Understanding Drug Abuse & Addiction: Myths vs. Reality - Seattle, Washington

United States

Introduction

Dear Colleague:

Welcome to Understanding Drug Abuse & Addiction: Myths vs Reality. The National Institute on Drug Abuse (NIDA) is pleased to cosponsor this town meeting to provide scientifically based information on drug abuse and addiction with the Office of the Governor, State of Washington; Office of the Lieutenant Governor, State of Washington; Washington State Senate; University of Washington Alcohol and Drug Abuse Institute; and Washington State Department of Social and Health Services, Division of Alcohol and Substance Abuse.

This meeting has three goals: to promote public awareness of NIDA-sponsored research and how this information can be used to address local drug problems, to hear about local needs for science-based information and materials, and to work with local organizations to facilitate dissemination of these materials. Specifically, this meeting features the results of research conducted by NIDA grantees and explores the application of these results to the problems of drug abuse and addiction. Topics included in today's meeting include

• Current research findings about drug abuse and addiction
• How the brain is involved in addiction
• New treatment advances
  • Medications development
  • Behavioral strategies
  • Benefits and outcomes of treatment
• HIV, hepatitis, and other health consequences of drug abuse
• Drug abuse and co-occurring mental health disorders
• Principles of effective prevention
• Research to Practice and Policy Roundtable

As NIDA celebrates its 25th Anniversary we invite you to help us disseminate the research-based information about drug abuse and addiction from this meeting to the media, civic organizations, educators, health care providers, State and local antidrug coalitions, and others in your communities.

Thank you for attending this town meeting. I hope it is useful to you and that together we will forge a successful partnership in response to the drug abuse problem in Washington State.

Sincerely,
Alan I. Leshner, Ph.D., Director, National Institute on Drug Abuse

Abstracts and Speaker Biographies

Understanding Drug Abuse & Addiction: Myths vs Reality

Alan I. Leshner, Ph.D.
Director, National Institute on Drug Abuse, National Institutes of Health

Research advances made over the past several decades have led to a better understanding of the full complexity of drug abuse and addiction and have built a sound scientific foundation on which to design prevention and treatment strategies that work. Metaphors that once were used to describe the harmful effects of drugs can now be replaced by scientific evidence showing real drug-induced physiological changes in the brains of drug abusers. Intuition- or ideology-driven interventions can be discarded for ones that are science-based. In addition to advancing the science base about drug abuse and addiction, it is equally critical that the knowledge gained from research be moved from the laboratory to the community. To make any real progress, all of the factions that play a role in this effort - researchers, practitioners, community leaders, and parents - must work together to identify the most feasible and effective means of using the science that is being generated to serve the needs of individuals and our communities.

Dr. Alan I. Leshner was appointed Director of the National Institute on Drug Abuse (NIDA) in February 1994. NIDA, one of the Institutes within the National Institutes of Health (NIH), supports more than 85 percent of the world's research on the health aspects of drug abuse and addiction. Before joining NIDA, Dr. Leshner had been with the National Institute of Mental Health (NIMH) from 1988, holding the position of Deputy Director and then Acting Director. He came to NIMH from the National Science Foundation (NSF), where he held a variety of senior positions focusing on basic research in the biological, behavioral, and social sciences, as well as on science education. Dr. Leshner went to the NSF after 10 years at Bucknell University, where he was a professor of psychology. Dr. Leshner's research has focused on the biological bases of behavior. He is the author of a major textbook on the relationship between hormones and behavior and numerous book chapters and papers in professional journals. Dr. Leshner received his undergraduate degree in psychology from Franklin and Marshall College and his master's and doctorate degrees in physiological psychology from Rutgers University.

Pharmacotherapies/New Addiction Treatment Medications

Frank Vocci, Ph.D.
Director, Division of Treatment Research and Development, National Institute on Drug Abuse

The Division of Treatment Research and Development (DTR&D) of the National Institute on Drug Abuse (NIDA) facilitates the development and evaluation of behavioral and pharmacotherapeutic approaches for the treatment of substance abuse disorders. Pharmacotherapy programs currently target the development of medications for the treatment of opiate and stimulant dependence. Buprenorphine, a partial mu-opioid agonist, and a buprenorphine/naloxone combination have recently been developed for the treatment of opiate dependence. Both forms of the medication, taken sublingually, effectively reduce opiate use and increase retention in treatment. Both buprenorphine products are currently undergoing U.S. Food and Drug Administration (FDA) review and could be approved as early as December 1999.

