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Significant Items in House, Senate, and Conference Appropriations Committee Reports



The following section represents FY 2003 Congressional requirements for reports and significant items derived from Senate Report 107-216. These actions discussed below are contingent on inclusion of similar language and funding in the final FY 2003 appropriation and related reports.

Additional items may be transmitted at a later date as a result of the final Conference report.

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Collaboration with SAMHSA and other agencies - The Committee encourages NIDA to continue to collaborate with SAMHSA and other agencies to bridge the existing gap between research and practice. The Committee is pleased that NIDA plans to support CSAT's Addiction Technology Transfer Centers. The Committee believes that this collaborative effort will have a significant impact on how communities receive and develop the skills, systems, and necessary support to implement new research findings. (p. 134)

Action taken or to be taken

Communities across the country have documented the growing interest for proven practice models and treatment approaches that prevent and treat drug abuse and addiction. Despite important scientific discoveries, the 'research to practice' gap between research and treatment remains extensive and traditionally takes nearly two decades between the time of the scientific discovery and the actual translation into clinical treatment. To reduce this gap and to have communities more involved in delivering quality health care, NIDA remains committed to building a unique intra-agency partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA) to expedite the application of research findings into clinical practice. NIDA is addressing this issue at many levels.

NIDA and SAMHSA recently launched an intra-agency agreement to co-fund projects, co-sponsor workgroups and serve as intra-agency consultants on a range of cross-cutting issues. As part of this partnership, NIDA provided $1.5 million to support SAMHSA's Center for Substance Abuse Treatment (CSAT) Addiction Technology Transfer Centers (ATTC). ATTC is a network comprised of 14 independent regional centers and a national office charged with increasing the knowledge and skills of addiction treatment practitioners and fostering alliances to support and implement best treatment practices. This agreement will link scientific findings generated by NIDA's National Drug Abuse Treatment Clinical Trials Network (CTN) and other NIDA-supported studies and will disseminate findings to community practitioners served by the ATTCs.

Additionally, the NIDA and SAMHSA partnership has expanded to include collaboration with other agencies and Institutions. For example, NIDA and the National Institute of Mental Health (NIMH) issued a three-year program announcement titled: "Effectiveness, Practice, and Implementation in the Center for Mental Health Services Children's Service Sites." The program announcement encourages research grant applications on services delivered to children, adolescents and their families through the Center for Mental Health Services (CMHS) Comprehensive Community Mental Health Services for Children and their Families Initiative. Another multi-agency collaborative effort is the HIV/AIDS Treatment Adherence Health Outcomes Cost Study Cooperative Agreement with CMHS. NIDA will contribute the expertise of staff scientists as well as funding toward the project, which is a collective effort between NIDA, SAMHSA, NIMH, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the Health Resources and Services Administration (HRSA).

In addition to these promising initiatives, the NIDA and SAMHSA collaboration will focus on finding the most effective way to train health care workers on newly developed medications. An important new treatment tool in NIDA's medication development program is buprenorphine, which was developed after more than a decade of NIDA supported research. Buprenorphine has recently been approved by the Food and Drug Administration to treat heroin and other opioid dependence. Although buprenorphine is related to morphine, it does not produce the same high, dependence or withdrawal syndrome. Buprenorphine's unique long-lasting effects and pharmacology make it an attractive and clinically helpful treatment option that is less likely to cause respiratory depression, and is well-tolerated by addicts. SAMHSA will apply NIDA's research findings on buprenorphine by partnering with NIDA to develop a buprenorphine training curriculum and certification process for physicians to prescribe the medication for drug abuse treatment. SAMHSA is establishing a nationwide registry of physicians to launch the buprenorphine training as well as an information campaign to assist health care workers and patients to identify qualified treatment professionals.

NIDA (with NIMH and NIAAA) and SAMHSA recently initiated several other new efforts to bring science to the service or practice arena. The intra-agency "Science to Services Workgroup" has been established to explore ways that NIH and SAMHSA can enhance collaboration. NIDA is also committed to conducting technical assistance training for current SAMHSA grantees interested in NIH funding opportunities. During fiscal year 2004, NIDA and SAMHSA will identify dedicated and sustained funds for more collaborative efforts.

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Community-friendly behavioral therapies - Research-based behavioral treatments are often criticized as too lengthy, costly, complex, or difficult for treatment providers to integrate with more traditional methods of care. The Committee applauds NIDA's efforts to remedy this situation by developing and bringing behavioral therapies to community treatment centers. NIDA is urged to encourage researchers to make behavioral treatments more "community friendly," while still maintaining their effectiveness. The Committee is pleased that NIDA has expanded the scope of its research beyond testing new treatments to include studies on financing and organizational adaptation and change. The Committee encourages NIDA to continue testing new treatments in clinical trials and supporting research on how to move effective treatments into health care systems. (p. 134)

Action taken or to be taken

The National Institute on Drug Abuse (NIDA) is committed to the development of behavioral therapies that will be utilized in community treatment settings. Research has shown that behavioral therapies do in fact work. Behavioral treatments can be very potent and can have long-lasting effects, that may even increase, after treatment ends. Despite the availability of effective behavioral treatments, they have not been adopted widely into community clinical practice. A major barrier to the adoption of research-based, efficacious behavioral treatments by community treatment providers is that these treatments may not be "community friendly." For instance, treatments may be too lengthy, costly, complex, or difficult to integrate with usual care to be considered feasible in a community setting. To encourage more research on how to make research-based therapies more "community-friendly," NIDA issued a Request for Applications "Modifying and Testing Efficacious Behavioral Therapies to Make Them More Community Friendly" in December of 2001. Seven grants were awarded in the fall of 2002. Some of the research that will be funded under this initiative include: Developing and testing an individualized, interactive computer-based training program for cognitive behavioral therapy that can be accessed directly by patients; creating and testing a "community friendly" manual-based individual plus group drug counseling package to treat cocaine abusers; testing a community reinforcement approach through religious communities for African American women who are abusing cocaine; and shortening the timeframe of a more lengthy, but proven to be effective family intervention that targets substance abuse and other HIV risk behaviors in adolescents. NIDA is also encouraging more research on group behavioral treatments.

Overall NIDA continues to build its behavioral treatment program with the goal of determining the "mechanism of action" or the how and why approach to what makes treatments work. Researchers are attempting to figure out what are the essential (and non-essential) components of treatments. This will enable us to pare down treatments, and make them more efficient. Once we determine what is and is not essential, we will only have to focus on delivering those parts of efficacious treatments that are essential.

