June 14–17, 2019
San Antonio, Texas
Executive Summary
The 24th NIDA International Forum was held June 14–17, 2019, in San Antonio, Texas. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the European Commission EU 4 Monitoring Drugs project cosponsored the meeting. The satellite to the College on Problems of Drug Dependence (CPDD) annual scientific meeting attracted 184 participants from 43 countries.
NIDA International Program Director Steve Gust chaired the meeting and presented outgoing CPDD International Committee Chair Clyde McCoy, University of Miami Miller School of Medicine, with a certificate in honor of his outstanding efforts to support international collaboration throughout his career. Dr. McCoy described early initiatives by CPDD and NIDA to expand international collaboration on drug abuse and drug-related HIV research, noting that participants in the NIDA International Forum add new voices to the discussion every year.
EMCDDA Scientific Director Paul Griffiths described the EU 4 Monitoring Drugs project to build capacity and understand the impact of drug trends in neighboring countries on European health and security. He stressed the importance of understanding commonalities in drug use and the need to build partnerships among countries to promote drug research and establish common models for monitoring, training, and development. Mr. Griffiths said EMCDDA views the NIDA International Forum as particularly relevant to capacity building and an outstanding opportunity to network with drug abuse researchers around the globe.
Nearly 100 researchers from 38 countries presented their research posters at a joint NIDA International Forum/CPDD Workshop on June 17. Speakers in the opening plenary session reported on a major U.S. longitudinal study to track brain development in children from age 9 or 10 through early adulthood, drug use trends in the Americas, and online training and resources in tobacco and nicotine research. Other sessions focused on potential U.S.–Canada collaboration on cannabis research, evidence-based drug demand reduction education programs, United Nations (UN) training materials on family therapy, social determinants of addiction, and publishing addiction research.
ABCD Study Update
Susan Weiss, director of the NIDA Division of Extramural Research, reported that full, curated baseline data for more than 11,800 substance-naive children recruited for the Adolescent Brain Cognitive Development (ABCD) study are now available for secondary analysis. Fifteen U.S. agencies are supporting the study to assess factors that influence individual brain development trajectories and functional outcomes. All ABCD protocols also are available. The 21 research sites used school-based recruitment to assemble a diverse sample that includes singletons, siblings, and twins. Samples are balanced by socioeconomic, demographic, and family education levels. The ABCD Data Repository houses all study data at https://nda.nih.gov/abcd. Within the repository, the ABCD Data Exploration and Analysis Portal (DEAP) permits authorized users to find measures of interest from more than 40,000 shared observations available for each ABCD participant, to test hypotheses using a multilevel regression model suitable for the ABCD study design, and to run novel multilevel statistical analyses directly from the DEAP interface. The study will collect data from biological samples and structural and functional brain imaging as well as standardized measures of physical and mental health, neurocognition, culture and environment, and substance use. Dr. Weiss noted that two of the three current NIDA funding opportunity announcements related to the ABCD study are open to international research teams: PAR-18-062: Accelerating the Pace of Drug Abuse Research Using Existing Data (R01) and PAR-19-162/PAR-19-163: Accelerating the Pace of Child Health Research Using Existing Data (R01/R21). She added that planning grant applications are under review for the related HEALthy Brain and Child Development study tracking brain development prenatally through ages 9 and 10, but significant logistical, developmental, ethical, and legal challenges must be resolved to work with babies.
Drug Use in the Americas
Marya Hynes, acting chief of the Inter-American Observatory on Drugs (OID) at the Organization of American States (OAS), reported on drug use trends in the hemisphere. Drawing on data submitted by 33 OAS member states and a report published in March 2019, she summarized four topics: trends, early onset of use, sex differences in use, and new challenges. Trends include increasing use of cannabis among secondary school students and the general population; increase in cocaine use among the general population in about half the countries, with more variability among students; and prevalence of binge drinking reported by half of all past-month users. Time-adjusted prevalence of cannabis use among high school students was highest in Chile, at more than 34 percent, and lowest in Paraguay, at nearly 4 percent. Tobacco was the only substance for which use declined among the general population. OID found that initiation of drug use begins as early as the 8th grade in some countries, increasing health risks and other consequences and demonstrating the need to prioritize prevention programs and interventions that delay the onset of use. In some countries, females now use certain drugs at the same or higher rates than males do. In almost every country, misuse of tranquilizer pharmaceuticals is higher among females. New challenges include the prevalence of new psychoactive substances (NPS), opioids, and benzodiazepines; high opioid and NPS overdose rates in the United States and Canada; increases in early onset and binge drinking patterns; and changes in the legal regulatory status of marijuana.
