Testimony
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Statement by
Nora D. Volkow, M.D., Director
National Institute on Drug Abuse
on
Fiscal Year 2005 Hearing on
Substance Abuse and Mental Health
before the
House Subcommittee on Labor-HHS-Education Appropriations
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April 29, 2004
Mr. Chairman and Members of the Committee, I am pleased to be here to present the President's fiscal year (FY) 2005 budget request for the National Institute on Drug Abuse (NIDA) of $1.019 billion. I am also pleased to discuss our remarkable scientific accomplishments, our strong collaborations with our fellow National Institutes of Health (NIH) research institutes and with the Substance Abuse and Mental Health Services Administration (SAMHSA), and how these advances and collaborations are setting the course for a better future.
NIDA supports more than 85% of the world's research on the health aspects of drug abuse and addiction, including the impact that drugs have on other diseases such as AIDS, hepatitis C, and tuberculosis. NIDA's comprehensive research portfolio focuses on all drugs of abuse, both legal and illegal, including nicotine, with the exception of alcohol. NIDA also rapidly translates all of its new findings into formats that will be useful and used by a variety of audiences.
Today I will focus on the progress that NIDA is making in supporting and translating science and provide examples of how NIDA both formally and informally works with the National Institute on Mental Health (NIMH), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the SAMHSA, and the Office of Safe and Drug Free Schools at the Department of Education to curtail drug use.
THE MAGNITUDE OF THE PROBLEM
Drug abuse and addiction are major public health problems that impact us all. To put it in dollar figures, substance abuse, including smoking, illegal drugs, and alcohol, costs our Nation more than $484 billion per year. Illicit drug use alone accounts for about $161 billion according to a report from the Office of National Drug Control Policy. But the impact drug abuse and addiction have on individual lives, families, and communities is even more devastating. Drug abuse is inextricably linked with the spread of infectious diseases such as HIV/AIDS, STD's, tuberculosis, and hepatitis C, and is also associated with domestic violence, crime in the community, child abuse, accidents, teenage pregnancies and other adverse effects. Substance abuse is also a problem that occurs frequently in patients with psychiatric disorders. Approximately half of those suffering from a chronic alcohol or drug disorder also suffer from a chronic psychiatric disorder. Given the magnitude of the problem, it is easy to see why the three NIH institutes collaborate in many research endeavors and work with others to bring new treatments and preventions to communities across the country.
Our investments in biomedical research to improve the health of ALL Americans are paying off. Scientific advances supported by NIDA are coming at an extraordinary rate and are significantly influencing the way this Nation approaches drug abuse and addiction.
SCIENCE IS HELPING TO REDUCE TEEN DRUG USE;
SCIENCE WILL ALSO HELP CURTAIL PRESCRIPTION DRUG ABUSE
I am delighted to report that we are making progress in reducing drug use. NIDA's long-standing Monitoring the Future Survey (MTF) showed an approximately 11% decline in illicit drug use over the last 2 years by students in the eighth, tenth, and twelfth grades combined. (See Figure 1) The use of MDMA or Ecstasy decreased by almost fifty percent for the three grades combined in that same time period. Also encouraging was the fact that tobacco use among this population was the lowest in the 28 year history of the survey. These dramatic reductions are the product of various agencies working together for a common goal – to decrease drug abuse in America.
However, not all of the news from the MTF Survey is positive, of concern is the high levels of abuse of prescription drugs reported by our teens. Particularly disturbing are the numbers reported for the abuse of pain killers; for example one in ten twelfth-graders reported abusing the prescription pain killer Vicodin® last year. Though medications like Vicodin® when used as prescribed can be very effective, when used improperly they can have serious adverse health consequences including addiction and/or death from overdose. NIDA will be supporting more research to prevent, educate, and treat prescription drug abuse. Developing new medications that have no abuse or diversion potential is also a high priority for NIDA.
ADDICTION IS A DEVELOPMENTAL DISORDER:
THE CRUCIAL ROLE OF PREVENTION
Research supported by NIDA and NIAAA and others is leading us to a common theme and understanding about the age of onset of drug addictive diseases including alcoholism. We are finding that these diseases begin during adolescence and sometimes even during childhood: therefore early intervention may prevent many of the social, behavioral and economic consequences caused by these diseases as well as providing an opportunity to treat problems before they become full blown and embedded in people's lives.
