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Dispelling the Myths about Addiction
Strategies to Increase Understanding and Strengthen Research
Committee to Identify Strategies to Raise the Profile of Substance Abuse and Alcoholism Research
Division of Neuroscience and Behavioral Health
Division of Health Promotion and Disease Prevention
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
Washington, D.C.
1997
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NATIONAL ACADEMY PRESS
2101 Constitution Avenue, N.W. Washington, DC 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.
This study was supported under a grant from the W.M. Keck Foundation of Los Angeles. The views presented are those of the Institute of Medicine Committee to Identify Strategies to Raise the Profile of Substance Abuse and Alcoholism Research and are not necessarily those of the funding organization.
Library of Congress Catalog Card No. 97-69691
International Standard Book Number 0-309-06401-5
Additional copies of this report are available from:
National Academy Press
2101 Constitution Avenue, N.W. Lock Box 285 Washington, DC 20055 Call 800-624-6242 or 202-334-3313 (in the Washington metropolitan area) or visit the National Academy Press's online bookstore at http://www.nap.edu.
Copyright 1997 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.
Cover: The cover of this report includes a circular motif, called a mandala, that was designed by Leigh Coriale of the National Academy Press. The term mandala comes from Sanskrit, and such motifs are prominent among many of the world's religions. In psychology, mandalas were studied and used most extensively by the psychiatrist Carl Jung, who viewed mandalas as abstract representations of the totality of the conscious and unconscious. Universal elements of the unconscious, or archetypes, were important in Jung's theory of individual psychological development and manifestations, but also were evident in symbols, myths, legends, and rituals. Color reprints of some of Jung's patient's mandalas are contained in R.F.C. Hull's English translation of Jung's book, The Archetypes and the Collective Unconscious (Second Edition, Tenth Printing; Princeton, NJ: Princeton University Press, 1990).
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COMMITTEE TO IDENTIFY STRATEGIES TO RAISE THE PROFILE OF SUBSTANCE ABUSE AND ALCOHOLISM RESEARCH
NANCY C. ANDREASEN, (Chair),* Andrew H. Woods Professor of Psychiatry and Director,
Mental Health Clinical Research Center, University of Iowa, Iowa City, Iowa
STANLEY J. WATSON, Jr. (Vice-Chair),* Codirector and Research Scientist,
Mental Health Research Institute, and
Professor and Associate Chair for Research,
Department of Psychiatry, School of Medicine, University of Michigan, Ann Arbor, Michigan
MICHAEL BYAS-SMITH, Assistant Professor of Anesthesiology,
Emory Anesthesiology Administration, Atlanta, Georgia
MARC G. CARON, Investigator,
Howard Hughes Medical Institute, and
Professor,
Department of Cell Biology, Duke University Medical Center, Durham, North Carolina
BRIAN M. COX, Professor and Chairman,
Department of Pharmacology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
JOHN GRABOWSKI, Professor,
Department of Psychiatry and Behavioral Science, University of Texas Health Science Center, Houston, Texas
SHARON M. HALL, Professor and Vice-Chairperson,
Department of Psychiatry, School of Medicine, University of California at San Francisco, San Francisco, California
STEVEN E. HYMAN, Director,
National Institute of Mental Health, Rockville, Maryland
TING-KAI LI, Distinguished Professor of Medicine and Biochemistry,
School of Medicine, Indiana University, Indianapolis, Indiana
HERBERT W. NICKENS, Vice President for Community and Minority Programs,
Association of American Medical Colleges, Washington, D.C.
DOROTHY P. RICE,* Professor Emeritus,
Institute for Health and Aging, University of California at San Francisco, San Francisco, California
SALLY SATEL, Research Psychiatrist,
School of Medicine, Yale University, Washington, D.C.
WILLIAM K. SCHMIDT, President and CEO,
NorthStar Research and Development, Ltd., Newark, Delaware
RICHARD W. TSIEN,* George D. Smith Professor and Chairman,
Department of Molecular and Cellular Physiology, School of Medicine, Stanford University, Stanford, California
JUDITH R. WALTERS, Chief,
Neurophysiological Pharmacology Section, Experimental Therapeutics Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
*
Institute of Medicine member.