Online Resources and Certificate Programs for Tobacco Researchers
Mona Johnson, Society for Research on Nicotine and Tobacco (SRNT), demonstrated a new online education platform, SRNT University. SRNT-U was created to address barriers to new research, such as limits on funding, robust data sets, training in research methods, access to journal articles, and opportunities to connect with collaborators and subject matter experts. Technology challenges also complicated lengthy internet searches. SRNT-U offers a virtual library of open-source, curated information organized by topics or themes, including research methods, tools and resources, selected journal articles, and relevant data sets organized by country. The virtual classroom includes seminars, recorded webinars, and a certificate program in smoking cessation. An online journal club, mini-courses, training about funding sources, and a platform for collaboration are under development. Ms. Johnson, director of SRNT-U, asked for Forum participants’ comments on potential courses and seminar topics such as the effect of nicotine on the developing brain, co-use of tobacco and other substances, funding and grantsmanship, and comorbidities. She also asked participants to indicate which collaboration tools would be useful, including discussion forums, virtual poster sessions, and mentor/mentee connections. Enrollment in SRTN-U is free at https://www.SRNT-U.org.
Cannabis Research: Opportunities for U.S.–Canada Collaboration
In October 2018, Canada legalized nonmedical use of cannabis for individuals 18 and older. Representatives from Canadian research organizations described how differences in provincial and federal regulations provide opportunities for natural experiments and challenges for policy researchers. Rebecca Jesseman, director of policy for the Canadian Centre on Substance Use and Addiction (CCSA), described the law’s objectives; the division of authority between federal, provincial, and municipal governments; and CCSA research policy objectives. She outlined the numerous opportunities to collect data via federal population surveys, provincial youth surveys, and cohort studies under way at academic institutions. Key research questions include the health and social impacts of regulatory approaches and products such as edibles and concentrates; consumption patterns; impact of regulation on the illegal market; equity of health, social, and criminal justice impact across populations; effectiveness of incentives for lower-risk use; applicability of evidence from alcohol and tobacco regulation; and risks and benefits of polysubstance use and substitution. Ms. Jesseman described the cannabis policy research network and the cannabis research database being established to address challenges such as establishing a standard dose, the provincial and municipal capacity for monitoring and evaluation, measuring the impact on illegal markets, the role of industry, the processing time for research licenses, disaggregation of data, and coordination of effort.
Nina Cluny, team leader for partnered initiatives at the Canadian Institutes of Health Research (CIHR) Institute of Neurosciences, Mental Health and Addiction, discussed the CIHR Integrated Cannabis Research Strategy. CIHR will provide $33 million (Canadian) over 9 years to support cannabis research on understanding harms, investigating medical benefits, and standardizing data. Dr. Cluny reported that the research strategy is designed to provide evidence to meet federal, provincial, territorial, and knowledge user needs; to ensure that data and information are shared by all stakeholders; and to facilitate collaboration. Workshops are held annually for multiyear grants and at the end of shorter grants to assess progress in closing knowledge gaps and to develop funding opportunities that build on previous research goals. Dr. Cluny added that CIHR also is teaming with other government agencies to research priority topics, such as cannabis-impaired driving, and will begin to build medical benefit partnerships.
The Canadian legislation made it possible for researchers to conduct clinical trials of cannabis-based medical therapies using well-regulated, clinical-grade cannabis products in dried, oil, and gel-capsule forms. Marcel Bonn-Miller, global clinical scientific director of Canopy Growth Corporation, and University of Pennsylvania Perelman School of Medicine, described current and planned research supported by the firm. He reviewed the need for improved knowledge where anecdotal or weak evidence suggests that cannabis-based therapies might be effective in treating a variety of medical conditions. Dr. Bonn-Miller also suggested ways that Canadian companies such as Canopy Growth can help researchers in other countries.
Translating Evidence for Drug Demand Reduction Education Programs
Kimberly Johnson, executive director of the International Consortium of Universities for Drug Demand Reduction, organized and chaired a session demonstrating how three countries adapted the UN Office on Drugs and Crime (UNODC)/Colombo Plan Universal Treatment Curriculum to meet specific national training needs.