Additionally, NIDA is very interested in promoting research that will allow us to better understand how to train community therapists to deliver efficacious behavioral therapies.

Toward this end, in September 2002, NIDA issued a request for applications, "Guidance for Behavioral Treatment Providers: Research on Knowledge and Skill Enhancement." This program will support studies for developing and testing novel, creative approaches to clinical training and supervision that will enhance community treatment providers' knowledge and skills so that they can administer behavioral treatments with evidence of efficacy for drug abuse and/or interventions for HIV/AIDS risk reduction among in-treatment drug abusers. For example, perhaps some individuals will learn best from virtual reality clients, interactive Internet networking, or supervised video training. Research from this initiative will also be useful in helping to enhance or update the skills of community therapists who have been practicing for long periods of time.

NIDA is also supporting efforts to move effective treatments into community health care systems. One way NIDA will accomplish this is by funneling some of the promising therapies that emerge into NIDA's National Drug Abuse Treatment Clinical Trials Network (CTN) for more extensive testing of their application with diverse populations nationwide. NIDA will also work with other government agencies to encourage implementation of science-based treatments. For example, NIDA will continue to work with the Substance Abuse and Mental Health Services Administration's's (SAMHSA) Center for Substance Abuse Treatment (CSAT) to help ensure that findings from NIDA's treatment research will be quickly and readily available to practitioners around the country. NIDA has provided funding to support CSAT's Addiction Technology Transfer Centers (ATTC), a network comprised of 14 independent regional centers charged with increasing the knowledge and skills of addiction treatment practitioners and fostering alliances to support and implement best treatment practices. The agreement will enhance efforts to disseminate and apply findings from NIDA's CTN as well as other NIDA-supported studies to practitioners served by the ATTCs.

In addition to modifying science-based behavioral treatments so they are more community friendly and more likely to be used in community settings, NIDA has continued to expand its health services research portfolio to support studies that look at financing and organizational adaptation and change. For example, one of NIDA's grantees is looking at the impact of financing on outcomes of methadone maintenance, and another grantee is studying cost models to support management applications in real world substance abuse systems. In the organization and management arena, NIDA supports over 10 grantees who are looking at issues such as the quality of care in the therapeutic community, and how to effectively adopt proven innovative practices in privately funded drug abuse and alcohol treatment centers. These types of studies will help facilitate improvements and innovations that reduce the cost and duration of treatment while increasing treatment quality and patient access to care.

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Hepatitis C treatment - The Committee notes the high incidence of hepatitis C among the U.S. population that uses drugs. Research into the efficacy of treating such individuals for hepatitis C concurrently with drug dependency protocols such as methadone is highly recommended. (p. 135)

Action taken or to be taken

The National Institute on Drug Abuse (NIDA) is committed to expanding its substantial research portfolio on Hepatitis C virus (HCV), particularly among drug using populations. Nearly 4 million people in this country are believed to have been infected with HCV, which is one of the leading known causes of liver disease. Given the current incidence and prevalence data, HCV infection is expected to remain a substantial health problem. NIDA currently supports a broad continuum of research in the virology, immunology, natural history and pathogenesis, epidemiology, treatment and prevention of HCV infection to achieve more effective outcomes.

One critical area that NIDA will continue to examine includes the effectiveness of treatment for individuals with HCV who enter methadone maintenance programs. Throughout the 1990s, the growing prevalence of HCV was documented and recognized as a serious disease among injection drug users and methadone maintenance patients. Epidemiological studies demonstrate that methadone programs contain large numbers of individuals with all stages of HCV infection. Expansion of methadone maintenance programs to include primary care treatment that will also provide medical management and comprehensive risk-modifying educational programs can be effective in preventing and decreasing HCV transmission and disease morbidity. The recent availability of buprenorphine to treat opioid dependence will expand treatment options for stabilizing individuals with HCV and NIDA has already initiated funding to examine these effects.

To accelerate research on the diagnosis, treatment and medical management of HCV in drug abusing populations, NIDA recently launched a new drug abuse research initiative titled "Hepatitis Diagnosis, Treatment, and Interaction with HIV/AIDS." This 2002 initiative will expand research on drug abuse-related aspects of the epidemiology, pathogenesis, prevention, treatment, and medical management of HCV and HCV/HIV co-infection. Research areas include innovative methods for early diagnosis, treatment regimens for HCV and its co-morbid conditions that are effective and deliverable in drug abusing populations, interventions that promote the prevention of transmission by infected drug abusers, diagnosis and treatment in special populations including minorities, women compared to men, pregnant women, women with childcare responsibilities, and models of delivery of diagnostic and treatment services that address issues of access, cost, organization and management and effectiveness.

In addition to NIDA's own comprehensive research on this topic, NIDA remains involved in numerous transdisciplinary activities. An initiative launched in FY00 through a NIDA and NIAAA partnership currently supports seven new grants that examine viral hepatitis and HIV to address gaps in prevention, natural history, pathogenesis, and treatment research in these populations. NIDA co-sponsored and participated in the June 2002 Consensus Development conference for the Management of HCV and is an active member of the trans-NIH Institute extramural HCV Work Group which meets regularly to develop joint research initiatives, plan scientific meetings, and share relevant information on Institute-specific research issues and activities. NIDA also participated fully in the development of the "NIH Framework for Progress in Research on HCV," a multidisciplinary approach to support research on HCV which was initially developed in 1999 and continues to be used by multiple institutes in setting the research agenda. NIDA has also joined with other Institutes to invigorate research in this area. NIDA is actively partnering with other Institutes to co-sponsor collaborative research projects and convene scientific seminars on HCV. One example is the "Hepatitis C Cooperative Research Centers" which is co-funded by NIDA. This program is a collaborative research network on HCV infection and disease, conducting both laboratory and clinical research. The primary purpose is to link basic and clinical research in order to provide further understanding of the stages and manifestations of HCV infection, disease, and recovery. NIDA conducted a workshop in the fall, 2002, to address issues associated with treatment models designed to systematically manage substance abuse and psychiatric co-morbidity of individuals with HCV. NIDA plans to convene a conference in 2003 related to the treatment and medical management of drug users with HCV infection. The conference will summarize the state of current knowledge and identify gaps regarding the consequences of co-infection with other infectious diseases such as HIV, eligibility criteria for therapy, access and utilization, therapeutic effectiveness, and interactions with other co-morbid conditions and their therapies.

