How The National Institute on Drug Abuse Illuminates the Science of Addiction
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As the neuroscientist in charge of the National Institute on Drug Abuse (NIDA), Dr. Nora Volkow believes addiction begins and ends in the brain. For Dr. Volkow, all forms of addiction come down to the dopamine. As the dopamine molecule surges and retreats deep in the brain, pleasure and pain are experienced. Dr. Volkow believes the super charging of dopamine in the brain by addictive substances is the key to understanding addiction.
A hard-working scientist with a colorful family background, Dr. Volkow is a first-generation American immigrant. She grew up in Mexico City where her mother found refuge after fleeing Franco’s Spain. In Mexico City, Nora’s mother met her husband, the grandson of Russian revolutionary Leon Trotsky. He had gone to live In Mexico City with his famous grandfather after losing his parents. Along with her three sisters, Dr. Volkow grew up in the house in Mexico City where the agents of Josef Stalin murdered Trotsky in 1940. She would give tours of her home on weekends.
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Dr. Volkow has devoted her career to fighting the rising tide of addiction in the United States and across the world. In recent years, Dr. Volkow has been tackling the tidal wave of the opioid prescription painkiller epidemic raging across the country. A strong early proponent of the scientific belief that addiction is a disease, Dr. Volkow has geared her work at NIDA towards both removing the societal stigma of addiction and focusing on the science. Taking time out of her busy schedule, Dr. Volkow spoke with The Fix about the challenges she faces on a daily basis.
As a federally funded research institute, the mission of the National Institute on Drug Abuse is to "lead the nation in bringing the power of science to bear on drug abuse and addiction." During your tenure as Director of NIDA since 2003, what have you done to help accomplish this mission?
In the past decade or so, NIDA has been at the forefront of the effort to tease apart the biological, developmental, social, and environmental factors that influence the likelihood of a person starting to use an addictive drug and of becoming addicted as a result of its repeated use. The far better understanding we have today about “addiction trajectories” and how they differ from person-to-person is transforming our approach to prevention and treatment. In parallel, NIDA has also funded research to understand the changes in the brain triggered by drugs that result in addiction.
These studies have shown that drugs produce long-lasting changes in specific neuronal circuits that implicate molecular synaptic changes akin to those used in memory and learning. As a result of these changes several key neuronal circuits are impaired that ultimately result in the loss of control that characterizes addiction. These discoveries have helped conceptualize addiction as a chronic brain disorder that can be treated. It has also helped develop new prevention and therapeutic interventions.
As notable examples, I can cite the development of new medications like Suboxone for the treatment of opioid addiction; the increasing involvement of the criminal justice system in the treatment of substance abusers thus reducing drug relapse and reincarceration; and the increasing involvement of the healthcare system in the management of substance use disorders.
In October 1992, NIDA became part of the National Institutes of Health that is managed under the United States Department of Health and Human Services. In addition, the Substance Abuse and Mental Health Services Administration is under the direction of the U.S. Department of Health and Human Services as well. SAMHSA was created to improve the quality and availability of prevention, treatment, and rehabilitative services for substance abuse and mental illness in order to reduce illness, death, disability, and cost to society.
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Can you explain how NIDA and SAMHSA work in conjunction to address what seem to be overlapping causes and missions?
The distinction between our missions is clear and logical. NIDA is in charge of guiding and supporting the basic and clinical research needed to develop the most effective ways for preventing and treating drug abuse and addiction. SAMHSA is in charge of ensuring the effective deployment of, and access to, evidence-based services for the promotion and maintenance of mental health and the prevention and treatment of psychiatric disorders, including addiction.
Your work has been instrumental in demonstrating that addiction is a disease of the human brain. As a research psychiatrist and scientist, you helped to pioneer the use of brain imaging to investigate the toxic effects and addictive properties of drugs. Can you describe a key moment in this process when you realized you had made a lasting breakthrough that would open a door and help change the world’s basic understanding of addiction?
There were several, but I think the tight relationship between the reductions in dopamine neurotransmission in the striatal regions involved with reward and motivation, and the lower activity in the brain frontal region involved with self-control that we discovered in individuals addicted to different drugs, spurred a real paradigm shift. This was compelling, physical evidence that addiction hijacks not only the ability to feel normal pleasure, but also the very circuits in charge of exerting free will.
Despite opening the door to the recognition of addiction as a disease by medical professionals, there still remains great doubt and even resistance to the idea in the general population. What can be done to convince the American public that addiction is a disease, helping to lift the damaging stigma that prevents so many people from accessing the treatment they need?
There is a long tradition in our culture that views psychiatric disorders as fundamentally different from physical disorders, a dualistic view rooted in intuition rather than evidence and that can be traced back at least to the times of Descartes. According to this view, things like free will, will power, or self-discipline operate in a disembodied realm, not unlike souls and spirits.