Basic neuroscience discoveries regarding the effects of drugs of abuse on the brain are providing new, hypothesis-driven approaches to the development of medications for the treatment of cocaine dependence. We have been interested in determining how drugs of abuse can promote relapse through long-term alterations in brain mechanisms. Of the several approaches currently being evaluated, two will be highlighted: the effect of potential medications on cue-induced drug-seeking behavior and the effect of stress on reinstatement/relapse to drug taking.

Dr. Frank Vocci is the director of DTR&D at NIDA. For more than 10 years he has been involved in the Medications Development Program at NIDA where he led the LAAM development effort and has helped to shape current efforts in the development of medications for opiate and stimulant dependence. Previously, he reviewed narcotic analgesic medications and other drugs for treatment of substance abuse disorders at the FDA. Dr. Vocci received his undergraduate degree from Loyola College and his doctoral degree in pharmacology and neuroscience from the University of Maryland. He was a postdoctoral fellow in substance abuse research in the Department of Pharmacology at the Medical College of Virginia.

Brain Targets of Drugs of Abuse

T. Celeste Napier, Ph.D.
Professor, Department of Pharmacology; Director, Neuroscience and Aging Institute, Division for Research on Drugs of Abuse, Loyola University, Chicago, School of Medicine

Recent NIDA-funded research has led to the important conclusion that drug addiction is a disease of the brain and that this disease will respond to treatment. To develop new treatments for addiction, we must understand the physiology of the "feel good" sensations that accompany the use of these drugs, as well as the intense desire for more drugs after these effects have worn off. This presentation will focus on NIDA-supported research under way to identify and characterize brain regions that are involved in these aspects of addiction. This work is providing new insights that will aid in the development of effective therapies for cocaine and heroin addicts.

Dr. T. Celeste Napier received her Ph.D. degree in pharmacology and experimental therapeutics in 1982 from the Texas Tech University Health Sciences Center. After her postdoctoral training at the University of North Carolina Medical School, she accepted a faculty position at Loyola University Chicago, School of Medicine, where she is a professor of pharmacology and neuroscience and the director of the Neuroscience and Aging Institute Division for Research on Drugs of Abuse. Dr. Napier is the author of numerous publications in scientific journals and an editor of a book on the anatomy and function of the forebrain. Her neuroscience endeavors also include membership on several NIH Grant Review Committees and service as secretary and president of the Chicago Chapter of the Society for Neuroscience.

Workshops

Workshop A: Drug Abuse and Co-Occurring Disorders

Richard Ries, M.D.
Professor, Psychiatry and Addictions, University of Washington, Director of Outpatient Psychiatry, Department of Psychiatry, Harborview Medical Center

Dr. Ries will discuss how comorbid substance use and mental disorders interact, differential diagnosis and definitions of the problems, and the best practices for treatments. Two main subpopulations of the dually diagnosed will be discussed: (1) those persons with severe and persistent mental illnesses whose substance abuse complicates their care and outcomes and (2) those persons with major addiction disorders who experience depression and suicidality. Material from a recent NIDA-sponsored grant in these areas will be presented.

Dr. Richard Ries is a professor of psychiatry and addictions at the University of Washington and directs the outpatient psychiatry, dual disorder, and addictions programs at Harborview Medical Center in downtown Seattle. He is certified in addiction medicine by the American Society of Addiction Medicine and in addiction psychiatry by the American Board of Medical Specialties. Dr. Ries is an editor for the "Principles of Addiction Medicine" text as well as a member of the editorial board of the American Journal of Addictions. He has specialized in developing treatment programs and research on persons with combined mental and substance use disorders (dual disorders). Dr. Ries has been supported by NIDA in evaluating treatment outcomes for this complex population.