NIDA will continue to fully support research among drug users that focuses on HCV. Future advances in the diagnosis and management of HCV require continued commitment concerning the management of clinical disease, extending treatment to populations not previously evaluated in treatment trials, and the introduction of new scientific discoveries that contribute to more effective treatment models.

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Information Dissemination - The Committee urges NIDA to use both the existing National Drug Abuse Treatment Clinical Trials Network infrastructure and the new prevention infrastructures that are currently being established as a part of NIDA's new Prevention Research Initiative to ensure that findings are put into practice in communities across the country. (p. 135)

Action taken or to be taken

The National Institute on Drug Abuse (NIDA) recognizes that science must be used if it is to be useful. With this in mind we remain committed to facilitating the dissemination of research findings in an effective, systematic, and efficient manner, while simultaneously supporting a comprehensive research base to ensure there is a continuous flow of new results to share. The National Drug Abuse Treatment Clinical Trials Network and the National Prevention Research Initiative serve as solid examples of our recent efforts in this area. Both provide vehicles to test and bring the newest scientific findings to the community level.

The National Drug Abuse Treatment Clinical Trials Network (CTN) is a cooperative undertaking of NIDA, university drug abuse scientists, and community treatment providers in which researchers and practitioners blend their experience to test research-based treatments in community settings. This infrastructure, established in 1999, is now enhancing our ability to move treatment research findings into practice.

NIDA continues to expand the number of treatment protocols being tested in community treatment programs. Currently six active treatment protocols are being studied. Plans are underway to expand the number of protocols by 13. This will serve over 8,000 patients. These new treatment protocols will include studies of pregnant drug-abusing women, adolescent drug abusers, drug abusing women with Post Traumatic Stress Disorder, a study conducted in Spanish for Spanish speaking drug abusers, three HIV risk reduction interventions, and a cigarette smoking cessation intervention for in-treatment drug addicts. As a result of the extensive field-testing that goes into developing a protocol, we expect that when a CTN study demonstrates that a research-based therapy works in the clinic, the protocol for that treatment will be adopted quickly as a standard of care by the treatment providers.

Since its establishment in 1999 the CTN has expanded from its original five sites to 17 sites. The three most recently added nodes - Northern New England (covering five states), New Mexico, and California/Arizona - were made possible by $6 million in NIDA awarded grants. The addition of the three nodes has expanded the CTN to cover a larger proportion of the country that now includes 27 states, thereby improving our ability to identify effective treatment options for more diverse populations. NIDA will continue to cultivate its relationships with researchers, clinicians, and community groups in a myriad of ways so that findings from the CTN can be rapidly disseminated and implemented in communities across the country.

In addition to the use of the CTN to transfer recent research findings NIDA has been, and will remain committed to, developing collaborative relationships with other agencies. NIDA and the Substance Abuse and Mental Health Services Administration (SAMHSA) recently announced a unique intra-agency agreement to expedite the application of findings from treatment research into clinical application. The $1.5 million agreement between NIDA and SAMHSA's Center for Substance Abuse Treatment (CSAT) will help ensure that findings from NIDA's treatment research will be quickly and readily available to practitioners around the country. This collaboration is an example of the type of action being taken in order to reduce the time between the discovery of an effective treatment and application of that treatment in the community.

Building on the successful model of the CTN, NIDA is also laying the groundwork to revolutionize our Nation's prevention efforts. One such initiative that holds great promise for the development and dissemination of drug abuse prevention programs is the National Prevention Research Initiative. The goal of this initiative is to provide the resources to bring the full power of science to bear on prevention efforts. There are essentially three main components to this initiative: Basic Prevention Science Research; Transdisciplinary Prevention Research Centers (TPRCs); and Community Multisite Prevention Trials. These three distinct phases represent NIDA's commitment to making sure that the latest research findings are communicated across fields of interest and that these findings directly benefit communities. After issuing three separate request for applications in these areas, NIDA awarded several grants in 2002. These grantees will work with other prevention researchers and community members to ensure that findings are put into practice in communities across the country. The Community Multisite Prevention Trials will be a major vehicle for helping accomplish this. The trials will test the effectiveness of drug abuse prevention programs in diverse populations and locations so that factors associated with successful adoption, adaptation, sustainability, and outcomes of these programs can be identified.

In addition to establishing research and dissemination infrastructures to bring findings to the community level, NIDA has also been active in developing additional methods of translating findings. One of the best examples of this effort can be found in NIDA's sponsorship of regional "blending conferences." At these conferences, teams of clinicians and researchers present cutting-edge scientific findings about drug abuse and addiction and real-life perspectives on overcoming obstacles that sometimes inhibit collaboration between researchers and providers. Focused workshops provide participants with technical assistance in applying research-based interventions into their own practice settings.

This year NIDA sponsored a conference titled "Blending Clinical Practice and Research: Forging Partnerships to Enhance Drug Addiction Treatment Research" in New York, March 14-15, 2002. Attended by 950 participants, this conference provided an opportunity for clinicians and researchers to examine the latest findings about drug abuse and addiction and their application to clinical practice. By bringing local officials, drug treatment counselors, social workers, criminal justice staff, marriage and family counselors, and public health workers who treat individuals with drug abuse or addiction together to discuss the recent progress in drug addiction research, NIDA is reaching the frontline people who are providing services to substance abusers. It was during this conference that a NIDA sponsored researcher first reported on the increased use of marijuana, alcohol, and tobacco immediately following the events of September 11, 2001. NIDA also held a science writer's seminar at this conference which provided the media with the opportunity to meet some of the experts that presented at the Blending conference, and to get first-hand information about the latest in substance abuse research and other related topics. These types of gatherings are just one way NIDA a ssists in communicating up to date information regarding drug abuse to vast audiences.

NIDA's collaboration with the Community Anti-Drug Coalitions of America (CADCA) is another example of a strong research dissemination effort. By partnering with CADCA NIDA is able to communicate the latest in drug abuse research to 5,000 community coalition members. There are a number of activities that NIDA conducts with CADCA, including developing a publication called the Practical Theorist that concisely delivers technical information to community groups for implementation at the community level.

Another important information pathway to disseminate new findings is through the use of NIDA produced printed materials. Recently NIDA released a curriculum geared toward second and third graders. "Brain Power ! The NIDA Junior Scientists Program" focuses on teaching children the biological effects of drug abuse on the body and the brain. Through the use of written materials and videos, children are taken on a scientific journey that covers six areas, including; scientific inquiry; brain function; brain communication; differences between drugs and medicines; use of nicotine; and a summary module that reviews the previous areas and offers a learning assessment. Currently we are in the process of developing materials on drug abuse for children in kindergarten and first grade, as well as those in the fourth and fifth grades.