It will take a very long time to do away with this pernicious view forever. But scientists have put in motion an inexorable process of erosion, by producing routine, incontrovertible evidence that every mental function and psychiatric disorder (including addiction), stems from identifiable and actionable, albeit complex processes in the physical brain. At its root, this is not a scientific question, but a cultural one.
Your studies have documented the changes brought on by drug addiction in the dopamine hormonal system that affect the functions of the frontal brain regions involved with motivation, drive, and pleasure. For people without a medical background or an understanding of how dopamine works in the human brain, can you describe the role of this neurotransmitter in the addictive process? Can you illuminate how it affects motivation, drive, and pleasure for the addict? Why is dopamine so important in addressing the question of how to overcome addiction?
Dopamine has many different functions in the brain. However, in the limited context of addiction, dopamine can be simply defined as the molecule that tells the brain that something important has happened (or is about to happen). This “something” is not just “important” but evolutionarily “significant” because it applies to things that should improve an individual’s chances for survival. The dopamine-based motivation system has evolved to codify “pleasure” as a neural signature designed to facilitate the repetition of selected behaviors (e.g., sex, food, nurturing the young) that grant obvious selective advantages.
The problem arises when the dopamine system is exposed to a drug that stimulates the system to unprecedented high levels. In some people (the proportion varies with different drugs and personal circumstances), the drug-induced dopamine boost is so high that natural rewards can no longer compete with it. At that point, the behavioral attraction (motivation) towards the drug becomes laser focused on seeking and using that drug, again and again.
From my personal experience as a former heroin addict in long-term recovery, I found the first couple of years of getting sober to be among the hardest. The heroin had so altered my dopamine levels that I no longer could feel the normal pleasure rushes brought on by everyday positive experiences, enjoyment and success. For a year or more, as my dopamine system readjusted, I felt very little; everything seemed sort of blah. In recovery, I have found this to be a major cause of relapse for newly sober addicts.
How should addicts in early recovery handle the dopamine readjustment process? Is there a way to kick the system back into action and speed up the rate of normalization?
There is no magic bullet, and every personal journey will be very different. But the common denominator of successful recovery appears to be the ability to transfer some of the destructive allure of a drug to another powerfully attractive focus of behavior, an alternative but “healthy addiction,” if you will. To find alternative behaviors that are rewarding and can motivate the individual helping him/her counteract the strong pull from drugs. This will be different, of course, for every person, but success stories often involve finding and embracing an alternative passion (such as sports, personal fitness, cooking; the list is infinite) that can be harnessed to fill the void with positive and long lasting meaning and purpose.
In a January 2013 Message From The Director entitled Overdose Deaths Among Homeless Persons on the NIDA website, you wrote: “Homelessness is a persistent problem—nearly 690,000 people are homeless on a given night in America—and it takes a terrible toll in sickness and mortality. The leading cause of death among homeless Americans used to be HIV, but that has been replaced by a new epidemic: drug overdose. A new study to appear next month in JAMA Internal Medicine found that overdoses—most of them involving opioids—are now the biggest killer among homeless people in the Boston area.”
There seem to be almost no resources to address this problem. What needs to be done in order to help the homeless population?
One of the recognized drivers of the overdose epidemic is an underlying substance-use disorder. Therefore, expanding access to addiction-treatment services is an essential component of what should be a truly comprehensive response. NIDA (from NIH), together with other HHS agencies, is actively collaborating with public and private stakeholders with the goal of expanding access to, and improve utilization of, evidence-based addiction treatments; particularly medication-assisted treatments, like buprenorphine, in tandem with other targeted approaches (i.e., development and deployment of “user friendly” delivery systems for naloxone) to reducing opioid overdoses. In addition, it is also critical to implement primary prevention policies that cut down the inappropriate prescribing of painkillers (which we also recognize as an important driver of the epidemic), while avoiding jeopardizing critical or even life-saving opioid treatment, when it is needed.
A comprehensive response of course should also address broader structural issues, which, like homelessness or poverty, are outside my area of expertise of my institute’s jurisdiction.
In a November 2012 Message from the Director entitled Addressing Drug Abuse in the Armed Forces, you wrote about the use and abuse of prescription opioids among combat veterans. In addition, you noted the issue of substance abuse problems among returning veterans. You ended by clearly stating, “NIDA will continue working with the Department of Defense and other agencies to address substance use problems faced by those who bravely serve the nation in our armed forces.”
In light of this spiraling problem of veterans with substance abuse disorders, what have you been working on with the Department of Defense to help? What do you think should be done in the future to address this heartbreaking challenge?
