Alan I. Leshner, Ph.D.
National Institute on Drug Abuse
National Institutes of Health
Department of Health and Human Services
November 15, 1999
Statement for the Record
Thank you for inviting me to participate in this important hearing. I am Dr. Alan I. Leshner, the Director of the National Institute on Drug Abuse (NIDA), one of the research institutes that comprise the National Institutes of Health. As the world's largest supporter of research on the health aspects of drug abuse and addiction, I would like to share with you today what NIDA-supported research has come to teach us about heroin abuse and addiction.
In the United States, there are over 810,000 people addicted to this illegal drug. Heroin is both the most frequently abused and the most rapidly acting of the opiates. It is processed from morphine, the naturally occurring substance extracted from the seedpod of certain varieties of poppy plants. It is usually sold as a white or brownish powder, or in some regions of the country (particularly in the Southwest) as a black sticky substance known on the street as "black tar heroin." Heroin can be injected, sniffed/snorted or smoked. It is important to point out at the outset that regardless of how heroin is taken it is extremely addictive and can lead to other detrimental consequences as well.
Heroin abuse is not a new problem. In fact opiate use dates back long in history. What is new and particularly alarming, however, is the high purity of today's heroin, its inexpensive price, and the way it is being taken, all of which appear to be recruiting new users. Heroin is now cheaper and purer than ever, making it more accessible to young people who can smoke or snort the drug rather than inject it intravenously. Until recently, the most common route for administering heroin was through intravenous injection. Today, given the purity of the drug, in many regions of the country, including the Philadelphia metropolitan area, where street-level heroin purity remains one of the highest in the Nation, people can snort heroin and achieve a high that is similar to what they can obtain from injection. Our research is showing that many of the new initiates to heroin are in fact trying the drug because they can snort it and think they would be protected by not injecting. In addition to that last fact being clearly wrong, studies also show that noninjecting heroin users are at considerable risk of becoming injection drug users (IDUs). In fact, more than 15% of participants in a recent study transitioned from other routes of administration to drug injection during an average period of little more than a year.
The health risks associated with both injecting and noninjecting heroin use are also substantial. For example, because of the behavioral factors (high risk sexual activity, sharing of drug paraphernalia) associated with heroin use, the chances of the individual contracting an infectious disease such as HIV, hepatitis B, and in rare cases hepatitis C, are greatly increased regardless of route of administration.
The misperceptions about the addictive properties of heroin, may account for why in 1997, an estimated 81,000 persons used heroin for the first time. We are also seeing increases in the annual number of heroin-related emergency room visits. From 1991 to 1997, the annual number of emergency room visits in major metropolitan areas increased from 36,000 to 72,000. Similar trends are being seen in the Delaware Valley. The number of emergency room visits involving heroin in Philadelphia has increased from 2,653 in 1990 to 3,817 in 1997.
We are also seeing increases in the number of individuals who are seeking treatment for heroin addiction caused by snorting or inhalation. Nationally, admissions for heroin use by injection have dropped from 77 percent of all heroin admissions in 1992 to 68 percent in 1997, while the percentage of heroin admissions for inhalation has increased from 19 percent in 1992 to 28 percent in 1997 (National Admissions to Substance Abuse Treatment Services: The Treatment Episode Data Set (TEDS) 1992-1997). This is also a trend we are seeing at the local level. For example, last year in Philadelphia, 39 percent of the heroin treatment admissions were for snorting heroin.
Now let me explain in a bit more detail, why these data are so alarming. Because of its chemical structure heroin is able to very rapidly enter the brain where it is actually converted into morphine. In this form, the drug rapidly crosses the blood brain barrier and attaches to the natural opioid receptors. By binding to these receptors the drug initiates its multiple physiological effects, including pain reduction, depression of heart rate, and the slowing of respiration. It is heroin's effects on respiration, in particular, that can be lethal in the case of heroin overdose. Heroin also acts on the brain's natural reward circuitry to produce a surge of pleasurable sensations.
It is of course these pleasurable effects that cause people to take drugs— basically, people like what drugs do to their brains. Research is showing that prolonged drug use can actually change brains. These changes are thought to play an integral role in the development of addiction. Powerful new technologies are giving us even greater insight into these dramatic brain changes.
This poster (right) allows you to see morphine's effects on the brain. The bottom images demonstrate the fact that when heroin addicts are given 30 mg of morphine the brain's ability to metabolize glucose is significantly reduced. Glucose is what actually fuels the brain cells. In other words, heroin reduces brain activity in some regions of the brain.