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STEPHEN M. WEISS, Professor and Codirector,
Division of Behavioral Medicine and Consultation Psychiatry, School of Medicine, University of Miami, Miami, Florida
Institute of Medicine Staff
LAUREN B. LEVETON, Study Director until September 1996
CARRIE E. INGALLS, Research Associate
THOMAS J. WETTERHAN, Project Assistant/Research Assistant
AMELIA B. MATHIS, Project Assistant
TERRI SCANLAN, Administrative Assistant
DIANA ZUCKERMAN, Consultant
MICHAEL A. STOTO, Director,
Division of Health Promotion and Disease Prevention
CONSTANCE M. PECHURA, Director,
Division of Neuroscience and Behavioral Health
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Preface
Research on addiction reveals fascinating paradoxes and contradictions. On one hand, there are enormous opportunities, such as those for furthering knowledge about the complex and sophisticated science of neurobiology. Scientists have identified many of the brain mechanisms that lead human beings to develop the cravings and physical dependencies that characterize addiction. These mechanisms appear to be at work with many different types of drugs, ranging from commonly used legal drugs, such as nicotine, to illicit drugs, such as heroin, which are abused and, in some individuals, lead to addiction.
There are enormous barriers, however, based on stigma and misunderstanding, which have undermined the benefits of increased scientific knowledge. To address this problem effectively, the public, health educators, policymakers, and clinicians who treat addiction must be educated about research accomplishments and critical questions, and additional researchers must be recruited into the field. This report attempts to identify key barriers that need to be overcome before a rational, science-based approach to drug addiction, one of our most pressing public health problems, can be achieved.
Many Institute of Medicine (IOM) studies are intended to serve as instruments of change that will shape future policies. The charge to the Committee on Raising the Profile of Substance Abuse and Alcoholism Research was to conduct a study and to develop a report to identify and address barriers to public understanding of the field and those that present obstacles for attracting and sustaining talented investigators and other health professionals who wish to pursue careers in addiction research. The committee was also charged with developing strategies to overcome the barriers.
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As work on this study progressed, a novel situation unfolded: the process itself became a catalyst for change. Committee members learned from one another—basic researchers from clinical and behavioral researchers, senior from younger, and those outside the field from those within. In particular, a workshop held in March of 1996 brought committee members, young* and senior investigators, and other health professionals and policymakers together in a meeting that helped to begin changes in attitudes and increases in knowledge (see Appendix A for the workshop agenda and Appendix B for a list of participants). The workshop provided new insights, encouraged constructive debate, and ultimately achieved consensus about the various barriers; it also stimulated innovative thinking about critical strategies. The results of the workshop and committee deliberations are presented in this report, which we hope will also be an instrument of change. It is addressed to several audiences, but particularly to the lay public, college and graduate students, university administrators, policymakers, and others who may be interested in understanding drug abuse and addiction.
This report sets forth a strategy to dispel the myths about addiction and to facilitate a better understanding of the accomplishments in addiction research and the critical questions that remain to be answered (Chapters 3, 4 and 5). Addiction to nicotine, alcohol, and illegal drugs is a preventable and treatable brain disease influenced by complex sets of behaviors that may be the results of genetic, biological, psychosocial, and environmental interactions, as this report emphasizes. The costs of these problems are high and underscore the need to approach the problems from a perspective that is more rational and evidence based.
The committee of 16 members was carefully selected to represent basic, clinical, and behavioral researchers both inside and outside the field of drug addiction with expertise spanning different disciplines (e.g., neuroscience, psychopharmacology, anesthesiology, behavioral medicine, economics) and different substances (e.g., nicotine, alcohol, opioids, stimulants). They were also selected for their experience in careers associated with academia, government, and industry. In addition, to improve understanding as to how various barriers may pose problems at different stages of a research career, the committee was selected to be representative of those different stages, ranging from junior to more senior researchers and clinicians.
The committee collected quantitative and qualitative data during the study, including data on prevalence and costs of addiction (Chapter 2), efforts made in educational settings from early grades through medical schools (Chapter 6), investments in research and training (Chapter 7), and initiatives to educate the
*
Young investigators were defined for the purpose of this study not by chronological age, but rather as individuals who were at early stages of their careers.
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public and the role of public perception in supporting or inhibiting increased understanding and implementation of effective public policies regarding research (Chapter 8).
The day-and-a-half workshop was a major data gathering activity that helped to shape the search for information and enriched the committee discussions. The workshop highlighted young investigators' perceptions of their experiences of the barriers and opportunities in pursuing careers in addiction research and treatment. The young investigators represented the entire spectrum of career pathways, from predoctoral and premedical students to recent postdoctoral and junior faculty individuals. In addition, they represented career paths spanning neurobiological, clinical, and behavioral areas both inside and outside addiction research and treatment. The workshop also included a broad representation of other individuals—senior investigators inside and outside addiction research, and medical and health professionals and policymakers representing universities, foundations, industry, government, and professional associations interested in addiction research.