NIDA-supported researchers are finding that drug addiction is a "developmental disease" that is, it often starts during the early developmental stages in adolescence and sometimes as early as childhood. Research indicates that exposure to drugs of abuse in adolescence may be a period of significantly increased vulnerability to drugs' effects because of all the changes occurring in the brain. Fortunately, advances in science and NIH-funded studies have now brought us to a point where our researchers can use new animal models, new brain imaging technology and other neurobehavioral assessment tools to probe the effects of drugs on the developing brain and its immediate as well as its long-term behavioral consequences. These new directions in adolescent research will help to inform us on important aspects of cognition, decision-making, motivation, emotional regulation, and risk perception during adolescence, and will help us determine how these play a role in the use and consequences of illicit drugs. Armed with new knowledge about how adolescents make decisions, how they control their impulses and desires and what motivates their behavior, NIDA will be poised to design interventions that can reduce drug experimentation and addiction. We are making progress in this regard through our National Prevention Research Initiative and through our science education activities like the "NIDA Goes Back to School Campaign" where science-based materials, which I have brought to share with you today, were disseminated to teachers and students all across America.
From NIDA-supported research, we know that comprehensive, school-based programs can reduce young children's antisocial behavior while boosting their social competency, academic performance, and commitment to school. Unfortunately, recent research indicates that only one in seven of the Nation's public and private schools offers prevention programs that incorporate proven elements and deliver them in the most effective way. For this reason NIDA works with its own grantees and with SAMHSA and the Department of Education to ensure that NIDA's science-based drug prevention principles and programs are more effectively integrated into communities, social settings, and schools throughout the country.
We have just begun working with SAMHSA's Center for Substance Abuse Prevention (CSAP) to develop a broad-based national prevention plan. NIDA will assist CSAP in developing State epidemiology monitoring systems to inform prevention decision-making and programming in States with new CSAP State Incentive Grants. NIDA is also collaborating with the Department of Education's Safe and Drug Free Schools to use their coordinators as well as Cooperative Extension Offices at 28 sites across two states to mobilize communities to do needs assessments so that appropriate prevention interventions are used.
ADDRESSING THE REALITY OF COMORBIDITY
As many as 6 in 10 people who abuse drugs and alcohol also suffer from mental illnesses, according to epidemiological studies. Conversely, some 25 to 60 percent of individuals with mental illnesses also have substance abuse disorders. The overwhelming reality of these concurrent disorders presents huge challenges for drug abuse research, prevention, and treatment.
To help these patients whose problems fall within our health missions, NIDA is working with NIMH, and NIAAA to support research that will increase fundamental knowledge about substance abuse and mental health comorbidity, and to advance efforts to prevent this destructive combination, and treat those already afflicted. NIDA is also actively working with SAMHSA, who has the lead in establishing action items to move The President's New Freedom Commission on Mental Health agenda forward. Also, by serving on the National Steering Council for the Co-Occurring Center for Excellence, NIDA provides advice and guidance on how to best develop, plan, communicate and disseminate information on the range of issues involved in co-occurring mental and substance abuse disorders.
USING THE NIH ROADMAP AND OTHER INITIATIVES TO BE
RESPONSIVE TO THE SERVICE NEEDS OF THE FIELD
NIDA continues to maintain a strong health services research portfolio to better understand how drug abuse prevention and treatment services are and should be delivered in "real life" settings and to ensure that research is used to identify the most effective ways to organize, manage, finance and deliver high quality care. NIDA's health services research portfolio has led to the identification of an array of evidence-based practices. SAMHSA then works with providers and State agencies to ensure the application of these evidence-based interventions into practice. To ensure that NIDA is equipped to address the future needs of the field, a Blue Ribbon Task Force on Health Services Research was convened by the NIH Director in May 2003. The recommendations articulated in the Report presented to me in February are currently being implemented and are sure to encourage the development of bold and innovative research that the field will need to meet future needs. One recommendation is for NIDA to study widely practices and commonly used interventions with the same rigor as we study new treatments (recommendation 6). To do so, NIDA will continue to collaborate with federal partners, such as SAMHSA, in conducting randomized clinical trials (Recommendation 24).