Workshop B: How Do Addictive Drugs Affect the Brain?

T. Celeste Napier, Ph.D.
Loyola University Chicago, School of Medicine

Charles Chavkin, Ph.D.
Professor of Pharmacology, University of Washington School of Medicine

Much is known about the immediate pharmacological effects of the addictive drugs: heroin, alcohol, cocaine, nicotine, sedatives, and marijuana. These effects will be briefly reviewed. More germane to this Town Meeting are questions relating to the way that these drugs produce lasting effects on human behavior and motivation. Our present understanding of how these acute drug effects lead to changes in brain function that result in drug addiction (compulsive drug use and persistent drug craving) will be discussed. The prevailing hypothesis is that addictive drugs produce lasting changes in the synaptic wiring of the brain. Using opiates as a starting point of the discussion, this presentation will describe the nature of these wiring changes and the mechanisms that may be responsible. Research in this area is helping to identify the mechanisms underlying the changes in the addicted brain. Our expectation is that a better understanding of these mechanisms would guide the development of new therapeutic tools for drug abuse treatment.

Dr. Charles Chavkin is a professor in the department of pharmacology within the University of Washington School of Medicine. He received his Ph.D. degree in pharmacology from Stanford University and additional training at the Salk Institute in La Jolla, CA, before joining the faculty at the University of Washington. In addition to his teaching responsibilities, Dr. Chavkin does research on the cellular and molecular effects of opiates in the brain. He studies the way the endogenous opioid peptides (endorphins) work as signaling molecules in the brain and the way that opiate drugs produce tolerance and affect learning mechanisms in the brain. Dr. Chavkin is the associate director of the Alcohol and Drug Abuse Institute at the University of Washington, helping to coordinate the research and education missions of that Institute.

Workshop C: Cognitive and Behavioral Approaches in the Treatment of Substance Abuse

Elizabeth A. Wells, Ph.D.
Research Associate Professor, University of Washington School of Social Work, Research Director, Evergreen Treatment Services

Dennis M. Donovan, Ph.D.
Professor, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine; Director, Alcohol and Drug Abuse Institute, University of Washington

In the past two decades NIDA-sponsored researchers have developed and tested the effectiveness of a number of therapies for drug addiction. In this session we will describe four nonpharmacological treatment approaches that have solid empirical support or currently show promise: cognitive-behavioral relapse prevention, the community reinforcement approach, motivational enhancement, and 12-Step facilitation. We will provide an overview of each therapy and resources for learning more about the therapy and address the following questions about each approach: With whom has each treatment been tried (e.g., women, people of color, dual disorder patients)? What are the potential advantages of implementing each treatment in workshop participants' settings? What are potential barriers to implementation? What more do we need to know about each treatment?

Dr. Elizabeth A. Wells has been involved in NIDA-sponsored treatment research for 15 years, including studies of skill training, relapse prevention, 12-Step facilitation, contingency management, and motivational enhancement approaches to treatment. Her current projects are studies of motivational enhancement interventions with street-based cocaine users and heroin injectors on a methadone maintenance waiting list.

Dr. Dennis M. Donovan is the director of the University of Washington Alcohol and Drug Abuse Institute and professor of psychiatry and behavioral sciences at the University of Washington School of Medicine. He has been involved in clinical practice and clinical research with substance abusers for the past 20 years. His areas of research interest involve enhancing treatment entry and engagement, treatment process and outcome, brief motivational interventions, cognitive-behavioral relapse prevention, and matching clients and treatments.

Workshop D: HIV and Drug Abuse: Co-Occurring Epidemics, Washington State's Methamphetamine Epidemic

E. Michael Gorman, Ph.D., M.P.H., M.S.W.
Research Scientist, Alcohol and Drug Abuse Institute, University of Washington

Drug use, including injection drug use, plays a major role in HIV transmission in Washington State. Among the State's cumulative AIDS caseload (approximately 8,700), 19 percent, or more than 1,600, have histories of injection drug use, a percentage that increases to 24 percent by 1998. Furthermore, injection drug use represents only part of the overall HIV risk - in that individuals who do not inject drugs are not counted. In Washington State, the primary drugs of abuse that are of concern with respect to HIV include heroin as well as stimulants, such as cocaine and especially methamphetamines.