Seventy people participated in the workshop and an additional 29 young investigators and 25 senior investigators and other professionals provided written contributions about their perceptions and experiences of barriers and strategies for attracting individuals into the field (Appendix B contains the list of workshop participants and contributors). The committee also heard about advances in addiction research from two keynote speakers, Drs. Avram Goldstein and Ivan Diamond, who shared valuable perspectives based on their extensive experience in this field (Appendixes C and D). Finally, to obtain a perspective on lessons learned, three speakers described how their fields had advanced and overcome the barriers posed by stigma. The fields (depression, epilepsy, and breast cancer) were selected by the committee to illustrate success stories that could serve as role models for advancing the field of addiction research.
Many individuals helped the committee do its work, but first we would like to thank the W.M. Keck Foundation of Los Angeles for their financial support, without which this study would not have taken place. We would like to thank the committee members for their dedication and diligence, but most of all for their open-mindedness and flexibility. Each made a unique contribution and broadened our perspective. We also appreciate the efforts of a number of people who obtained and provided information on the various federal agencies and their funding, and shared their knowledge and perspectives through interviews and questionnaires. Several people provided valuable assistance in preparing chapter drafts, workshop summaries, and in copy editing the manuscript (Diana Zuckerman, Sara Brookhart, Peter Slavin, and Beth Gyorgy). Most particularly, we are grateful to the IOM staff: Lauren Leveton for assuming in-house leadership for the study and the organization of the workshop until September 1996; Constance Pechura for providing wise oversight; Carrie Ingalls for exceptional
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research and writing assistance; Thomas Wetterhan for additional skilled research support, manuscript preparation, and logistical support; Terri Scanlan for consistently helpful administrative assistance; and Amelia Mathis for making our travel, meeting arrangements and meals comfortable and enjoyable. Also, we appreciate the efforts of Michael Edington, managing editor, Claudia Carl, administrative associate for report review, and Carlos Gabriel, financial associate. Finally, we would like to thank all the young investigators who have much to look forward to as they pursue the exciting challenges in addiction research.
NANCY C. ANDREASEN M.D., PH.D., Chair
STANLEY WATSON, M.D., PH.D., Vice-Chair
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Contents
SUMMARY
1
1
INTRODUCTION
11
Definitions and Concepts
13
Classification of Drugs
14
Organization of the Report
16
2
PREVALENCE, COSTS, AND INVESTMENTS
19
Prevalence
19
Economic Costs of Addiction
25
Investments
28
Conclusion
32
3
NEUROBIOLOGY OF ADDICTION: AN OVERVIEW
37
The Brain's Common "Reward" Pathway
39
Drug Effects on Brain Reward Systems
41
Emotion, Memory, and the Transition from Use to Addiction
42
Vulnerabilities to Addiction
47
Conclusion
49
4
PSYCHOSCIAL FACTORS AND PREVENTION
55
Psychosocial Factors
55
Prevention
57
Conclusion
66
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5
TREATING ADDICTIVE DISORDERS
73
Treatments for Alcohol and Cocaine Addiction
75
Treatments for Opioid Addiction
83
Smoking Cessation Programs
85
Conclusion
87
6
EDUCATION AND TRAINING
95
Career Pathways
96
Secondary School and Undergraduate Education
97
Graduate and Professional Education
99
The Importance of Mentors
106
Specialization and Credentialing Issues
109
Conclusion
111
7
RESOURCES NEEDED FOR YOUNG INVESTIGATORS
115
Funding Levels
119
The Pipeline
120
8
PUBLIC PERCEPTIONS, PUBLIC POLICIES
139
Stigma
139
Advocacy
141
A Model for Understanding the Educational and Public Barriers
142
Strategies
142
APPENDIXES
A Workshop Agenda
149
B Workshop Contributors and Participants
153
C Plenary Lecture I, Avram Goldstein, M.D.
161
D Plenary Lecture II, Ivan Diamond, M.D., Ph.D.