In addition to the materials for school aged children, in August 2002, NIDA launched its own peer reviewed journal "Addiction Science and Clinical Practice" which will be published twice a year and will provide up to the minute prevention and treatment findings from researchers; perspectives from service providers on what does and does not work in community settings; as well as true stories of successful collaborations. Yet another method of bringing research to communities is through NIDA's treatment manuals. These manuals were distributed on a large-scale basis using the Clinical Toolbox, which was mailed to over 12,000 drug abuse treatment providers last year.

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Methamphetamine - The Committee continues to be concerned about methamphetamine abuse across the Nation, especially in the Midwest. The committee again urges NIDA to expand its research on improved methods of prevention and treatment of methamphetamine abuse. (p. 135)

Action taken or to be taken

The National Institute on Drug Abuse (NIDA) recognizes the multi-faceted problems posed by methamphetamine abuse and addiction and has increased its research efforts accordingly. NIDA-supported scientific research serves as the foundation for the Nation's response to methamphetamine abuse and addiction. Our Community Epidemiology Work Group (CEWG) continues to track the patterns of methamphetamine manufacture and abuse throughout the United States. Basic and clinical research supported by NIDA has examined how methamphetamine and similar drugs (such as Ecstasy, also known as MDMA) work in the brain and precisely how they damage brain cells. Other NIDA-supported research has sought to identify effective methods to treat methamphetamine addiction. In the prevention arena, NIDA-supported researchers have evaluated drug abuse prevention programs, which typically target elementary and intermediate school students, to determine their potential for reducing methamphetamine abuse in older adolescents. Most recently, NIDA has worked in partnership with its constituent professional organizations across the country to address the issue of methamphetamine abuse through its Town Meetings and the widespread distribution of a Community Drug Alert Bulletin on methamphetamine.

Increased knowledge about the health and developmental consequences of drugs of abuse is allowing NIDA to rapidly provide communities with the science-based tools to prevent and treat drug problems at the local level. In addition, alarming research results about the long-lasting effects of methamphetamine on brain function have led NIDA to expand its research portfolio in all methamphetamine-related research areas, including a special emphasis on methamphetamine use by women of childbearing age and the potential health and developmental consequences to the developing fetus.

NIDA is also actively pursuing promising pharmacotherapies to treat methamphetamine abuse and addiction. In order to determine the best strategies for developing medications for the treatment of methamphetamine addiction and related problems, NIDA convened a Methamphetamine Addiction Treatment Think Tank that brought together preclinical and clinical experts. These experts provided NIDA with several recommendations that NIDA is now using to guide research related to methamphetamine abuse and addiction.

To capitalize on the input of its experts, NIDA has established a Methamphetamine Treatment Discovery Program (MTDP). The mission of the MTDP is to identify, evaluate, and recommend potential treatments for the medical management of methamphetamine dependence and its effects using a preclinical approach. The program will focus on discovering medications to reduce or eliminate drug-seeking behaviors. In addition, the MTDP will have the capability to evaluate, in animals, medications with an established rationale for possible effectiveness in reversing neurotoxicity and cognitive impairment.

This research is now providing critical information that is facilitating the development of effective medications for treating problems associated with methamphetamine abuse. NIDA-funded preclinical researchers are engaged in studies that could identify targets for medications to treat consequences of amphetamine and methamphetamine abuse such as acute intoxication, dependence, relapse to use, and brain damage. Animal models for many of the harmful consequences of methamphetamine abuse have also been developed. These include models for addiction, overdose, neurotoxicity, behavioral and neurological deficits due to the neurotoxicity, and damage to the developing fetus of pregnant methamphetamine users.

Also following the advice of the expert panel of preclinical and clinical experts, NIDA currently has several medications under development for treating different consequences of methamphetamine abuse. Many of these drugs target the brain's dopamine system. NIDA-funded research has shown that all drugs of abuse affect the neurotransmitter dopamine in some way. Initially, drugs cause increases in dopamine levels that are responsible for the high that is experienced with drug use. Over time however, the brain adapts by producing less dopamine. When this happens, the drug-addicted person must continue to use the drug to keep from feeling bad (dysphoric). These dysphoric feelings of malaise make it very difficult for methamphetamine addicts to stop using the drug. Medications that reduce the dysphoric feelings by causing an increase in dopamine levels would be a useful tool for helping methamphetamine addicts stop drug use.

To speed our medication development efforts, NIDA has recently established the Methamphetamine Clinical Trials Group (MCTG) to conduct clinical (human) trials of medications for methamphetamine. This group is capable of conducting both phase I and II clinical studies. It has sites in geographic areas in which methamphetamine abuse is particularly high, including San Diego, Kansas City, Des Moines, Costa Mesa, and Honolulu. The first MCTG protocol, is examining use patterns of methamphetamine and the withdrawal syndrome, followed by studies of the compound ondansetron. Ondansetron blocks a specific type of binding site for the neurotransmitter, serotonin. Human laboratory studies have indicated that ondansetron can block the effects of methamphetamine. In addition to ondansteron, NIDA has about a dozen other compounds that are being studied as possible medications for treating various aspects of methamphetamine addiction.

Research has clearly shown that behavioral therapies are an integral part of effective treatment programs. Consequently and following the advice of our experts, in addition to medication development efforts, NIDA is conducting research on behavioral therapies that might be effective for treating methamphetamine addiction. Studies have now shown that a treatment program known as the Matrix Model can be used successfully for the treatment of methamphetamine addiction. The Matrix Model was developed in the 1980s for treating cocaine addiction. It consists of a 16-week program that includes group and individual therapy and components that address relapse and how to prevent it, behavioral changes needed to remain off drugs, communication among family members, establishment of new environments unrelated to drugs, and other relevant topics. When applied to methamphetamine abusers, the Matrix Model has been found to be a useful treatment approach.

Because no single behavioral treatment will be effective for everyone, research into behavioral approaches for treating methamphetamine addiction is ongoing. It is expected that, as with other types of addiction, combining pharmacotherapies with behavioral therapies will be the most effective way to treat methamphetamine addiction.