The NIH Roadmap present us with a unique opportunity to capitalize on efforts to reengineer the clinical research enterprise, and to build research teams of the future. Health services research, as well as other important research areas in NIDA's portfolio will play a prominent role as part of NIH Roadmap activities to accelerate research from the bench to bedside and to the community.
SCIENCE TO SERVICES: ESTABLISHING SCIENCE BASED INFRASTRUCTURES TO TEST, TRANSLATE, AND BRING EVIDENCE-BASED PRACTICES TO COMMUNITIES
Over the past few years, NIDA has both established and strengthened strong collaborative relationships with a number of government agencies, including the SAMHSA to build national infrastructures that can facilitate the flow of research into community practice.
One example of this is the establishment of NIDA's National Drug Abuse Treatment Clinical Trials Network (CTN), which now serves 27 states plus the District of Columbia and Puerto Rico. The CTN, now in its fifth year, was developed to test the effectiveness of new and improved interventions in community-based treatment settings with diverse populations. The CTN has completed seven clinical studies, and 21 other studies are underway or in development. Research is also ongoing on how to incorporate new and improved interventions into community-based drug treatment programs. We have also established a formal partnership with SAMHSA's Addiction Technology Transfer Centers to encourage the use of current evidence-based treatment interventions by professionals in the drug abuse treatment field. By establishing "Blending Teams" to integrate the research-practice partnership, SAMHSA, NIDA and the field are working together to translate research findings into clinical practice.
Another outstanding example of cooperation between the research community and federal agencies that will improve the public health and safety of our citizens is the establishment of the Criminal Justice Drug Abuse Treatment Research Studies (CJ-DATS). Under NIDA's leadership, nine research centers and a Coordinating Center were created in partnership with researchers, criminal justice professionals, and drug abuse treatment practitioners to develop more successful strategies to assist drug abusing criminal offenders. Given that there are over 6.6 million adults on probation, in jail or prison, or on parole, and a large percentage of them are in need of drug abuse treatment, it behooves us to use research to address this public health and public safety issue. We know that left untreated, drug addicted offenders often relapse to drug use and return to criminal behavior. We need to understand how to provide better drug treatment services for criminal justice offenders to alter their drug use and criminal behavior.
PROGRESS IN TREATING DRUG ABUSE AND ADDICTION
Tremendous progress has been made in how we treat drug abuse and addiction. Research is continuing to provide new insight into the chronic relapsing nature of addiction. Understanding addiction as a chronic relapsing disease that involves the brain, behavior, the environment in which an individual is raised, along with genetic factors, frames how we must ultimately develop strategies to treat this disease. Fortunately, we now have treatments that are as effective as what is available for other chronic relapsing disorders, like hypertension, cardiovascular disease and type II diabetes. Like these other chronic diseases, drug addiction can be effectively treated and managed over its course, but this requires treatments to be readily available and adhered to. Developing treatments for drug abuse that are readily accepted by the populations we are serving is why NIDA-supported researchers worked for over a decade to bring the medication buprenorphine, to physicians allowing them to more effectively treat treating patients with opiate addictions. NIDA continues to work with SAMHSA's Center for Substance Abuse Treatment and other federal agencies to improve access to this medication.
NIDA is also encouraging researchers, as well as the pharmaceutical industry, to become more active in finding new medications and behavioral treatments for marijuana and for other drugs of abuse. With the fairly recent discovery of an endogenous cannabinoid system with specific receptors and endogenous ligands, the likelihood of finding new targets for medications development is increased. One form of a cannabinoid receptor antagonist (CB1-receptor) has already been developed by several pharmaceutical companies and is undergoing clinical investigation for the treatment of alcoholism and nicotine addition, as well as obesity. Knowledge derived from addiction research shows that the brain circuits involved in compulsive eating and impulse regulation are part of the same systems involved in addiction, with the neurotransmitter dopamine playing a prominent role. Hence, because of the commonalities of these disorders, NIDA is pleased to be participating in a National effort to develop new treatments and prevention strategies, not just for addiction, but for obesity as well.
