Testing New Treatments in the Nation's Clinics
In NIDA's first 30 years, its research programs produced many promising new medications and behavioral treatments. Yet, as in other areas of medicine, new and improved treatments for drug abuse have often taken too long to make their way into wide clinical use. In 1999, NIDA acted to bridge the critical gap between research and practice by launching the largest initiative in its history--the National Drug Abuse Treatment Clinical Trials Network (CTN).
The CTN embraces an ambitious plan to accelerate the transfer of new science-based behavioral and pharmacological approaches into treatment: to create a national research-practice infrastructure to test and modify promising treatments in community treatment programs, rather than specialized research settings, and rapidly transfer those proven effective into clinical practice. The network also seeks to develop new treatments that reflect the practical knowledge of the clinic, thus accelerating their acceptance and application in practice.
Beginning with 5 regional research and training centers, each linked to as many as 10 community treatment programs, the CTN brought researchers into community clinics to work alongside practitioners in testing research-based treatments. In little more than a year, NIDA and the pioneering group of university researchers, treatment programs, and practitioners built the organizational and procedural foundation for the CTN, selected promising pharmacological and behavioral approaches, developed standardized clinical protocols, and began testing them in trials with a variety of patients at multiple sites.
The CTN now encompasses 17 regional research and training centers and 115 community treatment programs across the Nation. Minorities, pregnant women, adolescents, and drug abuse patients suffering from post-traumatic stress disorder or depression are among the pool of nearly 9,000 drug abuse treatment patients in 27 States who have or will soon participate in 22 clinical protocols--some under way, some still being refined--for a variety of new treatment approaches. Medication trials range from assessing the effectiveness of buprenorphine in detoxifying opiate-dependent patients to determining whether a combination buprenorphine/naloxone tablet can help treat heroin-addicted adolescents. Behavioral treatment trials take many approaches: tests using motivational enhancement techniques or tangible incentives for staying drug-free to enhance standard counseling approaches, several HIV risk-reduction interventions, and an intervention to help patients in drug abuse treatment stop smoking.
Taking Prevention Programs Into Our Communities
Although a relatively new science, drug abuse prevention has already yielded a bounty of programs capable of steering many young people away from drug use. As with drug abuse treatments, however, many of these research-proven programs stayed on the shelf, while simpler, less effective approaches were used. Even when such approaches were selected, they often were not delivered to maximum effect.
Community-based prevention programs teach children strategies to avoid drug initiation and other harmful behaviors.Taking a cue from the CTN, NIDA began to partner prevention researchers and practitioners to establish research-based programs in the Nation's communities. A major component of NIDA's recently launched broad-based National Prevention Research Initiative instituted four large-scale field trials of proven drug abuse prevention approaches. These trials find scientists and practitioners collaborating to deliver a research-tested intervention to diverse groups of children and adolescents in urban, suburban, and rural sites. Each trial examines factors with potential impact on a program's effectiveness, such as how different training methods affect its delivery or how accurately community service programs deliver an intervention to different groups in various settings.
Results of these joint research-practice studies will reveal practical barriers to widespread dissemination and implementation of research-tested programs. Equally important, they will point to how programs can be adapted to meet the needs of local communities while still reducing drug use. Ultimately, blending science-based knowledge with community realities will produce more practical prevention programs that will be used by more communities to divert children and adolescents from initiating drug use.
Advancing the Frontiers of Addiction Research and Practice
The first three decades of NIDA leadership ushered drug abuse science toward full maturity. The result: profound and practical insights into the complex biological, behavioral, cognitive, and environmental interactions that influence every aspect of drug abuse and addiction. Practitioners now have many effective tools for preventing and treating drug abuse and addiction and their costly public health and social consequences. Yet, much work remains. Too many children and adolescents continue to experiment with drugs, putting themselves at risk for addiction. Research to speed the development and application of prevention strategies stands at the forefront of NIDA's priorities.
Additional NIDA research initiatives continue to address the critical need for treatments for drug abusers who suffer from mental illnesses or abuse multiple substances, including nicotine and alcohol. And more broadly effective prevention and treatment approaches will enable NIDA to fulfill its public health mission of reducing the severe health consequences of addiction, including increased risk of contracting and transmitting infectious diseases.
Collaborating to Combat Tobacco Use and Nicotine Addiction
The transdermal patch, based on early NIDA research, has proven helpful to many smokers trying to overcome nicotine dependence.In July 1998, NIDA, with the National Cancer Institute (NCI), the Centers for Disease Control and Prevention, and The Robert Wood Johnson Foundation (RWJF), sponsored "Addicted to Nicotine," a national research conference on tobacco use and nicotine addiction. This event shed new light on the complexity of research challenges posed by nicotine addiction. Informal conversations among researchers and policymakers highlighted the need for an innovative research approach to meet these challenges. Within a year, this dialogue yielded a proposal: develop Transdisciplinary Tobacco Use Research Centers (TTURCs) to foster collaborations among scientists across many disciplines and allow them to investigate tobacco use and nicotine's effects at levels ranging from molecular genetics to peer interactions. By October 1999, NIDA and NCI announced the first TTURC awards and committed about $70 million to the effort over 5 years. RWJF committed an additional $14 million.
Today, investigators at seven TTURCs across the country are carrying out the research agenda that gave birth to the centers. Their collaborations have produced scores of published studies that advance our understanding of nicotine's addictive effects and the scope of influence smoking has on the Nation's health. Consider the following research accomplishments and initiatives:
Brown University--described intergenerational effects, including maternal smoking during pregnancy, that influence smoking initiation and increase the risk for nicotine addiction among adolescents.
