CBAM sat down with Dr. Matthew Worley to find out how his interest in research and the field of addiction have developed. Dr. Worley is a long-time CBAMer, having been a staffer on two of our addiction research projects before going off to graduate school. He rejoined us in 2013 as a postdoctoral research fellow.
How did you decide that you wanted to pursue a PhD in Clinical Psychology?
I took a general psychology class in high school because mainly I was interested in what drives human behavior and why people do the things they do. In college I then took a couple of courses in the clinical area of psychology, like Abnormal Psychology, and learned about the dysfunctional piece of human behavior, such as different disorders and their symptoms. I found this very interesting. We also learned about different types of therapy. I was intrigued by this idea that a one on one interaction can help coach people to correct dysfunctional behaviors and provide them with skills to feel better. I met with a professor of one of the clinical courses and asked him, “What do most people do to get where you are?” He gave me some good advice, which was to get a job working with psychologists and doing research to prepare to apply to a PhD program in psychology. As a result, my decision coming out of undergrad was to apply to research-related positions and get a job in a lab, which is what ended up happening.
What kind of research did you do straight out of college?
I worked with a psychologist at the University of Pennsylvania named Paul Crits-Christoph. He is a major name in the field of psychology and treatment research. He was the Primary Investigator on the largest multi-site clinical trial for cocaine dependence ever conducted. He had a very strong track record of helping students build higher level research skills and setting them up to enter graduate school. I worked on a study that used performance improvement as an intervention for substance abuse treatment clinics. Patients would participate in group substance abuse treatment sessions, and then fill out surveys about their level of satisfaction and alliance with the group leader. We would take the numbers from the surveys and provide reports to the clinic on a weekly basis to allow treatment providers at the clinic to look at their different areas of performance. This method provided real time feedback for clinicians and the clinical directors.
Is that experience how you got interested in substance abuse and addiction?
It was, because I didn’t have a specific interest in addiction when I came out of undergrad. When I worked with Paul, I got the chance to interact with counselors in treatment settings and learned a lot more about addiction and started reading more about it. I became really interested in this idea of a persistent continuing behavior that just does not make sense, that people want so hard to stop and have so many reasons to stop but so many of them can’t. I became exposed to this idea that it is a very difficult disorder to treat and that a lot of people who get treatment tend to relapse, and that current treatment doesn’t work very well in the way it’s currently delivered. It’s also very interesting from a biological and medical perspective, because drugs affect the brain in pretty strong ways, so you can look at this problem from many different angles: biological, psychological, and behavioral. Once I got exposed to this specific field I started to develop those interests more.
How did your interest in statistics come about?
Before graduate school, I had done very basic statistics. I started to realize that it would be a good idea to learn many different kinds of statistical techniques because addiction is a very complex behavior and problem. I personally believe that in order to learn more about a complex problem like addiction you need to use methods that represent that complexity. I became more interested in multivariate and longitudinal statistics after taking our second year statistics course. I spent the rest of that year on my own trying to strengthen those skills. The good thing was that my advisor had a lot of big data sets to analyze. This was another driver of my growth in statistics: having the availability of appropriate data to do this statistical analysis on an advanced level.
What are you working on now?
I became interested in the intersection of chronic pain and prescription opioid abuse and addiction during my clinical internship, when I worked in a pain clinic and an addiction clinic. People could only look at this problem from their own camp: so you have pain doctors over there who see the problem one way and addiction clinicians who see it in another way. There isn’t really a blending between those two viewpoints. We would see patients who were clearly developing some sort of addiction to their pain medication and refer them to the addiction clinic, but then the addiction clinic doctors would say, “This isn’t an addiction, they were prescribed these medications and don’t belong in this clinic.”
The piece that I’m most interested in is the fact we don’t know a whole lot about why some people end up developing addictions to pain medications. There’s not yet a good way to identify these people ahead of time. I’m working on figuring out ways of doing that. One of the ways is a study that uses behavioral economics to understand how people make choices about their pain medications and managing their own pain. In addiction behavioral economics can be used to incentivize behavior—i.e., providing vouchers or a number of lottery draws for abstinence. More generally, behavioral economics is also used to understand how people attach value to certain outcomes or objects, and how they allocate their resources to obtain certain commodities or why they prefer certain choices versus others. This is an interesting way to study addiction because problems with decision making and valuation of different types of outcomes, like drugs compared to non-drug rewards, are very fundamental to the disorder.