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Nicotine - The Committee applauds NIDA's efforts to support a comprehensive research portfolio that has indisputably demonstrated the addictive nature of nicotine. The Committee encourages NIDA to work independently and, where possible, collaborate with other Institutes and organizations to identify and develop targets for new treatments. The Committee recognizes that treating addiction to nicotine remains among the most cost effective approaches to reducing cancer risk. (p. 135)

Action taken or to be taken

Nicotine addiction takes an enormous toll on American health. More than 430,000 people die in this country each year from smoking-related causes.

Despite growing public awareness of the deadly dangers of tobacco use, more than 3,000 people under 18 years of age become smokers every day and, once addicted, find it very difficult to stop. It is addiction to nicotine that continues to drive the use of tobacco in this country and a major reason why the expertise of the National Institute on Drug Abuse (NIDA) is so integral to national efforts to reduce this chronic disease burden.

In an article published in the October 9, 2002, issue of the Journal of the American Medical Association the researchers found that if the smoking interventions that have been proven to be effective were broadly implemented, a larger proportion of the 46 million U.S. adult smokers would try to quit and that among those who would attempt to quit, the likelihood of success would be substantial. This research was from NIDA supported scientists from the University of Wisconsin and the University of Minnesota Transdisciplinary Tobacco Use Research Centers. The researchers conclude by stating that because evidence-based assistance to help individuals battle nicotine dependence is at an all-time high, there is no better time than now to try to stop smoking.

For these reasons NIDA continues to support a comprehensive research portfolio on nicotine addiction. NIDA's nicotine-related research portfolio covers a variety of topics including the areas of basic, prevention, and treatment research as well as developing effective science based educational outreach activities to ensure that new findings are rapidly disseminated to the public. For example, NIDA seeks to bring about scientific advances on the biological, behavioral, and pharmacological bases of nicotine addiction; basic and applied behavioral research targeting children and adolescents to improve strategies to prevent smoking initiation; research that will increase the effectiveness of long-term smoking cessation treatment, by developing both nicotine and non-nicotine replacement medications in combination with behavioral strategies; and behavioral research on nicotine and smoking; and epidemiological studies that monitor patterns of drug use, including nicotine; and studies that examine the progression from initiation of tobacco use to chronic use to addiction and the risk factors associated with each stage. Through NIDA's Children and Adolescents Research Initiatives, NIDA continues to focus on research areas such as the consequences of prenatal drug exposure; understanding the genetic factors that make individuals, particularly children, more or less vulnerable to addition and harnessing cutting edge neuroimaging technology to study the unique effects of substances of abuse including nicotine on children and adolescents.

NIDA's support of basic neuroscience research has taught us much about how nicotine and other drugs of abuse affect the brain. Receptors such as the nicotinic cholinergic receptor (nAChR) have been cloned and the circuitry underlying nicotine's many behavioral effects has been identified. A strong science generated during the past decade is now being used to translate basic research observations into new medications to treat nicotine addiction. To expand the number of treatment options for tobacco users NIDA is working with other NIH institutes to develop a more strategic process for developing new medications for nicotine dependence. NIDA has recently released a Request for Applications with the National Institute of Mental Health entitled "National Cooperative Drug Discovery Groups For The Treatment Of Mood Disorders Or Nicotine Addiction" to establish long-term partnerships between NIH, academia, and industry that will advance the development and testing of fundamentally new, rationally designed medications and treatments for mental disorders and nicotine addiction. Since the creative talents in the required scientific disciplines are rarely available in a single institution, a multi-institutional, group approach involving academic, nonprofit, commercial, and/or industrial institutions is envisioned. Academic and pharmaceutical scientists are being strongly encouraged to form partnerships that take full advantage of their combined intellectual and material resources for drug discovery, lead optimization, and model development. It is hoped that the interaction of academic and non-profit research institutions with pharmaceutical industry and NIH will facilitate the subsequent development and marketing of new pharmacologic treatments.

Because little is known about effective treatment approaches for adolescents, NIDA's intramural research program supports the Teen Tobacco Addiction Treatment Research Clinic in Baltimore, Maryland. The Clinic's aim is to study pharmacological and behavioral modalities that might help to treat adolescent cigarette smoking. A first treatment study is examining whether teenagers, like adults, can safely use and benefit from the nicotine replacement patch and gum. Over 900 teens have been screened for enrollment in the program with 140 consented, 100 randomized, 39 completers, 5 currently active. The screening process is also viewed as a venue to establish both level of demand and contextual characteristics of community teenage smokers that seek cessation treatment. So far, side effects of the patch and the gum have been minor and similar to those seen among adult smokers, while abstinence rates among these adolescent cigarette users, who also have psychiatric comorbidity and alcohol and drug use, have been promising.

The depth and comprehensiveness of our understanding of tobacco use and nicotine addiction is unprecedented. In an attempt to capitalize on this knowledge base, NIDA has partnered with the National Cancer Institute and the Robert Wood Johnson Foundation to create the Transdisciplinary Tobacco Use Research Centers (TTURCs). These centers bring together diverse perspectives of nicotine addiction with the goal of cross fertilizing basic and clinical research. The Centers are helping us to understand the complex interaction of genetic, environmental, neurophysiological, and behavioral effects of tobacco use and nicotine addiction.

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Prevention research - The Committee is pleased that NIDA has launched a multi-component National Prevention Research Initiative that will involve partners at the State and local levels. The Committee urges NIDA to expand this initiative to test the effectiveness of new and existing science-based prevention approaches in different communities, while also studying how best to adapt the programs for local needs. (p. 135)

Action taken or to be taken

The National Institute on Drug Abuse (NIDA) recognizes that community participation is key to the successful implementation of prevention interventions. Consequently, NIDA launched a new National Prevention Research Initiative (NPRI) in the Summer of 2001 at NIDA's 2nd National Conference on Drug Abuse Prevention Research. This conference was the ideal place to launch this initiative because it brought together the nation's premier researchers, prevention practitioners and policymakers to collectively set a course to stem drug use by the Nation's youth. Participation at the state and local levels is a critical component of the NPRI and is integral to ensuring that prevention programs meet the local needs of the community and can be sustained.

The three-pronged initiative calls on basic researchers to mine new discoveries for prevention applications; asks basic, clinical and applied researchers, and practitioners to work together to synthesize knowledge from all relevant scientific fields; and lastly, asks researchers and State and local practitioners to collaborate to rapidly assess proposed new prevention approaches in diverse communities and populations.

