealing thing to me about being a medical director and working and treating patients on a daily basis, and substance use treatment. You see all the negative stuff, in the newspapers and all over, but really, a lot of people get a lot better. There's a lot of positivity there.
Dr. Jennifer Potter: So when I started this activity, I used to say, I don't want any more pictures of parents holding pictures of their dead children, and I still believe that. And I think we have a lot more because of groups here out in the audience and a lot of others. And we have a small role in that, a very small role, but I'm grateful for that. We still have work to do, because not everybody is ready for what's out there and the services that are available. And I struggle with that. I struggle with when people aren't ready, when they're not at that moment, when they're not ready to connect is when we lose people. So it's not the first time or the second or the third, it's how do we keep going for the fourth and the fifth and the sixth and the seventh and so on? And how do we activate that intrinsic motivation that allows somebody those moments of connection when they're not ready the first or the second time? So I used to say I want it on demand for everybody the moment they're ready, but we've got to have resilient systems that stick with it for the moment when they're ready, even if it isn't the first time or the second time. So I think that's where we're headed with the next little while… and addiction, adolescent treatment! So, 885-BEWELL, and that'll connect you to us and also other organizations that we can connect you with.