Methamphetamines represent a growing concern to the public, social, and psychological well-being of the people and State of Washington. Treatment admissions to publicly funded programs in Washington State for methamphetamines have grown dramatically over the past 7 years, increasing statewide on the order of nearly 1,000 percent (ADAI, University of Washington; DASA). In calendar year 1998, admissions for individuals indicating methamphetamine as their primary drug of abuse exceeded those for heroin and cocaine. In 1998, between 36 and 50 percent reported that their primary route of administration was injection. More than 50 percent of those coming to treatment in 1998 were women. Ninety-one percent were white, with the largest number of people from ethnic and racial minorities being Hispanic and Native American. In King County alone, methamphetamine admissions during the period of July 1998 through December 1998 increased a dramatic 850 percent over 1992, relative to comparable cocaine and heroin increases of 119 percent and 234 percent, respectively.

Dr. E. Michael Gorman is a research scientist at the University of Washington's Alcohol and Drug Abuse Institute and principal investigator of a NIDA-funded community study of methamphetamine and HIV. He has experience working on drug abuse and HIV-related issues as a researcher, clinician, and policy analyst, reflecting his training in epidemiology, anthropology, and clinical social work. His primary focus is research and policy issues with respect to social work, public health, HIV, and substance abuse. He is a member of NIDA's Seattle Community Epidemiology Working Group (CEWG) and sits on the Washington State scientific advisory committee for the State's Division of Alcohol and Drug Abuse. Since March 1995 he has made more than 50 presentations and papers on the topics of drug abuse and HIV/AIDS and hepatitis C. He was cochair and coordinator of the NIDA-sponsored Pacific Northwest Regional HIV and Substance Abuse Conference held at the University of Washington in September 1997. He is a member of the Institute for the Advancement of Social Work Research (IASWR) and a member of the new NIDA-IASWR curriculum project targeting social work researchers. He is a consulting editor of the Journal of Social Work Research and a member of the editorial advisory boards of the Journal of Social Work and Substance Abuse Practice and the Journal of Gay and Lesbian Social Services. He is also a member of the American Public Health Association, the Council on Social Work Education, and the American Anthropological Association, where he sits on the steering committee of the AIDS and Anthropology Research Group.

Workshop D: Relapse Prevention: Recent Developments in Drug Treatment

G. Alan Marlatt, Ph.D.
Professor and Director, Addictive Behaviors Research Center; Department of Psychology, University of Washington

The purpose of this workshop is to provide an overview of relapse prevention in the treatment of addictive behaviors. A cognitive-behavioral model of the relapse process is described, along with implications for prevention and management of relapse episodes. Applications with alcohol and other drug problems will be presented, along with evidence of the efficacy of this approach.

Dr. G. Alan Marlatt is a professor of psychology and director of the Addictive Behaviors Research Center at the University of Washington. He received his Ph.D. degree in clinical psychology from Indiana University in 1968. After serving on the faculties of the University of British Columbia (1968-1969) and the University of Wisconsin (1969-1972), he joined the University of Washington faculty in the fall of 1972. His major focus in both research and clinical work is the field of addictive behaviors. In addition to many journal articles and book chapters, he has published several books in the addictions field, including Relapse Prevention (1985), Assessment of Addictive Behaviors (1988), and Harm Reduction (1998). In 1996, Dr. Marlatt was appointed a member of the National Advisory Council on Drug Abuse for NIDA. His research is supported by a Senior Scientist Award and a MERIT Award from the National Institute on Alcohol Abuse and Alcoholism. In 1990, Dr. Marlatt received the Jellinek Memorial Award for outstanding contributions to knowledge in the field of alcohol studies.