Shortly after announcing the new prevention initiative, NIDA issued three new Request for Applications (RFAs) specifically for the NPRI. Four grants totaling more than $4.5 million have already been awarded under the first RFA issued December 2001, to conduct multi-site clinical trials that will test science-based drug abuse prevention interventions. These trials will accelerate research on the processes and mechanisms that contribute to the adaptation and implementation of drug abuse prevention models and will examine prevention delivery factors such as organization and management practices and financial strategies that foster the sustainability of such models in community settings. The other two components of the new prevention initiative focus on supporting basic research to develop new directions in drug abuse prevention interventions and the establishment of transdisciplinary prevention research centers (TPRCs). In addition to the grants already awarded, NIDA will make additional funds available to reissue its RFA for the establishment of more transdisciplinary prevention research centers.

An important aspect of each prevention grant is the involvement of an advisory board representing local and state policymakers, researchers and prevention practitioners. The NPRI sees prevention practitioners and other stakeholders as an integral part of the prevention research process. Drug abuse prevention is funded and delivered through a variety of not-for-profit and for-profit groups and agencies. Research to address the problems inherent in developing and testing effective drug abuse prevention programs for delivery in a variety of settings (e.g., schools, religious communities, organized clubs, mental health settings, private business) must draw on the insights of those with the most experience in the actual adoption, adaptation, implementation, financing and management of interventions. Thus, there is a natural feedback process between research and practice that this Initiative seeks to capitalize on and strengthen in an effort to improve both the science and the utility of research-based interventions.

Another important outcome of NIDA's Prevention initiative will be a significant update scheduled to be released in spring 2003 of NIDA's well-regarded guide to drug abuse prevention for communities (the red book entitled Preventing Drug Use Among Children and Adolescents). First published in 1997, the updated guide will expand the principles of drug abuse prevention and will include a wealth of new science-based information reflecting new science findings.

In addition to activities under the NPRI, NIDA has a robust prevention research portfolio. The etiology of drug use and escalation to abuse in pre and young adolescents, and the development of novel prevention interventions to prevent escalation among those who have initiated use, will be a high priority area for NIDA. Also, as part of NIDA's continuing effort to fill knowledge gaps about preventing drug abuse, NIDA recently issued a new RFA on child psychopathology to stimulate new studies and augment ongoing studies to address unanswered questions concerning associations between certain psychiatric conditions and substance use disorders. These grants will assess the impact of treatment for childhood psychological problems on subsequent substance use. Researchers will address such questions as - which children are at greater risk for substance abuse; what shared or unique characteristics or factors constitute risk for psychopathology and substance use disorders; are there effective interventions for such conditions; and do some interventions unintentionally increase vulnerability to substance use disorders?

Finally, science has taught us a tremendous amount about the factors involved in the initiation and escalation of drug use and some of the best ways to prevent it. Recognizing that the ultimate worth of science lies in the extent to which it is useful and used, NIDA is pleased that five NIDA-funded prevention programs were among those to receive exemplary substance abuse prevention program awards for their contributions as outstanding programs that are reducing alcohol, tobacco, and illicit drug use. Programs are selected by the Center for Substance Abuse Prevention of the Substance Abuse Mental Health Services Administration, in collaboration with the National Association of State Alcohol and Drug Abuse Directors, the National Prevention Network, and the Community Anti-Drug Coalitions of America after a rigorous scientific review. These awards recognize prevention programs that are innovative and effective and that successfully respond to the needs of their target populations. For example, "Lions-Quest: Skills for Adolescence," is a comprehensive school-based program for youth that aims to develop their self-discipline, responsibility, and good judgment; positive commitments to their families, schools, peers and communities, and their commitment to lead healthy, drug-free lives. Designed for middle school adolescents 12 to 14 years old, Skills for Adolescence has been translated into 20 languages and is widely used in the U.S., Canada, and 23 other countries. The program uses a school-parent-community network to address risk and protective factors related to reducing substance use, violence, and other health compromising behaviors. Funding for research and development of the Skills for Adolescence program was provided by NIDA, the Kellogg Foundation, and the Centers for Disease Control and Prevention. The prevention program is an outreach effort of the Lions Clubs, a community service organization.

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Stress and substance abuse - Stress plays a major role in initiation and continuation of drug use and in relapse to addiction. The Committee encourages the NIDA to increase its research portfolio on this topic as well as on post-traumatic stress disorder and substance abuse. (p. 135)

Action taken or to be taken

Years of research and clinical observation have shown that stress is one of the most powerful triggers of drug craving and relapse to drug abuse, even after long periods of abstinence. Stress has also been found to impact the initiation of drug use. The National Institute on Drug Abuse (NIDA) has long recognized the important role of stress in addiction and for several years has put significant resources into addressing this problem from many different approaches.

In 2002, in addition to NIDA's continuous support of a comprehensive research portfolio that looks at the relationship between stress, drug abuse and related disorders, such as post traumatic stress disorder (PTSD), NIDA also issued a new request for applications (RFA) in September 2002 entitled "Chronic Stress and its Relation to Drug Abuse and Addiction." The purpose of the RFA is to increase our understanding of drug abuse and addiction by encouraging research into the neural and behavioral consequences of exposure to physiologically relevant chronic or repeated stressors. NIDA also expects to release an RFA on clinical chronic stress that will examine epidemiology, prevention, and treatment issues. Other relevant Program announcements and RFAs that promote research focusing on the role of stress or trauma in addiction, include the following topic areas: child neglect; co-morbid psychopathology and substance abuse in children; gender differences in the epidemiology, prevention and treatment of addiction; behavioral, social, and mental health and substance abuse research with diverse populations; and service delivery to children and families. These funding mechanisms are intended to include research on basic brain mechanisms; pathways to substance abuse and co-morbid psychiatric disorders within various populations; identification of vulnerability and resilience factors for substance abuse and stress; treatment development and evaluation; service delivery; and mechanisms for inclusion of minority and underserved populations in research. In some cases, these funding opportunities are jointly sponsored with other institutes, offices, and agencies, including the National Institute of Mental Health (NIMH), the National Institute of Child Health and Human Development (NICHD), the Office of Behavioral and Social Sciences Research (OBSSR), the Office of Research on Women's Health (ORWH), the Department of Justice, and SAMHSA.

NIDA also continues to support basic research using animal models to determine how stress contributes to initiation and continuation of drug use and to the complex phenomenon of relapse. These models have elucidated brain circuits and molecules affected by early exposure to stress. With this information, rational choices can be made as to what medications or behavioral strategies should be tested to reverse the long-term impact of early stress.