University of California, Irvine--elucidated the neurobiological impact of nicotine, particularly on the developing brain.
University of Pennsylvania/Georgetown University--shed new light on how inherited variations in enzymes increase or decrease the likelihood of becoming addicted to nicotine or contribute to the effectiveness of smoking cessation treatments.
University of Southern California--expanded understanding of the role of cultural, ethnic, and peer influences on smoking behavior.
Yale University-- identified sex differences that contribute to differential success of treatment for men and women and is developing treatments to help smokers who have had the most difficulty quitting
University of Minnesota--began developing and evaluating new smoking cessation treatments, including vaccines to prevent nicotine from reaching the brain.
University of Wisconsin--is pursuing strategies to expand access to and increase use of smoking cessation programs and identify measures that reduce the risk of relapse.
NIDA is applying revolutionary new techniques in molecular biology, brain imaging, and cognitive neuroscience to these outstanding issues in drug abuse etiology, prevention, and treatment. For example, neuroscientists in the Institute's proteomics program are using 3-dimensional imaging technology to map how distinct proteins in different regions of the human brain function, interact, and change from initial drug use through the transition to addiction. Such research promises new understanding of the molecular mechanisms of drug addiction and the underlying processes of normal and diseased brain function. While offering important new targets for the next generation of therapeutic approaches, this research may someday allow clinicians to match an intervention to a patient's physiological or genetic traits.
Environmental factors, such as a positive home life, may boost brain chemicals that offer resistance to drugs' reinforcing effects.The role that interactions between genetic factors and the environment play in vulnerability to addiction is another area of promise recently opened up through advances in scientific technologies. For while genes and the proteins they produce may increase or reduce the risk of addiction, they do not function in isolation. Using brain-imaging techniques, researchers recently found that social environment can modify monkeys' neurobiology, thereby reducing their likelihood of self-administering drugs. In the study, housing conditions and social interactions altered the genetic expression of proteins in the brain that enable animals, including humans, to experience pleasure and the effects of drugs.
The complexity of drug abuse questions that have come to the fore requires investigation from multiple perspectives. To achieve this goal, NIDA has launched broad research initiatives involving Federal, State, and local government agencies; scientists from many different fields; public and private health service providers; prevention and treatment professionals; and private pharmaceutical companies. One key feature of these collaborations is their emphasis on the resources and practical needs of communities at all research stages--from basic discovery through intervention development to actual trial and integration in community prevention and research programs. Examples of collaborative initiatives include the following.
Transdisciplinary Research Centers. Teams of researchers pool their expertise to search for new knowledge about the interplay of individual, cognitive, social, and environmental circumstances in fostering drug abuse and its many harmful consequences. NIDA currently supports transdisciplinary centers in prevention and tobacco use research. In the tobacco use centers, NIDA, with the National Cancer Institute and the Robert Wood Johnson Foundation, supports investigation of all aspects of tobacco use, from factors that influence initiation through those that aid cessation. The goal is to discover new ways to prevent and treat nicotine addiction, particularly in adolescents.
Collaborating With Other Federal Agencies. NIDA is participating in research initiatives with other NIH Institutes, including those that research allergy and infectious diseases, neurological disease and stroke, mental health, alcoholism and alcohol abuse, cancer, and child health and development. Studies funded under these initiatives will help the biomedical research and practice community better understand the links between addiction and comorbid mental and physical disorders. This research will accelerate discovery of prevention and treatment interventions for such disorders as hepatitis, HIV, mood and conduct disorders, and other problems often associated with drug abuse as cause, consequence, or both.
Working With Private Industry and Practice. Research partnerships with private pharmaceutical companies are fostering new approaches to treat drug abuse and addiction, including vaccines currently in clinical trials. Agreements negotiated with pharmaceutical companies are enabling NIDA's Medications Development Program to explore the potential of patented compounds in treating cocaine, methamphetamine, and nicotine addiction. NIDA also is working to raise private medical practitioners' awareness that they can play a critical role in improving their patients' health by being alert to the signs and symptoms of substance abuse and aware of treatment options for addiction and related medical and psychiatric problems.
Fostering research-clinician partnerships is a focus of Science & Practice Perspectives, NIDA's peer-reviewed journal.Strengthening Research-Practice Partnerships. To broaden the research-practice partnership that the CTN has initiated, NIDA has organized regional blending conferences to extend the reach of treatment research into the Nation's community treatment programs. The conferences allow clinicians and researchers to examine how to apply cutting-edge findings about drug use and addiction in clinical settings. NIDA also supports the Substance Abuse and Mental Health Services Administration (SAMHSA) in developing, deploying, and evaluating evidence-based treatment approaches for drug abuse in community-based clinics. These efforts bring research and practice closer together, inform development of more effective and useful interventions, accelerate adoption of research-tested approaches, and improve the quality of drug abuse prevention and treatment.
Improving Criminal Justice Drug Abuse Treatment Services. The majority of the 600,000 inmates who return to their communities from prison each year have untreated substance abuse problems that can quickly lead to relapse to drug abuse and criminal behavior. Thus, NIDA has taken the lead in building a multi-agency consortium to develop integrated approaches to the treatment of incarcerated individuals with drug abuse and addictive disorders and test them at multiple sites throughout the Nation. Joining the Institute in this much-needed National Criminal Justice Drug Abuse Treatment Study to improve drug abuse treatment services for offenders are SAMHSA, the Centers for Disease Control and Prevention, and the Department of Justice.