Richard A. Millstein
National Institute on Drug Abuse
National Institutes of Health
Department of Health and Human Services
March 18, 1999
Statement for the Record
Mr. Chairman and Members of the Committee:
I am pleased to be part of this distinguished panel to share with you what science has come to show about drug abuse, its prevention, and its treatment. I would like to start by stating that all of the research activities that I will discuss today are in fact part of a concerted government effort to reduce drug use in this country that is outlined in the Office of National Drug Control Policy's National Drug Control Strategy.
In large part because of the research that the National Institute on Drug Abuse (NIDA) supports and conducts, we now know that drug abuse is a preventable behavior and that drug addiction is in fact a treatable disease. Research has come to define addiction, though it originates as a voluntary behavior, as a chronic, and for many people reoccurring disease characterized by compulsive drug seeking and use that results from the prolonged effects of drugs on the brain. A variety of studies in both humans and animals have demonstrated that chronic drug use does in fact change the brain in fundamental ways that persist long after the individual has stopped taking the drug. Of course, this change from abuse to addiction occurs at different times for different people, and is dependent upon a variety of genetic and environmental factors. By using advanced brain imaging technologies we literally are able to see that the addicted brain is different from the non-addicted brain. These brain changes are essentially what makes addiction a brain disease.
The good news is that addiction is in fact treatable, though it is never a simple disease to treat. One of the overarching goals of treatment is to reverse or compensate for these brain changes. Another treatment goal is to return the individual back to a functioning member of society. Similar to the way addiction affects all aspects of a person's life, his or her treatment program must address the "whole person." It must address not only the individual's drug use, but also provide him or her with the tools necessary for maintaining a drug-free lifestyle, while also helping with the achievement of productive functioning in the family, at work, and in society. Because addiction is so complex, and can impact so many aspects of the patient's life, effective treatment programs typically must incorporate many components, with each directed to a particular aspect of the illness and its consequences.
Fortunately, just as with other illnesses, drug abuse professionals have at their disposal an array of quite useful tools to treat addicted individuals, although admittedly not enough. NIDA-supported research, for example, has helped to bring to the world LAAM (levo-alpha-acetyl-methadol) and methadone, the most effective medications to date for heroin addiction; and we have standardized notable behavioral interventions, such as cognitive behavioral therapies and contingency management, that are effective in treating both adults and adolescents. We are also working to bring new medications for cocaine addiction to the Nation's forefront. In fact, NIDA's medications development program is taking the first promising anti-cocaine medication into multisite Phase III Clinical trials. These trials will evaluate two innovative routes of administration for the medication selegiline, in the form of a transdermal patch and as a time released pill, to determine which is most beneficial to the populations being studied.
This trial will also include a behavioral component, since treatment researchers are finding that although behavioral and pharmacological treatment approaches can be extremely useful when employed alone, integrating both treatments, in ways specific to an individual's needs, is likely the best way to treat addictive disorders. This is the kind of information that needs to be disseminated and translated in a way that is both useful and used by busy treatment providers. We realize that just supporting research is not enough. NIDA is also committed to working with the drug abuse professional community to actively transfer research knowledge in a proactive way into the community setting. To do this, NIDA works with a large number of constituent organizations and our federal colleagues, such as those in the Substance Abuse and Mental Health Services Administration and at the Office of National Drug Control Policy, to help disseminate research findings.
One of the major ways that we are planning to disseminate important treatment information is by launching our National Drug Abuse Treatment Clinical Trials Network. As is the case for other chronic disorders, effective treatments for addiction exist. However, the efficacy of these new treatments has been demonstrated primarily in specialized treatment research settings, with somewhat restricted patient populations. As a consequence, few of these new treatments are being applied on a wide-scale basis in real life practice. In response, NIDA is establishing this Clinical Trials Network which will serve as both the infrastructure for testing science-based treatments in diverse patient and treatment settings, and the mechanism for promoting the rapid translation of new science-based treatment components into practice. We already have quite a number of efficacious behavioral and pharmacological therapies ready to be tested including new cognitive behavioral therapies, operant therapies, family therapies, brief motivational enhancement therapy, and new, manualized approaches to individual and group drug counseling. Medications to be studied include naltrexone and buprenorphine for heroin addiction, and those currently being developed by NIDA for cocaine. We are also optimistic that this Network will allow us to form successful partnerships between university-based medical and research centers and community-based treatment providers to test and deliver a wide array of treatments, while simultaneously determining the conditions under which the novel treatments are most successfully adopted. Demonstrating effectiveness will foster the incorporation of new interventions into ongoing community-based drug treatment, thereby improving treatment throughout the country.
The other encouraging news in the treatment arena is that research shows that drug treatments are as, or more, effective than treatments for other chronic, often reoccurring, disorders with major medications and behavioral compliance issues, such as diabetes, hypertension, and asthma. NIDA's own exhaustive study on the effectiveness of treatment, the Drug Abuse Treatment Outcomes Study (DATOS), which tracked a sample of over 10,000 drug abusers in nearly 100 treatment programs in 11 cities across the Nation for three years, overwhelmingly confirmed the effectiveness of drug abuse treatment. Among the patients that DATOS studied, drug use in the year after treatment was significantly lower than in the year prior to treatment. This was true for all four types of treatment studied: outpatient methadone, outpatient drug-free, long-term residential, and short-term inpatient. Treatment also led to significant improvements in other aspects of patients' lives, such as reduced involvement in illegal acts. It is also important to note that DATOS findings are corroborated by urinalysis testing.