Iryna Pinchuk, Ukrainian Ministry of Health and director of the Ukraine and Central Asia Addiction Technology Transfer Center supported by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), reported on an assessment of training needs. The questionnaire was answered by 1,008 specialists from all regions of Ukraine who provide help to people with substance use disorders. About one-third of respondents were medical practitioners (32 percent); another third were nurses (21 percent) or social workers and psychologists (13 percent); and the remainder were administrators (16 percent), social workers and psychologists at criminal justice institutions (13 percent), or addiction counselors (5 percent). About 150 reported working with medication-assisted treatment (MAT), and 350 worked with clients receiving MAT from another medical professional. Dr. Pinchuk reported that respondents expressed interest in obtaining new knowledge and skills and observed that existing training courses do not always cover their questions comprehensively. Respondents recommended that accessible, science-based, practical training should be a priority throughout all regions.
Maria Isabel Melgar, director for clinical and community services, Fr. Jaime C. Bulatao Center for Psychology Services, Ateneo de Manila University, Philippines, reported on Philippine adaptations to the Universal Treatment Curriculum for Substance Use Disorders. After an initial training course, Philippine instructors determined that the organization of courses needed to change and that the 10-day workshop was too long for treatment providers to be away from work. The adaptation split the course into two 5-day workshops and added information about local laws, drug policies, research, case studies, and programs. Dr. Melgar said next steps would include finalizing the training manual, validating and pilot testing the adapted course with a new cohort of participants, incorporating feedback from the pilot testing, and integrating the new courses into graduate curricula at Philippine universities.
Beatrice Kathungu, lecturer at Kenyatta University, Kenya, described her university’s 4-year planning process to launch the Postgraduate Diploma in Addiction Treatment Science this year. The program is designed for individuals who hold a first degree in relevant disciplines and work in the field of substance use disorder treatment. Based on the Universal Treatment Curriculum, the Kenyatta University program balances theory and practice, adds supervised practicum and mini research requirements, and uses a multicultural approach to focus on the local context within the regional and global substance use treatment environments. Dr. Kathungu stressed the importance of understanding and building on existing systems, opportunities, and strengths; engaging stakeholders and university leaders; creating well-structured partnerships and collaborations with formal agreements; and continually lobbying and advocating for resources.
UN Family Therapy
In response to the lack of access to effective treatment services for adolescents with drug use disorders and their families in low- and middle-income countries, the United Nations Office on Drugs and Crime (UNODC) and its partners developed UN Family Therapy (UNFT), a science-informed, skills-based, and scalable treatment training package with elements of family therapy. Anja Busse, expert on drug dependence treatment and rehabilitation, UNODC, described the underlying evidence supporting family therapy as a treatment regimen that seeks to reduce family distress and conflict by improving interactions between family members. Family therapy has been shown to increase engagement and retention in treatment and to reduce adolescent substance use. Ms. Busse said UNODC was also interested in the potential of family therapy to prevent violent extremism because the program also has been shown to reduce delinquency. Draft materials were developed by an expert group meeting and pilot tested in Indonesia, Uzbekistan, and Sri Lanka before the UNODC Treatnet released the final materials in March 2019.
Philippe Cunningham, associate professor of psychiatry, Medical University of South Carolina, described the unique aspects of family therapy as it is used to treat substance use disorder. He stressed that substance use might be a symptom of other issues and that effective family therapy recognizes that the family is not the only influence affecting an adolescent’s behavior. Dr. Cunningham added that therapy connects family members over their values or recreates values, bringing back fundamentals such as love, connection, bonding, and trust. Because family units are present in every society, families are uniquely positioned to manage the process of adolescent development that occurs in the local context, and symptom-free family members may receive preventive benefits. He concluded by describing how the UNFT training manuals are important in helping improve fidelity in implementation.
Le Minh Giang, chair of the Department of Global Health, Hanoi Medical University, Vietnam, described how Vietnamese families are uniquely supportive of people who inject drugs and have HIV infection, which makes family therapy especially useful. Treatment resources are limited in Vietnam, Dr. Giang added, but the UNFT tools are provider-friendly and adaptable. Three Vietnamese HIV-Addiction Technology Transfer Centers, supported by SAMHSA and the U.S. President’s Emergency Plan for AIDS Relief, will use UNFT for a comprehensive intervention package for HIV+ methadone maintenance treatment patients who use methamphetamine, and then for adolescents who use methamphetamine. The pilot programs will be used to develop training materials for Vietnamese health care providers.