Workshop E: Communities That Care: Utilizing the Scientific Knowledge Base for Effective Prevention

Richard F. Catalano, Ph.D.
Associate Director and Professor, Social Development Research Group, University of Washington

Until relatively recently, one of the major impediments to effective prevention was the absence of a framework for empirically based prevention. Preventive efforts often failed because they were based on models of adolescent problem behaviors that were inconsistent with the empirical evidence. However tremendous strides have been made in identifying longitudinal predictors, often called risk and protective factors, of adolescent problem behaviors. Prevention programs that reduce risk and enhance protection are likely to interrupt the processes that produce adolescent problems. Carefully conducted evaluations of prevention programs have demonstrated that they are able to reduce risk, enhance protection, and, in some long-term follow-up studies, reduce problem behaviors. To take advantage of these advances in prevention at the community level, communities must assess and prioritize their children's exposure to these risk and protective factors and match these priorities with effective prevention programs.

The Communities That Care strategy was developed to assist communities in utilizing the scientific knowledge base for effective prevention planning and programming, assessing risk and protection and current prevention resources, and putting effective programs in place to prevent adolescent problems. This presentation will review the research base and prevention principles and provide an understanding of the Communities That Care operating system for prevention planning and action.

Dr. Richard F. Catalano is a professor and associate director of the Social Development Research Group at the University of Washington's School of Social Work in Seattle, Washington. He received his bachelor's degree in sociology from the University of Wisconsin and his Ph.D. degree from the University of Washington. For more than 20 years, he has led research and program development to promote positive youth development and prevent problem behavior. His work has focused on discovering risk and protective factors for positive and problem behavior and designing and evaluating programs to address these factors. He is a frequently published author and much sought-after consultant.

Dr. Catalano is the principal investigator on a number of Federal grants, which include family, school, and community-based prevention approaches to reduce risk while enhancing the protective factors of bonding and the promotion of healthy beliefs and clear standards. He is chair of the Washington State Research Subcommittee of the Department of Alcohol and Substance Abuse. He has served on the Office of Juvenile Justice Delinquency Prevention's Study Group on Serious Chronic and Violent Offenders, the CSAP Prevention Enhancement Protocol System for Family Programs, the National Academy of Sciences Panel on Evaluating Needle Exchange and Bleach Distribution programs, the NIDA Epidemiology and Prevention Review Committee, and the Washington State Advisory Committee for Alcohol and Substance Abuse. He is the codeveloper of the Social Development Strategy, cofounder of Developmental Research and Programs, codeveloper of parenting programs entitled Preparing for the Drug-Free Years and Parents Who Care, and codeveloper of the community prevention approach Communities That Care.

Workshop F: New Medications Development and Treatment

Frank Vocci, Ph.D.
Director, Division of Treatment Research and Development, National Institute on Drug Abuse

Andrew J. Saxon, M.D.
Director, Addictions Patient Care Line; Associate Professor, Veterans Administration Puget Sound Health Care System, University of Washington School of Medicine

Naltrexone, methadone, and LAAM have approval for treatment of opioid dependence, but LAAM is just gaining more widespread use. Understanding of its optimal clinical applications requires ongoing investigation. Buprenorphine as a partial mu-opioid agonist differs somewhat from other agonist medications and is also receiving intensive investigation. Methods for a "Multicenter Safety Trial of Buprenorphine/Naloxone for the Treatment of Opiate Dependence" will be discussed.

No approved medications for cocaine or other stimulant dependence currently exist. As bench research reveals the increasing complexities of the pharmacology and neurobiology of stimulant dependence, a number of medication approaches warrant exploration including those which might work outside the central nervous system (CNS) or on various neurotransmitter systems within the CNS. On a clinical level, most cocaine users pair their cocaine use with alcohol use. Medications used for alcohol dependence, such as disulfiram, may also have utility in management of cocaine dependence.

Dr. Andrew J. Saxon serves as director of the Addictions Patient Care Line at the Veterans Administration Puget Sound Health Care System and is an associate professor of psychiatry and behavioral sciences at the University of Washington. Since his experience as an emergency room physician where he frequently managed the medical sequelae of substance-related problems, he has devoted his career to the treatment and understanding of substance use disorders. Prior research includes outcome trials in HIV prevention and in opioid agonist treatment. Ongoing pursuits focus on the testing of medications for alcohol, cocaine, and opioid dependence through participation in large, multisite, cooperative trials.