An abundance of other studies also confirm the effectiveness of treatment. Several conclude that drug treatment reduces drug use by 40 to 60 percent and significantly decreases criminal activity during and after treatment, whether measured by self report or by urinalysis and records review. Treatment also has been shown to be highly effective in preventing the spread of HIV. Not only do individuals who enter drug abuse treatment programs reduce their drug use, but this in turn has been found to lead to fewer instances of other high-risk behaviors as well. For example, in a longitudinal study of injection drug users, over 20% of those not in treatment had become seropositive after 18 months, compared to less than 5% of those receiving methadone maintenance treatment. NIDA-funded scientists have also demonstrated that comprehensive treatment of drug-addicted prison inmates, when coupled with treatment after release from prison, reduces almost by 70% the probability of their being rearrested and the likelihood they will return to drug use.
In short, research has established that drug treatment reduces crime, reduces the spread of infectious diseases such as AIDS and hepatitis C, and restores the ability of addicted individuals to be functioning contributing members of society.
As with all medical conditions, it is science that will lead the way as we look to develop even more effective approaches to treat addiction. In fact it was a series of basic scientific discoveries that pointed us to one common reward pathway in the brain where all drugs of abuse act. The data now suggest that, independent of a drug's initial site of action, every drug--be it nicotine, heroin, cocaine, marijuana or amphetamine--appears to increase the levels of the neurotransmitter dopamine in the brain pathways that control pleasure. We have come to believe that the ability to increase brain dopamine levels is a common characteristic of most drugs of abuse, although we are simultaneously exploring other neurochemical systems and neurocircuits hat might be involved in the addiction process.
Understanding these neurotransmitter systems and brain circuits is central to understanding one of the country's most alarming emerging drug problems, methamphetamine abuse. The use of this highly addictive drug, once dominant primarily in Hawaii and the Southwest, is spreading rapidly across the country. Just a decade ago methamphetamine was confined to relatively limited pockets of use in the West. It has now reached crisis proportions in Western and mid-Western parts of this country. This is of particular concern because of recent research demonstrating the neurotoxic effects of the drug. NIDA has made methamphetamine research a high priority area. We have expanded our research portfolio to develop effective medications to treat the addiction, as well as to develop new tools such as anti-methamphetamine antibodies to be used by emergency room physicians to treat the growing number of overdoses. We are confident that we can develop effective medications for this dangerous drug, as well as effective prevention approaches tailored to the populations known to use this drug.
Ultimately we know that our best treatment is prevention. We also know that we must provide the public with the necessary tools to play an active role in preventing drug use in their own local communities. This is likely one of the reasons that NIDA's "Preventing Drug Use Among Children and Adolescents, " has become one of our most popular publications since we debuted it last year. This user-friendly guide of principles summarizes knowledge gleaned from over 20 years of prevention research. Over 200,000 copies have been circulated to communities throughout the country as they evaluate existing prevention programs and develop new ones. The prevention booklet is just one example of how we are using research to reduce drug use.
NIDA is also entering what many would consider the next generation of drug prevention research -- that is, taking the fundamental principles of effective drug abuse prevention programming to the next level so that they are effectively integrated into every community and social system in the country. To accomplish this, we are supporting research that allows us to have a better understanding of what makes people more susceptible to a potential drug problem, and to learn how they progress from their first drug exposure to developing an addiction. Researchers are also working to identify protective factors, those behaviors, environments, and activities that seem to enable many people to avoid drug use altogether, or, for those seeking treatment, to get right back on track if they falter or relapse. All of these prevention activities reflect our commitment to have prevention interventions directed at the specific needs of different groups of youths at risk for drug abuse, including members of different ethnic groups and those living in different socioeconomic situations.
In short, we are interested in providing the broadest audiences possible with the tools necessary to reduce the Nation's overall drug use. Thus, in addition to our research to prevent and treat drug abuse and addiction, NIDA is also concerned about education on these topics. That is why we continue to support Town Meetings across the Nation to disseminate our research findings and to educate the public about what the science is teaching us about addiction. In fact, one of our first Town Meetings was in San Francisco, an area particularly hard hit by methamphetamine, followed by a more recent meeting in Des Moines, another area being severely affected by methamphetamine. Our next Town Meeting, scheduled for May in Atlanta, will focus on the topic of treatment. In addition to going to the home towns of those in need of research information on drugs of abuse, NIDA has an active information dissemination program that develops and disseminates materials on a continuous basis. Publications such as NIDA's Research Report Series and our Community Drug Alert Bulletin on Methamphetamine present the latest information on drugs of abuse in a concise manner that is understandable to members of the general public. We also have a strong science education program to ensure that our Nation's youth have accurate science-based information to make healthy lifestyle choices. For example, we have developed award winning materials such as our "Mind Over Matter" series that was sent to every middle school in the Nation. "Mind Over Matter" is a series of drug education brochures for students in grades five through nine to spark their curiosity and to inform them with scientific research findings on the brain effects of drug abuse. Educating the public about drug abuse and addiction will continue to be a high priority for NIDA.
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. Unfortunately, a "great disconnect" still exists between the public's perception of drug abuse and addiction and the scientific facts, though we are committed to eliminating this gap and ensuring that ideology is replaced with science.
Although scientific advances have brought us a long way in our understanding of and approaches to drug abuse and addiction, we still have a lengthy journey ahead in finding solutions to this complex problem. There will be no magic bullet that is going to make drug abuse and addiction go away, but there is great cause for optimism that science will provide us with the tools necessary to solve this complex and compelling issue that affects us all.
Thank you for the opportunity to testify at this hearing.