Molly Bobek, family therapist at the Center on Addiction, described how family therapy can be clinically complex and difficult to sustain with fidelity, and training can be demanding and expensive. To prepare UNFT training materials for low-resource settings, the expert group distilled four scalable, sustainable, and effective factors of existing family therapy practice: interactional change, relational reframe, adolescent engagement, and relational emphasis. To increase use of family therapy and help therapists improve family participation in treatment, the UNFT team developed 45 brief videos featuring expert therapists demonstrating family therapy techniques in sessions. Every week, trainees can access a 5- to 8-minute video of a clinician delivering a sample of family therapy techniques, followed by a 3- to 5-item coding quiz asking trainees to identify which techniques were used in the video. Trainees receive immediate feedback on the coding quiz. Trainees also will audio record their own treatment sessions for observational coding and will receive monthly feedback reports summarizing their self-report data.
International Networking: The Social Determinants of Addiction
The International Networking session explored how addiction is influenced by disparities in the organization of care and the social environment in a country. Laura Schmidt, professor of health policy at University of California San Francisco School of Medicine, stressed that recent global increases in social and economic inequity have driven increases in negative health consequences, including the rising incidence of addiction in the United States and other countries. She described the “dark side of development,” where emerging economies benefit from improved access to clean water and education as well as decreases in infant mortality and death from infectious diseases, but suffer when increases in discretionary income contribute to increases in consumption of addictive substances such as alcohol, tobacco, and drugs. Dr. Schmidt demonstrated how social disadvantage increases the risk of addiction in multiple, reinforcing ways, as socially disadvantaged groups simultaneously experience differential vulnerability, exposure, and consequences. She concluded by warning that the multiple causes of treatment disparities make them persistent and difficult to address even in developed countries. The most critical causes of treatment disparities include overall lack of treatment capacity, geographically inaccessible treatment centers, and the multiple needs and higher disease severity of disadvantaged groups who seek care.
Two former NIDA Hubert H. Humphrey Drug Abuse Research Fellows described social determinants of addiction and health disparities that exist in their countries as well as efforts or proposals to address the availability of evidence-based treatment services. Both cited a lack of funding for health care, limited access to evidence-based treatment, and the need to expand training for health care professionals and to establish family and community drug abuse education programs.
Rabia Hanif, clinical psychologist at New Horizons Care Centre, Pakistan, described how Pakistani women, people who inject drugs, and lesbian, gay, bisexual, transgender, and questioning individuals suffer double discrimination based on their social status and drug use. She added that drug-related stigma for women is reinforced by the central role women play in family and society as well as patriarchal restrictions on women’s access to health care and lack of options for child care. Ms. Hanif reported on the efforts to increase monitoring and accountability among drug treatment professionals in Pakistan and to promote adoption of evidence-based national treatment and prevention standards through the International Society of Substance Use Professionals.
Adrian Abagiu, senior doctor and medical coordinator of ARENA Opioid Substitution Treatment Center, National Institute for Infectious Diseases “Prof. Dr. Matei Balș,” Romania, described how emigration from Romania and the country’s socioeconomic challenges contribute to significant health disparities for all citizens and lack of funding for evidence-based drug treatment. Dr. Abagiu added that most drug-dependent Romanians are also members of other stigmatized groups—including men who have sex with men, Roma ethnic minorities, sex workers, and people living with HIV—and that government policies limit access to social services for drug users and members of these stigmatized groups.
ISAJE Workshop: Preparing Your Research for Publication
Richard Saitz, chair and professor of community health sciences at Boston University School of Public Health, conducted a workshop on preparing research results for publication. He offered suggestions for writing a manuscript, choosing the appropriate journal, responding to reviewers’ comments, and revising and resubmitting a manuscript. Dr. Saitz is president of the International Society of Addiction Journal Editors (ISAJE), editor in chief of the Journal of Addiction Medicine, and an associate editor of the Journal of the American Medical Association. ISAJE developed a textbook and online training materials for Publishing Addiction Science: A Guide for the Perplexed (www.ISAJE.net). Dr. Saitz also highlighted tools to help authors avoid predatory journals, including a Rutgers University Library website (https://libguides.rutgers.edu/predatory) and joint guidelines adopted by the Committee on Publication Ethics, the Directory of Open Access Journals, and the World Association of Medical Editors.