We also know from research the impact that our drug abuse prevention and treatment efforts can have on curtailing the spread of infectious diseases like HIV/AIDS. Injection drug use has directly and indirectly accounted for more than one-third (36%) of AIDS cases in the United States. Data show that drug abuse treatment can reduce activities related to drug use that increase the risk of getting or transmitting HIV. Also the fact that the health and social consequences of drug abuse, including HIV/AIDS, disproportionately affect racial and ethnic minority populations; for example, among intravenous drug users, almost half of HIV/AIDS cases occur in African Americans even though they constitute only 11% of the population according to the latest Census data, which highlights the urgency to conduct research that can benefit all populations. (See Figure 2.)
CONCLUSION
Reducing the adverse health, economic, and social consequences to individuals, families, and communities that are associated with all drugs of abuse, including nicotine, is the ultimate goal of our Nation's investment in drug abuse research. As you can see, from the examples I have provided, each of us appearing before you today has an important contribution to make in reducing the burden of substance abuse and mental illness.
Nora D. Volkow, M.D.
Director
National Institute on Drug Abuse
National Institutes of Health
Nora D. Volkow, M.D. is the Director of the National Institute on Drug Abuse (NIDA). Before assuming this position on May 1, 2003, Dr. Volkow was Associate Director for Life Sciences at Brookhaven National Laboratory (BNL), Director of Nuclear Medicine at BNL and Director of the NIDA-Department of Energy Regional Neuroimaging Center at BNL. She was also Professor at the Department of Psychiatry, State University of New York (SUNY) at Stony Brook and Associate Dean for the Medical School at SUNY-Stony Brook. Dr. Volkow received her M.D. in 1981 from the National University of Mexico, in Mexico City, Mexico, and performed her residency in psychiatry at New York University.
Her main area of interest is the investigation of the mechanisms underlying the reinforcing, addictive, and toxic properties of drugs of abuse in the human brain. Dr Volkow was the first to use imaging to investigate the neurochemical changes in the human brain that occur during drug addiction. Her studies have documented a decrease in function of the dopamine system in addicted subjects that is associated with a disruption in function of frontal brain regions involved in motivation and drive. Her work has also focused on the investigation of the neurochemical mechanisms responsible for intersubject variability in response to drugs of abuse and its potential link to vulnerability to drug abuse and alcoholism.
Dr. Volkow has also used imaging to investigate the effects of stimulant drugs with respect to both their rewarding as well as therapeutic actions. By doing a systematic comparison of the pharmacological effects of cocaine (one of the most addictive drug of abuse) and of methylphenidate (a drug used to treat children with attention deficit hyperactivity disorder) in the human brain, her studies have highlighted the relevance that drug pharmacokinetics play in enabling the reinforcing effects of stimulant drugs to occur. These studies have also shown that stimulant drugs, when used therapeutically, amplify DA signals in the brain, enhancing the saliency of a stimulus and thus improving attention and performance.
She has also used imaging to investigate the changes in the dopamine system that occur with aging and their functional significance. Her work has documented that the loss of dopamine brain function with age in healthy subjects with no evidence of neurological dysfunction is nonetheless associated with motor slowing and with changes in performance of cognitive tasks that involve executive functions. Her work now focuses on strategies to minimize the age-related losses in dopamine brain activity as a means to improve quality of life in the elderly.
Dr. Volkow has authored or coauthored more than 300 peer-reviewed publications, three edited books, and more than 50 book chapters and non-peer reviewed manuscripts. She is the recipient of multiple awards for her research, and has been elected to membership in the Institute of Medicine in the National Academy of Sciences. Dr. Volkow was named "Innovator of the Year" in 2000 by US News and World Report.
Department of Health and Human Services
Office of Budget
William R. Beldon
Mr. Beldon is currently serving as Acting Deputy Assistant Secretary for Budget, HHS. He has been a Division Director in the Budget Office for 16 years, most recently as Director of the Division of Discretionary Programs. Mr. Beldon started in federal service as an auditor in the Health, Education and Welfare Financial Management Intern program. Over the course of 30 years in the Budget Office, Mr. Beldon has held Program Analyst, Branch Chief and Division Director positions. Mr. Beldon received a Bachelor's Degree in History and Political Science from Marshall University and attended the University of Pittsburgh where he studied Public Administration. He resides in Fort Washington, Maryland.
Last revised: April 29, 2004
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