Patients with substance use disorders “often have underlying trauma or mental illness that was never addressed and led them to this place," said Ellen Eaton, M.D., assistant professor in the Division of Infectious Diseases at UAB. "Regardless of our area of medicine, we as physicians will continue to see patients presenting with substance use disorders and need to capitalize on opportunities to integrate education, treatment and care to slow the progression of the ongoing opioid epidemic."

At UAB's renowned 1917 Clinic for HIV/AIDS, Eaton directs the Outpatient-Based Opioid Treatment Clinic, where patients can receive specialized treatment including access to medications such as Suboxone, supplemental education, counseling and referrals to rehabilitation.

Even before the COVID-19 pandemic limited access to health care worldwide, Eaton and colleagues at the 1917 Clinic had been exploring ways to use telemedicine to address mental health care as well. "When you can control patients mental health issues and addiction, you can get a better handle on their HIV," Eaton said.

Implementation in the real world

With a major new R01 grant from the National Institute of Mental Health (NIMH), Eaton will explore innovative ways to expand diagnosis and treatment for these same issues to underserved patients at several Ryan White HIV clinics across Alabama. Her five-year, $3.3 million grant is titled HIV+ Service Delivery and Telemedicine through Effective PROs — or Positive STEPs for short. PROs are patient-reported outcomes, and they are a key component of the grant, which focuses on implementation science, Eaton said. "This is about implementing research-based practices in a real-world setting, with all the challenges and barriers that brings."

The first year of the project will focus on assessing partner clinics' ability to implement screening and improve linkage to mental health services and addiction services , Eaton explained. "We are going to be linking clinics and their patients to telemedicine, but before that we are asking the clinics to do a more thorough screening for those patients with mental health or substance use concerns."

The readiness assessment will include evaluation of clinics' capabilities of handling telemedicine, but also patients' willingness to participate in telemedicine appointments rather than face-to-face visits. "There is a lack of trust in technology and the security of telemedicine visits among some patients, especially our rural patients," Eaton said. But telemedicine has already proven to be beneficial for patients in the 1917 Clinic, Eaton added. "We started with telemedicine for patient safety reasons as the COVID-19 pandemic escalated, but now it is more often used for patients who are in crisis and need to talk with someone right now. A common scenario is that a patient has been released from jail or rehab and it's a Wednesday and I don't have a clinic until Monday. They may need a refill or may need to talk."

Pittman funding

Eaton's research program had another boost recently with her selection as one of the UAB School of Medicine's Pittman Scholars awards for 2021. "This is an investment in early-career investigators and in our long-term research success," Eaton said. Eaton's Positive STEPs grant, and another grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) that is focused on substance use and HIV prevention (learn more about project LEAP), are both focused on community settings.

In the future, "I'm hoping to leverage what we're doing in the hospital setting, too," Eaton said. She is particularly concerned about patients who come to UAB with infections caused by injection drug use and other problems. "They don't have HIV yet, but many of these patients have skin infections and other infectious that have been caused by opioid use," Eaton said. "The majority of these patients are uninsured and don't have a primary care doctor. Many of them have a very protracted stay with antibiotics and even surgery. By virtue of their substance use these patients often don't have a place to stay and have lost contact with their families. A lot of work I'm doing is capitalizing on touchpoints in the hospital or health system. The hospital setting is a great time to counsel them on HIV prevention, link them to HIV prevention and an outpatient addiction treatment clinic."

With her Pittman award, "I'm hoping to take the same type of work that I am doing in the community and apply these interventions in the hospital setting,” Eaton said. “I would like to focus not just on people who have HIV, but reaching patients before they have HIV so they don't end up in our HIV clinic."

Persistence pays off

Although Eaton's recent string of major grant funding is a considerable success — and is benefiting Alabama patients — it did not come easily, she emphasized. "This is my fifth year as a faculty member and I wrote multiple unfunded NIH grants over those years,” she said. “A lot of young scientists who are eager to start a research program in an area they are passionate about end up frustrated. I was tempted at times to say, 'Forget about it — I'll forget about writing grants. I'm going to just focus on seeing my patients and quit spending my nights and early mornings writing applications.'"

Toward the end of 2020, Eaton felt like she was reaching a breaking point. But when the requests for proposals that led to her SAMSHA and NIMH R01 grants came out at the end of the year, she decided to try again. "That is how I spent the holidays," she said with a laugh. "I put in the SAMSHA grant on Dec. 26 and the R01 on Jan. 1. Writing over the holidays with little kids is not ideal, but I give my mentors and my division leadership huge kudos for encouraging me to keep going. You often hear about the early-career successes, but not so much about the failures. I failed so many times but I know I'm a better writer and tougher scientist because of it. To all those out there who are not sure if they should keep at it, I say, Try one more time. As long as you love doing it, persistence pays off.”