Statement of the Director
Mr. Chairman and Members of the Committee:
The President in his FY 1999 budget has proposed that the National Institute on Drug Abuse receive $395.1 million, an increase of $35.3 million over the comparable 1998 appropriation. Including the estimated allocation for AIDS, total support provided for NIDA is $576.3 million an increase of $49.1 million over the FY 1998 appropriation. Funds for NIDA efforts in AIDS research are included within the Office of AIDS Research budget request.
I am pleased to report that during these historic times for science, the National Institute on Drug Abuse (NIDA) has had another year of exceptional accomplishment, as NIDA-supported researchers made enormous strides toward improved understanding, prevention and treatment of one of our Nation's most serious public health problems--drug abuse and addiction.
We now know more about abused drugs and the brain than is known about almost any other aspect of brain function. New technologies and new knowledge have revolutionized our insight into the brain. I mean this in the most literal sense. Using functional magnetic resonance imaging (fMRI), we have moved beyond a single snapshot of a brain high on drugs to being able to actually look at the dynamic changes of the brain that occur as an individual takes a drug. We can observe the different brain changes that occur as a person experiences the "rush," the "high," and finally the craving of a commonly abused drug like cocaine.
We are also using imaging technology to explore what neurochemical changes are occurring during addiction. As shown in Figure 1, using Positron Emission Tomography (PET) technology we can now see what tobacco smoking is doing to the human brain. Here you can see in the brain of the smoker a tremendous decrease in the levels of an important enzyme known to be responsible for breaking down dopamine, called monoamine-oxidase-A (MAO-A). This decrease in MAO-A actually results in an increase in dopamine levels. This may be a reason that smokers continue to smoke-- to sustain the high dopamine levels, which result in the sensation of pleasure.
|Effects of Cigarette Smoking on Brain Monoamine Oxidase A
At an even more refined level, NIDA-supported scientists have identified one of the critical brain proteins that mediates nicotine addiction. Scientists pinpointed the beta 2 subunit of the nicotinic cholinergic receptor as being essential to the process of nicotine addiction. Using bioengineering tools, these researchers produced a new strain of knockout mice which lack this important protein. In contrast to normal mice, mice without this receptor did not self administer nicotine, though they did take cocaine. This clearly demonstrates that the brain reward pathway thought to be common to all addictions remains intact, even though nicotine itself loses its pleasurable effect.
These findings support a convergence of data which show that nicotine, just like cocaine, heroin and marijuana, all work to elevate levels of the neurotransmitter dopamine in the brain pathways that control reward and pleasure. It is this change in dopamine that we have come to believe is a fundamental characteristic of all addictions.
Averting a Methamphetamine Crisis
Dopamine activity is central to one of the country's most alarming emerging drug problems, methamphetamine abuse. The use of this highly addictive drug, once dominant primarily in the Southwest, is spreading rapidly across the country. As shown in Figure 2, just a decade ago methamphetamine was confined to relatively limited pockets of use in the West. It is now spreading through the mid-West and becoming an emergent new problem in previously "untouched" cities.
If you would like to look at these figures in more detail and be able to print them clearly, please use the PDF version of this file. You will need the Adobe Acrobat Reader to view this file.
Methamphetamine Crisis [PDF format, 448K]
This is of particular concern because of recent research demonstrating the neurotoxic effects of the drug. In non-human primates exposed to methamphetamine doses that are routinely used in human abusers, scientists have found profound effects on both the brain's dopamine and serotonin neurotransmitter systems. These long-lasting neurochemical effects are thought to be partly responsible for the severe behavioral abnormalities that accompany prolonged use of this drug. To avert a potential methamphetamine crisis, we need to develop effective medications to treat the addiction, as well as 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 will be able to develop effective treatments for methamphetamine, just as we have for other serious drug addictions such as heroin and nicotine. We have effective addiction treatments in our clinical toolbox and countless others that are being tested, although admittedly not enough. We do already have methadone and LAAM (levo-alpha-acetyl-methadol) for opiate or heroin addiction, and will be seeking approval for both buprenorphine and buprenorphine combined with naloxone in 1998. For tobacco addiction, there are several nicotine-replacement therapies, such as the patch and gum, and several non-nicotine ones as well, such as bupropion ( Zyban®) that are readily available.
We do not, yet, have a medication to treat cocaine addiction, which remains both a national need and a NIDA priority. But we do have encouraging news. We are about to launch our first ever large scale multi-center clinical trial for a cocaine medication. In designing this trial we are capitalizing on a body of current findings that suggest that medications consistently work better when they are used in combination with behavioral therapies. When we initiate the trial in the Fall we will add a standardized behavioral component to one of our most promising compounds, selegeline.
NIDA hopes to expand upon this trial by launching a National Drug Treatment Clinical Trial Network to ensure that all potential addiction treatments are tested in real life settings. Our science has matured to the point where we can take a more systematic approach to rapidly and efficiently test the effectiveness of behavioral, psychosocial and pharmacological treatments in large-scale, multi-site clinical trials.