NIDA has been working collaboratively for several years with the Department of Defense (DoD), Department of Veterans Affairs (VA) and other NIH institutes (e.g., National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Center for Complementary and Integrative Health (NCCIH), and the National Cancer Institute (NCI) to fund research to better understand, prevent, and treat substance abuse and co-occurring mental health problems in service members, veterans, their families, and communities. In 2010, NIDA, NIAAA, NCI, and the VA collaborated in funding 14 grants to support research focused on understanding, preventing and treating substance abuse and related conditions experienced by veterans returning from the wars in Iraq and Afghanistan (RFA-DA-10-001). In 2013, NIDA, NIAAA, NCCAM, and the DoD collaborated in funding 12 grants on substance abuse prevention and health promotion among those who served in Iraq and Afghanistan (DA13-012/013). In 2014, NCCIH, NIDA, and the VA collaborated in funding 13 research grants focused on non-pharmacological approaches to pain management in military personnel, veterans, and their families (AT14-003/004/005). The grants will explore non-drug approaches to managing pain and related health conditions, such as PTSD, drug abuse, and sleep issues.
On November 12, 2013 on the NIDA website, you published a blog entitled Talking to the Dalai Lama about Addiction Science. Illuminating your meeting with the Dalai Lama in Dharamsala, India, you wrote, “The Dalai Lama said that Buddhism can help best with this goal of preventing drug abuse, both through training the brain to balance emotions and self-restraint (for instance through meditation) and through promoting education and working to create a less materialistic society. He acknowledged that once a person becomes addicted, Buddhism may have less to offer, and said that medical science may be the best solution to treating their disease.”
12-step programs describe addiction as a three-fold disease—physical, mental and spiritual. Do you agree with the Dalai Lama that spirituality needs to play an essential role in helping to prevent the onset of addictive disorders? How could such spiritual practices be offered to young people by federal programs while also maintaining the separation between church and state that is so essential to American democracy?
If we define “spiritual” practices as non-pharmacological, evidence-based practices that, like meditation or mindfulness, can help an individual reestablish a mental balance and a healthier life, then I would agree with the statement that “spiritual” practices can play a role as legitimate active ingredients of a holistic-therapeutic approach. Because of the way I just defined spirituality (i.e., in non-religious terms), I don’t think such approaches would raise any issue vis á vis the separation between church and state.
On the NIDA website in a March 2013 Message From The Director entitled Marijuana’s Lasting Effects on the Brain, you wrote, “Given the current number of regular marijuana users (about 1 in 15 high school seniors) and the possibility of this number increasing with marijuana legalization, we cannot afford to divert our focus from the central point: Regular marijuana use stands to jeopardize a young person’s chances of success—in school and in life.”
In light of your strong conviction in regards to the dangers of marijuana use, what do you think about the burst of new marijuana legalization laws in states across the country? For example, are the marijuana vending machines at restaurants and the edible THC-infused mints and truffles offered for sale in Colorado a real danger for kids? Are such ventures reducing a dangerous drug to a consumer fancy despite the threat of long-term health problems and damaging side effects?
Absolutely. All these trends add to the confusion that young people must feel when the public message so clearly contradicts the scientific message. We are very concerned that these trends will steadily erode the perception among youth that smoking marijuana is not good for them. And this erosion, surveys show, has a close historic correlation with increased use.
You were born in Mexico and your great-grandfather was the Russian revolutionary leader Leon Trotsky. Many years before you were born, the agents of Josef Stalin assassinated Trotsky in his home in Mexico City in 1940. Still, you and your three sisters grew up in the house where your great-grandfather had been murdered. On weekends as a teenager, you led visitors on tours of the house, which is now a museum.
Leon Trotsky once said, “Life is not an easy matter... You cannot live through it without falling into frustration and cynicism unless you have before you a great idea which raises you above personal misery, above weakness, above all kinds of perfidy and baseness.”
When you relate this quotation to the context of your chosen field, it makes a lot of sense. In the New York Times, when asked about politics in your early family life and the influence of your great-grandfather on your personal perspectives, you clearly stated, “I've never become politically involved. If you want to be a scientist, you cannot allow politics to get in the way of your objectivity.”
At the same time, wouldn’t your great-grandfather have seen your work in establishing the scientific principles behind addiction as a disease a brilliant scientific extension of his ideas? In a sense, when you examine the very best of his revolutionary program and the egalitarian ideas that remain valid to this day, isn’t your tremendous success as both an immigrant and a woman in the United States a positive realization of those ideas coming to fruition?
My great-grandfather has always been an inspiration to me, for he led his life with a conviction that he could do something to improve the lives of others and that of future generations. I have tried to do that with my life, too.
You were included in Washingtonian magazine’s 2009 and 2011 list of the “100 Most Powerful Women” and named “Innovator of the Year” by U.S. News & World Report in 2000. Given your duties as the Director of the National Institute on Drug Abuse, how do you plan to build on this past success as a scientific innovator? What would you most like to accomplish from a realistic perspective?
I would like to help change the way we treat addiction from that mostly of a criminal behavior to one of a health disorder that can and should be treated. While there is increasing recognition that addiction is a brain disorder this has still not materialized in changing the way we treat most individuals that suffer form a substance use disorder.