A Veteran Addiction Researcher Tells All
You were the Principal Investigator of the SAMHSA contract to establish the Vietnam HIV-Addiction Technology Transfer Center. Can you describe this project and illuminate the connection between Vietnam and HIV?
What the United States has done in the last decade in Vietnam has really been something that we can be proud of when compared to what happened in the past which was such a different story. In the last decade, the PEFAR Program or the President’s Emergency Plan For Aids Reduction has been in Vietnam providing technical assistance to the Vietnamese government along with the World Health Organization and Global Fund to help the government and the people address the problem of HIV and injection drug use. Earlier studies done by WHO indicated that in certain pockets of Vietnam like Ho Chi Minh City, Hanoi, Haiphong and a number of other places, among injection drug users, the HIV rates were extremely high – 60 to 70% in some places. They had limited treatment for HIV and no treatment at all for injection drug use.
Beginning in 2008, a pilot project with methadone treatment began in Haiphong and soon after Hanoi. Since methadone treatment has been introduced, the data has been extremely promising on the ability of methadone to reduce not only heroin use, but injection use and transfer of HIV in Vietnam. It’s been a really remarkably successful example of how the proper treatment can not only reduce the damage from addiction, but the damage from infectious diseases as well. Vietnam has been a real shining light in this area, and they’ve done a tremendous job. They now have in the neighborhood of 40 to 50 clinics in the country, and they’re treating somewhere in the neighborhood of 20 to 25,000 people with methadone. They are well on their way to reaching the goal of treating 80,000 people by 2016.
One of the biggest challenges is finding the workforce to deliver the treatment. All of these clinics require doctors, nurses, counselors, pharmacists to run them. None of these people were available in 2008. The VH-ATTC (Vietnam HIV-Addiction Technology Transfer Center) that we’ve helped to develop in conjunction with PEFAR and SAMHSA is all about creating the workforce to handle the treatment needs. It’s a huge undertaking and we could not have done it without the folks at Hanoi Medical University. They have been remarkable in terms of their ability to gear up and develop training and become very active across the country. Their expertise is just superb and it’s such that they could now do trainings in the United States.
Even though technical assistance from American professionals is still being provided around injection drug use and HIV, the big demand now is around amphetamines. Just as we start to make inroads in terms of opiate dependence, they start to have problems with amphetamine abuse in Vietnam. As a result, we are starting to help them develop the behavioral treatments that we have been using in the United States. That’s an even bigger job because training doctors and nurses to provide methadone with some counseling is very different from training them to treat amphetamine dependence. Since it is a behavioral treatment, it is much more training intensive. Being successful with such training is the next issue on the horizon and hopefully it will be continued with a subsequent contract.
You have said the Affordable Care Act is one of the most significant transition points in how addiction will be treated. Can you tell us why?
In my almost 40 years in my work in addiction – it will be 40 years in September – I have worked pretty much exclusively in the silo of addiction treatment. I’ve set up methadone clinics, outpatient clinics, helped people set up residential care and looked up the data from all of them and done training for all of them. One of the intentions of the Affordable Care Act is to help better integrate treatment services into the broader world of healthcare. The ACA provides the opportunity for people like me and the future generations working in addiction to see how we can better integrate our services into mainstream healthcare.
The goal is to get out of our silos and to expand outwards into a much broader set of services beyond the 2 million people we treat every year in all of our specialty clinics and silos of addiction care. We want to provide services for the other 20 million Americans with substance use problems who don’t go into specialty care. They might see doctors, nurses and psychologists in broader healthcare settings, but their substance use problems are not addressed because historically addiction is not a concern of primary care. Unfortunately, this separation of the silo of addiction care from the rest of healthcare has really restricted our impact and our ability to see the impact of how our substance use knowledge and treatment services would benefit the larger health system.
It’s going to be a fascinating next ten years of figuring out how to move substance use services into mainstream healthcare, how to educate and serve mainstream healthcare. If substance abuse service providers want to integrate into the bigger healthcare system, they have to understand their role in that system. It’s not like everyone is going to drop everything else they are doing and say, “Okay, addiction folks, you’re right and we’re going to focus all of our efforts on addiction because it’s really important.”
The people in the bigger healthcare system actually have lots of other really important stuff that they need to pay attention to so we have to learn how to helpful to them. We have to make our services of value to them and not the other way around. We have to show them that if you treat alcohol and substance abuse issues, you will see broader benefits to patients' lives and to their overall health issues.
It’s going to take a good deal of time, some very creative models, a lot of persistence and working on the funding mechanisms to make sure all the pieces can fit together.
Where do you think the most notable progress has been made in addressing substance use disorder problems?
The benchmark that changed things in how people viewed addiction in the United States was in the late 1990s when Alan Leshner, the then Director of the National Institute on Drug Abuse together with Barry McCaffrey, then the Drug Czar, took on a campaign to reeducate the public about addiction as a brain disease. Up until that point, we would talk about substance use, about alcoholism and drug addiction "as if" it were a disease.
There was always the “as if” because it was like a disease and it was "a disease of the spirit" or "a disease of attitude" or some kind of "allergy" to alcohol. There were all kind of metaphors of how addiction was a disease, but nobody really understood it as a disease.
I didn’t understand it as a disease. But when I first started seeing the pictures of how addiction changed the brain and how the brain recovers or doesn’t recover depending on the study and the type of drug, a switch flipped. It was like, okay, now I get it. You start using drugs and alcohol for a whole variety of reasons; because you’re curious, because your friends do it, because it’s cool, but after you use them for a while, your brain changes. Then the process of your decision-making and your continuing use of drugs is based on a whole different set of brain circuitry. Not only did that help me understand addiction, it also helped me to communicate with other people about addiction.
As I’ve gone around the world, it’s been the one message that seems to resonate with all audiences whether you’re talking to judges or to people in rural Egypt or to people in Vietnam in the mountains. If you can make it clear and express it in a way that they can understand it given their educational level, if you can communicate the fact that drugs and alcohol change your brain and that changes how you make decisions by affecting your impulse control, it really makes a difference in people viewing addiction as a health problem as opposed to misbehavior or criminal behavior. That’s been the single biggest point that I’ve seen; the recognition, acknowledgement and acceptance of addiction as a brain disease.
What do you hope to accomplish in the future?
As a result of these efforts that we’ve been doing around the world, UCLA and these colleagues of mine have gotten a reputation for conducting training of young professionals. I’m hoping that we’ll have more of an opportunity over the next decade to help train the first generation of addiction clinicians and addiction researchers in many parts of the world. In the Middle East and Southeast Asia, there was no history of doctors going into addiction, psychiatrists specializing in addiction, nurses and psychologists developing careers in addiction. We seem to have the opportunity now to be able to really increase the knowledge and work with different universities to develop addiction programs.
I really hope to be able to continue spreading the information and not just the information, but spreading the relationship between U.S. professionals and professionals in other parts of the world in a mutually collaborative way. Those relationships have been some of the most rewarding parts of my life; the people I’ve met in Egypt and the United Arab Emirates and Beirut and Iraq and Iran and Vietnam. Those relationships have become extremely valuable to me, and I think if we can do more of that kind of work and have a bigger impact on the training of new professionals in those parts of the world, it’ll have both a good impact on the image of the U.S. in those parts of the world as well as helping people develop high quality and effective treatments for people with substance use problems in their societies.