NIDA supports research that focuses on increasing our understanding of the factors leading to the initiation of drug use and relapse to addiction. Stress and stress hormones have been demonstrated to facilitate initial drug-taking and to prompt reinstatement of drug-seeking in formerly dependent animals that had been abstinent for weeks to months. Several compounds, known as corticotropin-releasing factor (CRF) receptor antagonists, have recently been developed to block the initiation of the stress response in the brain. These compounds have shown a remarkable ability to also block both the initiation of drug taking in animals and the stress-induced reinstatement of drug-seeking for a number of drugs of abuse. Based on these and other findings, NIDA is continuing to encourage research on CRF receptor antagonists for the treatment of drug abuse. These findings are also leading to an increased emphasis on the need for treatment programs for substance abuse to also address stress-related factors to maximize chances for long-term recovery.

In addition, NIDA vigilantly monitors the community at large in our attempts to further our understanding of the relationship between stress and drug abuse. As one example, NIDA responded immediately following the September 11th terrorist attacks by awarding grant supplements to researchers in the New York metropolitan area to provide a rapid assessment of the impact of these events on drug abuse and addiction rates and to re-evaluate service delivery needs and opportunities. NIDA-funded researchers reported in the American Journal of Epidemiology (2002) that there was an increase in substance use soon after the attacks, particularly in individuals with stress-related and depressive disorders. Tobacco, marijuana and alcohol use all increased significantly in much of Manhattan. Increase in the use of different substances may be associated with the presence of different co-morbid psychiatric conditions, including posttraumatic stress disorder (PTSD).

There is an emerging body of research documenting a very strong association between PTSD and substance abuse. It is estimated that between 30 and 59% of women with substance abuse problems also suffer from PTSD. These numbers are even higher (55-99%) when trauma (childhood physical or sexual assault) is considered independently of PTSD. It is often the case that substance use begins after the exposure to trauma; however, the reverse can also be true. Thus, PTSD and trauma are strong risk factors for drug abuse.

Recognizing the strong correlation between PTSD, trauma and drug abuse, particularly among women, NIDA has a growing research portfolio in this area. One program, called Seeking Safety, developed by researchers at Harvard Medical School, has shown promise in a preliminary study. It was found that women who completed the program experienced a decrease in substance use, suicidal ideation, and trauma-related symptoms. This program is now being evaluated against more standard treatments at other sites.

NIDA will continue to encourage more research to better delineate the relationship between trauma, mental disorders and substance abuse; to identify windows of opportunity to prevent some of the devastating consequences of trauma exposure; to better understand the brain mechanisms leading to and associated with co-morbid substance abuse and PTSD and/or other mental disorders; and to determine what treatments and services will ultimately lead to the most promising and long-lasting outcomes.

In addition to our research efforts, NIDA also sponsors meetings and conference symposia focused on the relationship between stress and drug abuse. These meetings have included basic and clinical scientists, treatment providers, and members of the community, and are used to discuss leading edge research and clinical findings. One goal of these conferences is to help develop a research agenda that will optimally meet the needs of the public for improved prevention and treatment efforts; with a secondary goal of determining how to most effectively leverage the accomplishments from many areas of science to advance the understanding of drug abuse and addiction.

For example on September 9, 2002, NIDA joined with the New York Academy of Medicine to bring together national and regional leaders to convene a daylong conference in New York to examine the physical, mental and environmental health consequences of the worst terrorist acts in U.S. history. Experts in public health, science and medicine presented data on the wide-ranging effects of September 11th, including panels on the mental, physical, environmental consequences, substance abuse, and the public health response. They also brainstormed about future preparedness planning initiatives related to terrorism within our borders. At the 18th Annual Meeting of the International Society for Traumatic Stress Studies on November 7-10, 2002, in Baltimore, Maryland, NIDA participated in a number of scientific events. NIDA's Acting Director Dr. Glen Hanson led a plenary session on "How the Science of Stress and Substance Abuse can Inform Treatment." The meeting examined and discussed the range of psychological disturbance, including substance abuse that can arise from complex traumatic events. NIDA also sponsored a symposium entitled "Neurobiology of Relapse: Neuroscience Advances and Opportunities" at the Society for Neuroscience meeting this past November, 2002. This symposium brought together top neuroscientists to present findings related to the neurobiology and prevention of relapse, including the role of CRF and stress in relapse.

NIDA has developed and disseminated a new publication on "Stress and Substance Abuse" as part of its Community Drug Alert Bulletin series. The Alert is part of NIDA's effort to ensure that clinicians, researchers, and members of the public have the most reliable and timely information available on this topic.

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Translating Basic Research - NIDA's strong basic research foundation has provided great insight into the addiction process and has helped identify molecular targets for the development of medications as well as new behavioral treatment strategies. The Committee urges NIDA to use tran slational research to continue to rapidly bring knowledge from the lab into clinical practice. (p. 135)

Action taken or to be taken

The explosion of knowledge in the fields of neuroscience, genetics, molecular biology, and basic behavioral science has provided new hope for the development of novel and more effective medications and behavioral treatments for addiction. The National Institute on Drug Abuse (NIDA) plans to make the most of these opportunities by supporting a broad range of innovative and far-reaching projects. Supporting basic research and bringing that knowledge from the laboratory into clinical practice is one of NIDA's highest priorities. The convergence and application of powerful new scientific tools and emerging technologies have us poised to more rapidly translate our discoveries into clinical interventions. NIDA is accomplishing this in many domains of its portfolio.

Significant progress made by NIDA's basic research scientists over the past 20 years has allowed us to identify the initial targets of action in the brain of almost all drugs of abuse. In addition, several circuits in the brain have been demonstrated to be critically involved in the rewarding effects of drugs of abuse and in addiction. These discoveries have led to the development of several effective medications for the treatment of addiction, including, most recently, buprenorphine (and buprenorphine plus naloxone), which has just received FDA approval for use in the treatment of opiate addiction. Buprenorphine's mechanism of action is similar to that of opiate drugs; however, it does not produce the same high, dependence, or withdrawal symptoms. Buprenorphine's unique long-lasting effects make it an attractive and clinically useful treatment option that is unlikely to cause respiratory depression, and is well-tolerated by addicts. The FDA approval of buprenorphine is a particularly important advance, since treatment will now be more widely available through physicians who are trained to administer the medication.

NIDA's long-term investment in understanding the basic mechanisms of addiction have paid off as well. The investment has resulted in the discovery that nicotine receptors in the brain were responsible for the addictive properties of tobacco. This in turn led to the development of nicotine replacement therapies, which have greatly improved smoking cessation efforts for thousands of people. However, tobacco addiction is not yet extinguished, and remains one of the most costly public health concerns. Therefore, NIDA remains committed to developing useful tools for the treatment of nicotine and tobacco addiction.