Although it can be done, addiction is not a simple disease to treat. Addiction is a chronic relapsing disease that results from the prolonged effects of drugs on the brain. It can affect every aspect of a person's life. This is why an individual's treatment program must address not only the individual's drug use, but also help restore their abilities to function successfully in society. The most effective treatment approaches must attend to all of addiction's biological and behavioral components.
It is these kinds of research-based concepts and approaches that are most needed by the frontline clinicians who are facing the day-to-day realities of treating their patient's drug addictions. We know that we cannot just disseminate research findings through journal articles in the hopes that a busy treatment provider will have time to read, analyze and implement a particular finding. That is why we translate these findings in a way that is both useful and used by treatment providers at every level. Toward this end, NIDA is sponsoring a National Conference on Drug Addiction Treatment next month. At this conference, NIDA will release the first two in a series of treatment manuals developed to help drug treatment practitioners provide the best possible care that science has to offer. The manuals take scientifically-supported therapies for addiction and offer detailed guidance on how to implement them in real-life practice settings.
Replacing Ideology With Science
Undertakings like these exemplify our commitment to sharing research findings with the broadest community possible. An example of the positive impact that our research findings can have on society is seen in the recent efforts by many of our criminal justice colleagues to provide treatment to prison populations. NIDA-funded scientists have demonstrated that comprehensive treatment of drug-addicted prison inmates, when coupled with treatment after release from prison, reduces by 70% the probability of their being rearrested and the likelihood they will return to drug use.
Other important societal issues were addressed through a number of major conferences that NIDA supported such as our National Heroin Conference, and NIH's Consensus Development Conference on Effective Treatment of Heroin Addiction. Additionally, we are continuing to take our science to the true beneficiaries of our research endeavors--the American public. We joined with local partners across the country to sponsor a series of Town Meetings. Our April Town Meeting with the citizens of Boston will coincide with the March 29th premier of an outstanding five part series on addiction that Bill Moyers and his staff at National Public Television have produced. NIDA has provided substantial technical assistance in the development of this series and its accompanying educational materials.
We at NIDA want to replace ideology about drug abuse and addiction with science. We also want to provide the public with the necessary tools to play an active role in preventing drug use in their own local communities. Last year I showed you what has now become one of our most popular publications -- "Preventing Drug Use Among Children and Adolescents." This user-friendly guide of principles summarizes knowledge gleaned from over 20 years of prevention research. Over 150,000 copies have been circulated to communities throughout the country as they evaluate existing prevention programs and develop new ones.
Preventing Drug Use Among Children and Adolescents
Understanding what makes a person more susceptible to a potential drug problem, and progression from first drug exposure to developing addiction, will enable us to much more effectively target our prevention efforts. Just as important, however, is the identification of protective factors, those behaviors, environments and activities, that seem to enable many people to avoid drug use altogether, or get right back on track if they falter or relapse during treatment.
We are also supporting research that focuses on the special needs of older children and adolescents who have been placed in juvenile court detention programs, dropped out of school, or have become homeless. It is particularly important that we find effective prevention and treatment approaches for these special populations in light of a 1998 study which found that 13-19 year-olds who have both conduct and drug abuse problems, already are meeting standard adult criteria for marijuana dependence.
We are also continuing to study the effects of prenatal drug exposure. We are finding that some, though not all, of the cohorts of crack-exposed babies now entering elementary and middle school may be significantly, although perhaps subtly, affected. Because these effects can be subtle and expressed only as children develop, long-term follow-up is needed. Longitudinal studies will also enable us to examine whether prenatally drug-exposed children are more vulnerable, or at increased risk for drug abuse in childhood and adolescence.
Genetics of Drug Addiction
Determining who is at most risk for addiction will be a critical research area addressed through NIDA's new Genetics of Addiction Initiative. A culmination of NIDA-supported family and twin studies, coupled with neurobiological and molecular breakthroughs, has provided us with the confidence to more aggressively explore the role of genetics in drug addiction. NIDA's multi-faceted approach in this endeavor will include the use of genome-wide scans, linkage and association studies in humans, and the continuation of animal studies to test and confirm the role of new candidate genes.
Government Performance and Results Act (GPRA)
NIDA's activities are covered within the NIH-wide Annual Performance Plan required under GPRA. The FY 1999 performance goals and measures for NIH are detailed in this performance plan and are linked to both the budget and the HHS GPRA Strategic Plan which was transmitted to Congress on September 30, 1997. NIH's performance targets in the Plan are partially a function of resource levels requested in the President's Budget and could change based upon final Congressional Appropriations action. NIH looks forward to Congressional feedback on the usefulness of its Plan, as well as to working with Congress on achieving the NIH goals laid out in this Plan.
Understanding the Complexity of Addiction
All of these exciting research efforts are moving us closer to truly understanding the complexity of addiction. It is only through a multi-disciplinary approach that we will be able to unravel the remaining mysteries of addiction. NIDA will continue to use the most sophisticated research equipment and techniques, and seize all scientific opportunities that present themselves to ensure that no more lives are lost to what is ultimately both a preventable and, if not prevented, a treatable disease. I will be happy to answer any questions you may have.