Understanding the neurobiology of addiction has led us to develop a number of effective tools to treat heroin addiction and to help manage the sometimes-severe physical withdrawal syndrome that accompanies sudden cessation of drug use. Of course we now know that withdrawal and physical dependence are only a minor part of the problem that must be addressed when treating heroin addicts. In fact, withdrawal symptoms can now be effectively managed through the use of modern medicines.
But it is the compulsive drug seeking behaviors that we have defined as the essence of addiction, which must be addressed in a comprehensive treatment program. And many behavioral and pharmacological treatments are available, although not always widely used.
For example, pharmacotherapies can be an important component of treatment for many addicts. Twenty-five years of NIDA-supported research have given us quite a number of effective medications to combat heroin addiction. For example, LAAM (levo-alpha-acetyl-methadol), a newer drug for the treatment of heroin addiction was developed and is now available as a supplement to methadone. Both methadone and LAAM block the effects of heroin and eliminate withdrawal symptoms. Treatment with methadone requires daily dosing. LAAM blocks the effects of injected heroin for up to three days. Research has demonstrated that, when methadone or LAAM are given appropriately, they have the ability to block the euphoria caused by heroin, if the individual does in fact try to take heroin. Both methadone and LAAM, especially when coupled with a behavioral treatment component, have allowed many heroin addicts to lead productive lives.
By the way, it is important to emphasize here that contrary to popular myth, methadone is not actually a substitute for heroin. Although it does bind to the same brain receptors, it acts dynamically in the brain quite differently from heroin. While heroin de-stabilizes the brain of the addict, methadone actually stabilizes the heroin addicts brain and behavior.
In an effort to give treatment providers another effective tool to combat heroin addiction, NIDA is working with the Food and Drug Administration and the pharmaceutical industry to bring to market a new medication called buprenorphine-naloxone. This medication has the potential for administration in less traditional environments, such as in physician's offices, thus expanding treatment to populations who either do not have access to methadone programs or are unsuited to them, such as adolescents. Buprenorphine would not be a replacement for methadone or LAAM, but yet another treatment option for both physicians and patients.
Although we have some quite effective behavioral and pharmacological treatments in the clinical toolbox, many of the most recently developed science-based treatments have not found their way into normal practice settings, and we see that as a tremendous national need. This idea of bringing science-based treatments to those who are in need of treatment is fast becoming a reality, however. Recent advances in treatment research, coupled with the generous appropriations that NIDA received last fiscal year, have allowed the Institute to accelerate the launch of its much-anticipated and needed National Drug Abuse Treatment Clinical Trials Network. This Network will serve as both the infrastructure for testing science-based treatments in diverse patient populations and treatment settings, and the mechanism for promoting the rapid translation of new treatment components into actual clinical practice in community settings throughout the nation.
I am especially pleased to announce that one of the first five research nodes we have awarded resources to is the Delaware Valley Node, which will be centered at the University of Pennsylvania. This Node is affiliated with ten community treatment programs in the region including providers in the Thomas Jefferson Health System, The Belmont Center, Fresh Start, the Northeast Treatment Centers, the Robert Wood Johnson Medical School-Mercer Trenton Addiction Sciences Center, the Philadelphia Health Management Corporation, the University of Pennsylvania Health System, the Rehab After Work Program, the Mercy Health System, Achievement Through Counseling and Development, and the Caron Foundation. The community treatment programs are in Pennsylvania, New Jersey and Delaware. It is in these patient populations that we will be testing some of the world's most promising behavioral and pharmacological treatments. In addition to being treated, these patients will also be helping researchers determine what works best for whom and under what circumstances. We have also established Research nodes in four other regions of the country to feed into the Network.
We hope to expand this Network each year. When complete, the network will consist of 20 to 30 regional research treatment centers or nodes.
Developing and bringing new medications and behavioral therapies to populations that are in need is just one aspect of a comprehensive solution we must continue to take to solve this Nation's drug problem. Because addiction is such a complex and pervasive health issue, we must include in our overall strategies a comprehensive public health approach, one that includes extensive education and prevention efforts, adequate treatment and aftercare services, and research. Twenty-five years of research has provided us with effective prevention and treatment strategies that can be used to combat heroin addiction, as well as other drug problems. Research has shown that these strategies are effective in reducing not only drug use but also in reducing the spread of infectious diseases such as HIV/AIDS, hepatitis, and in decreasing criminal behavior.
Thank you once again for the opportunity to testify at this hearing. I will be happy to answer any questions you may have.