NIDA is attempting to accelerate the process of discovery by collaborating with the NIMH to promote the formation of a National Cooperative Drug Discovery Group (NCDDG) Program to accelerate innovative drug discovery and the development of pharmacological tools for basic and clinical research in tobacco addiction and mood disorders. A new RFA was issued in 2002 to invite applicants from academia and pharmaceutical industries to partner to develop new medications for mood disorders or nicotine addiction, identify new molecular targets for drug discovery, and develop rational pharmacotherapies for the treatment of mood and substance abuse disorders.

In addition, NIDA is organizing a workshop on the structure of the nicotinic cholinergic receptor and the design of molecules to interact with it. This will engage medicinal chemists in a structured program to create molecules for screening as tools in imaging studies and as potential medications. The goal of this workshop is to help promote the development of molecules that act at the nicotinic cholinergic receptor (the site at which nicotine influences brain function, including addiction), as well as other neurochemical systems that have been shown to be involved in nicotine addiction in relevant animal models.

NIDA has also been working with NCI and NIAAA to organize efforts to accelerate the translation of research findings relevant to nicotine/tobacco addiction to the logical next-steps. External scientists with expertise on the development of new medications have provided feedback and input to the research agenda. A one-day symposium was held at the Society for Research on Nicotine and Tobacco that engaged the research field more broadly. These efforts are important underpinnings for the near-future activities of NIDA in the translation of existing tobacco research to treatment application.

Also in the tobacco arena, NIDA continues to support with NCI the Transdisciplinary Tobacco Use Research Centers (TTURCs). The research conducted in several of these centers is now moving to application. For example, studies at the University of Minnesota TTURC are examining whether a reduction in the use of tobacco products, a treatment strategy that might be advocated for users unable or unwilling to quit, translates into a reduction in harm. Other research at the site probes the extent to which higher doses of nicotine replacement might be superior to lower doses in facilitating smoking cessation. Other TTURC sites are also contributing to the translation of research to practice, in such diverse dimensions as cultural differences in patterns of tobacco use in the US, and the genetics of smoking.

NIDA's Medications Development Program continues to be a leader in translating basic research findings into treatments that can be used in clinics. The Program has taken a multifaceted approach in the development of new pharmaceuticals for addiction, and is currently making great strides in the development of effective medications for the treatment of dependence to stimulants. Using a top-down approach, NIDA-funded scientists are in the process of evaluating pharmaceuticals already approved for other indications (e.g., antidepressants, anticonvulsants) for their effectiveness against certain forms of drug abuse. Examples of this for the treatment of cocaine abuse include: disulfiram (antabuse), which is currently a treatment for alcoholism; naltrexone, currently approved for the treatment of alcoholism and opiate abuse; buproprion, an antidepressant that is being examined in patients with co-occurring Attention Deficit Hyperactivity Disorder (ADHD) and stimulant abuse; and valproate, an anticonvulsant used in the treatment of bipolar disorder.

The second approach, of going from the bottom up uses basic science discoveries about how drugs of abuse work in order to identify new molecular targets for medication development. Because of our knowledge of the sites of action in the brain for all commonly abused drugs, it is possible to search for compounds that are active at these specific sites. Not only can vast existing libraries of candidate compounds be searched by high-speed computers, which sift through the compounds' chemical make-up, but new compounds also can be synthesized to match a desired profile. Compounds are being examined for their effects on different factors that influence addiction and relapse, including cues associated with the drug experience, stress effects, and the effects of priming or exposure to a small amount of the drug.

For example, GBR12909, a compound that acts at the dopamine transporter, the site where cocaine exerts its predominant effect, was discovered using this bottom up approach. GBR12909 binds to this transporter for a prolonged period, in contrast to cocaine, which attaches and detaches rapidly from the transporter. It is thought that this property of cocaine is important for its "rush" and/or euphoric effects. Therefore, GBR12909, by preventing cocaine from binding to the transporter, should block cocaine's euphoric properties, while not inducing similar rewarding effects of its own. GBR12909 is currently in Phase I clinical trials.

A second example of how a basic research finding is being translated for potential clinical application can be seen in the CRF-receptor antagonists, which have been found to block some of the effects of stress in the brain. In preclinical models, these compounds have shown remarkable efficacy in inhibiting both the initiation of drug use and relapse to drug-seeking in dependent animals that had been abstinent. These compounds are currently in development for the treatment of anxiety and depression, and NIDA is seeking to encourage their evaluation for substance abuse as well.

NIDA has also formed a collaboration with Xenova Group plc, a United Kingdom company, to support the development of a vaccine to prevent cocaine from entering the brain. The vaccine has been shown to be effective in preclinical studies and is now being tested for safety in humans. NIDA is also supporting a similar strategy for nicotine addiction.

NIDA also remains committed to better understanding the neurobiological, behavioral, emotional, and cognitive dimensions of relapse to addiction. In February 2002, NIDA sponsored a workshop on "Lapse and Relapse: The Chronic Recurring Nature of Drug Addiction" in Rockville, MD. This workshop brought together leading researchers from various areas of drug abuse research and researchers studying other chronic, relapsing disorders or conditions to identify areas of research that are ripe for exploration. NIDA is planning to issue an RFA to encourage more multidisciplinary research on this topic.

Finally, NIDA is working to ensure that behavioral therapies, developed in experimental settings, will be utilized in community treatment centers. Research has demonstrated that behavioral therapies work, and can have long-lasting effects, which persist or may even increase after treatment ends. Despite the availability of effective behavioral treatments, there have been significant barriers to their adoption in community clinical practice. For instance, treatments may be too lengthy, costly, complex, or difficult to integrate with usual care to be considered feasible in a community setting, where resources are limited.

To help overcome these barriers, NIDA will continue to work through the Clinical Trials Network to implement and evaluate promising and evidence-based practices in community settings. NIDA will also expand its behavioral treatment program by focusing on identifying the "mechanisms of action", or the how and why behavioral treatments work. By understanding what components of treatment are essential, NIDA hopes to be able to enhance the efficiency of behavioral programs and facilitate their delivery into the community. NIDA has also issued a RFA "Modifying and Testing Efficacious Behavioral Therapies to Make Them More Community Friendly" in December of 2001. Seven grants were awarded under this RFA in the Fall of 2002.

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