These days a lot of people with chronic pain disorders are prescribed opioids. Many inevitably develop a physical dependence and tolerance to the medication. Over time the same dose doesn’t provide the same level of pain relief, and the dose is increased to get the same effect you did initially. People who end up at super high doses are more likely to become addicted, but there’s a difference between physical tolerance and addiction. Some patients can stay on similar doses and not develop a psychological addiction. Over time, some start to rely on these medications more than others, and become hyper focused on it. They start behaving in ways that are similar to ones we usually think about with drug abuse, this compulsive behavior: taking more than what’s prescribed for them, or showing up to the ER because they’ve already taken all of their pain medications, or seeing multiple doctors at the same time to get more of the drug. It has been a hard problem for researchers and clinicians to identify and conceptualize because these are prescribed medications for a medical problem, so a lot of the criteria that normally apply to substance use disorders don’t make sense for these patients. For example, because most people develop tolerance to pain medication, how do you break that apart from addiction?
If people still need a medication to treat their chronic pain, but they are now addicted to the medication that is prescribed to treat it, what is their alternative?
There are alternative medications like Suboxone that have opioid-like effects but that have less potential for abuse and have an antagonist. Prescribers can also monitor their patients with urine screens or meet with them more frequently, and taper their doses down to safer levels. The reality is, that there’s no strong evidence that long term opioid use for chronic pain actually reduces chronic pain. A lot of the rationale for doing this was questionable and came from studies that weren’t adequately designed to represent what’s going on in the field now, which is that people end up taking these medications for a long time, for 1, 2, 3 years or more. Ironically, there’s pretty good data to suggest that for many people, this pattern of prescribing results in long term disability, worse functioning, and bad health utilization outcomes (like increased ER utilization). It’s not to say that opioids can’t be useful, but they should be a tool, just one part of the pain management picture. But a lot of patients are “primed” for bad outcomes once they are exposed to long-term opioids. The problem is that doctors often can’t identify who these patients are. The predictors we know about aren’t very specific so it’s hard to justify using them to withhold opioids from individual patients.
What exactly is chronic pain?
The experience of pain is influenced by many factors. Most people think of chronic pain as a medical problem, but something I learned in my internship is that chronic pain is a bio-psycho-social problem. It’s also a brain disease. The situation is actually similar to addiction, in how it used to be viewed as a “moral failure” but we now know it’s a brain disease. Most people think about pain related to something acute going on in the body like getting a burn or breaking a bone—in those cases, there are specific biological causes of the pain and the pain has value to the organism, because it motivates a behavior, like to take your hand away from the fire, or to rest. But chronic pain often doesn’t signal a problem in the body that needs to be taken care of or that has an explanation. The experience of chronic pain is also influenced by a lot of things in a person’s life. The medical findings, like an X-ray, don’t match the level of pain that a patient reports. Two patients can have the same exact X-ray of their back and be experiencing drastically different levels of pain. So sometimes doctors doubt a patient’s pain, and they say, “You shouldn’t be in this much pain”, which is very invalidating to a patient when they are subjectively experiencing intense pain. So what makes up that gap? According to the bio-psycho-social model, it’s the biological and the social factors: the experience of pain is influenced by mood, stress, depression, social interactions, sleep—those are things you can work on using therapeutic techniques such as mindfulness and Cognitive Behavioral Therapy (CBT). Unfortunately those treatments are not well integrated in the medical system. Most of the time people with chronic pain are seen by primary care physicians who don’t have time to do CBT or don’t work directly with mental health providers. One of the advantages of CBAM is that we bring psychologists into primary care to work directly with primary care physicians and their patients.
What do you hope to focus on after your postdoctoral fellowship with CBAM?
Research interests me the most. Coming up with unique questions and designing ways to obtain and model data to answer those questions is really rewarding to me. Doing a small amount of clinical work would also be a good thing, as it would allow me to stay in touch with the human aspect of psychology and the day to day interactions of treatment. I’ve enjoyed giving lectures so I think I would enjoy teaching as well. My ideal job would involve a lot of research and a little teaching and clinical work.