Spotlight On…Judith Tsui

Judith Tsui, M.D., M.P.H., Associate Professor of Medicine at the University of Washington Division of General Internal Medicine
As told to URBAN ARCH Admin Core staff, December 2019

Tell us more about your academic and research background. What led you to study substance use; more specifically, to chronic hepatitis C virus (HCV) infection and pain?

I have always wanted to focus on vulnerable populations, including persons with substance use disorders, as that was really part of my initial desire to become a physician. I went to medical school at NYU because I wanted to work at Bellevue Hospital, where there is a long history of serving disadvantaged populations. Over time, I think almost everyone who goes through medical training realizes how much substance use disorders contribute to the burden of death and disease we see as physicians.

My first job out of my residency was working at Grady Memorial Hospital in Atlanta through Emory. I worked with a group that started a treatment program for HCV in primary care. This work was quite innovative at the time, as it was before highly effective and tolerable medications for HCV were available. After this, I did a GIM fellowship at UCSF, where my research initially focused on extrahepatic complications of HCV. But over time I gravitated towards addressing the upstream reasons for why people get HCV: namely substance use and injection drug use. The overlapping issues that contribute to opioid use disorders, pain and HCV, and innovative interventions to address this “syndemic”, are of particular interest to me right now.

What has been one unanticipated or most interesting finding from your research so far?

The link between pain and substance use was not completely surprising, but important to demonstrate in a non-U.S. population, as so much research on opioids and pain has been generated here. Opioids are often used to treat chronic pain in the US, but Russia is such a unique environment where use is much more limited. It has been interesting to see how pain is associated with use of alcohol and heroin in Russia. This has given some insight into how important these relationships between pain and substance use are, and that this is a global problem, not just a U.S. problem.

For the UH2 study, which examines the tolerability of the opioid receptor antagonists (nalmefene and naltrexone) among persons living with HIV who have chronic pain and unhealthy alcohol use, we quickly learned that nalmefene was not tolerable: all of the initial participants we enrolled experienced side effects and discontinued this medication very early in the study. This was extremely useful, as it shaped the UH3 study which will no longer include a third nalmefene arm compared to placebo and naltrexone. Instead we will have a new comparison arm which is gabapentin. I am excited about what that will show, as gabapentin is a widely used medication for pain, despite a paucity of evidence to show that it is useful for patients who have generalized chronic pain.

How has your involvement with URBAN ARCH allowed you to further examine your interest in the mechanisms that lead to chronic pain in patients with substance use disorders?

I have used URBAN ARCH to initiate investigations into the effect of opioid receptor agonists on pain and inflammation among individuals living with HIV and who use alcohol in the UH2/UH3 study. Russia is a unique environment to study pain, as opioids are highly regulated and not used for chronic pain as compared to the U.S. As such, Russia becomes an ideal setting for studying relationships between substance use and pain “free” from interference from prescribed/pharmaceutical opioids.

What have you enjoyed most about your work on your UH2/UH3 grant, “Pilot study of opioid-receptor antagonists to reduce pain and inflammation among HIV-positive persons with alcohol problems”? What impact do you hope to make through this study?

I most enjoy working with our wonderful Russian collaborators, they are terrific! I am so grateful for their support on this study. I hope that this work will provide preliminary information as to the true benefits of low-dose naltrexone and gabapentin for pain among persons living with HIV and chronic pain. Patients are so desperately looking for new medications for their pain, and providers are equally desperate for safe, non-opioid options. We need more evidence for patients and providers to help them make an informed decision.

What should researchers consider when developing interventions to reduce chronic pain among patients with substance use?

It is important to find a question that is clinically relevant and translatable to real-world settings. There are too many interventions developed that are not easily implemented and do not appeal to patients outside of the context of clinical studies. As a clinician, I appreciate the role of non-pharmacologic treatments for chronic pain, but they can be a really hard “sell” to patients. What excites me about the UH2/UH3 research is that it is examining medications that are currently used for treatment of chronic pain (albeit in an “off-label” fashion) so that we can get some real answers about how useful or not useful these medications are for pain among HIV-positive individuals who use alcohol.

It is important to consider what happens if your intervention fails. Part of the reason I want to study low-dose naltrexone is because I want to know the answer to this research question. Low-dose naltrexone is currently used by some physicians in the US to treat chronic pain. It not ideal to have physicians prescribing something that is potentially a “sham” treatment. Yet there is some basic science and clinical research to suggest that low-dose naltrexone can impact pain pathways and ultimately be of benefit to patients. Hopefully this study, no matter the outcome, will provide important preliminary information for clinicians and researchers.

Tell us one thing about yourself that readers might find surprising.

People get excited to hear that my father won a Nobel Prize in Physics in 1997. I don’t often share that; it is a lot of pressure on me as the daughter of a Nobel Prize winner! Another surprising fact is that I was once in a McDonald’s commercial playing the cello. I had studied cello at Julliard before college and a casting agent was looking for young cellists to star in a McDonald’s commercial, so I auditioned and was selected. So for a brief moment there I was, daughter of a Nobel Prize winner playing cello on TV with a McDonald’s hamburger next to me. Is this the American dream fully realized?