169
E History of Drug Addiction Research: Key Discoveries/Events, National Policies, and Funding
177
F Recent Advances in Addiction Research
193
G Recent Advances in Pharmacotherapy
199
H Recent Advances in Behavioral Sciences and Treatment
201
I Key Barriers and Critical Strategies in the Research and Public Arenas
205
INDEX
211
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TABLES, FIGURES, AND BOXES
Tables
1.1
Classification of Abusive and Addictive Drugs
17
2.1
Trends in Past Month Use of Marijuana, Alcohol, and Cigarettes by 8th Graders, 10th Graders, and High School Seniors, 1992–1996
24
2.2
Estimated Economic Costs of Illicit Drug, Alcohol, and Nicotine Abuse, 1990 (Millions of Dollars)
26
2.3
Costs of Illness for Selected Diseases and Conditions (Billions of Dollars)
29
2.4
NIDA Funding History (1988–1997): Research Training Grants, Research Grants, and Total Budget (Thousands of Dollars)
31
2.5
NIAAA Funding History (1988–1997): Research Training Grants, Research Grants, and Total Budget (Thousands of Dollars)
31
3.1
Some Future Challenges in Basic Research
50
4.1
Some Future Challenges in Psychosocial and Prevention Research
67
5.1
Duration of Addiction Treatment
76
5.2
Some Future Challenges in Pharmacotherapy and Treatment Research
88
7.1
Total Costs to Society and Training and Research Support for Specific Diseases (Millions of Dollars)
119
7.2
R01 Success Rates
129
7.3
NIDA Research Training Funding as a Percentage of Total Extramural Research Funding (Millions of Dollars)
130
7.4
NIAAA Research Training Funding as a Percentage of Total Extramural Research Funding (Millions of Dollars)
130
Figures
2.1
Past Month Illicit Drug Use by Age: 1979–1995
20
2.2
Past Month Illicit Drug Use, by Past Month Alcohol Use, Age 12 and Older, 1995
22
2.3
Economic Costs of Addiction by Type of Cost and Drug, 1990
27
3.1
Schematic Diagram of the Brain Reward Circuitry
40
3.2
The Effect of Cocaine and Amphetamine
42
7.1
Total Institute Budgets, 1986–1995 (Constant Dollars)
122
7.2
Total Institute Research Grant Budgets, 1986–1995 (Constant Dollars)
123
7.3
Total Research Training Grant Budgets, 1986–1995 (Constant Dollars)
124
7.4
Total Number of T32, F31, and F32 Applicants, 1986–1995
125
7.5
Total Number of T32, F31, and F32 Awards Granted, 1986–1995
126
7.6
Total Number of R01 and R29 Applicants, 1986–1995
127
7.7
Total Number of R01 and R29 Awards Granted, 1986–1995
128
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8.1
Critical Links in the Strategies for Raising the Profile of Addiction Research
143
Boxes
2.1
Estimating the Cost of Drug Abuse in New York City
28
3.1
Animal Models: Examples from Alcohol Research
38
3.2
Effects of Alcohol on Neurotransmission
43
6.1
American Association for the Advancement of Science
98
6.2
Faculty for Undergraduate Neuroscience
99
6.3
Case Study: Harvard Medical School, Division on Addictions
102
6.4
Case Study: University of Pennsylvania, School of Medicine
103
6.5
North Carolina Governor's Institute on Alcohol and Substance Abuse, Inc.
105
7.1
Description of Awards
116
7.2
Foundation-Funded Research: A Model Program
132
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Acronyms
AA
Alcoholics Anonymous
AAAS
American Association for the Advancement of Science
AAMC
Association of American Medical Colleges
ABPN
American Board of Psychiatry and Neurology
ACS
American Cancer Society
ADA
American Diabetes Association
ADD
attention-deficit disorder
ADH
alcohol dehydrogenase
ADHD
attention-deficit hyperactivity disorder
AHA
American Heart Association
AHCPR
Agency for Health Care Policy and Research, United States Department of Health and Human Services
AHEC
Area Health Education Centers
AIDS
acquired immunodeficiency syndrome
ALDH2
aldehyde dehydrogenase
AMA
American Medical Association
AMERSA
Association for Medical Education and Research in Substance Abuse
APA
American Psychological Association
ASA
American Sociological Association
ASAM
American Society of Addiction Medicine
ATP
adenosine triphosphate
AVP
arginine vasopressin
B/START
Behavioral Science Track Award for Rapid Transition
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BAC
blood alcohol concentrations
BLS
Bureau of Labor Statistics
cAMP
cyclic adenosine monophosphate
CASA
Center on Addiction and Substance Abuse
CCK-8
cholecystokinin-8
cDNA
deoxyribonucleic acid, complementary sequence
cm
centimeters
CME
continuing medical education
CNS
central nervous system
CRA
community reinforcement approach
CRF
corticotropin releasing factor
CSAP
Center for Substance Abuse Prevention
CSAT
Center for Substance Abuse Treatment
DARP
Drug Abuse Reporting Project
DEA
Drug Enforcement Administration
delta-9-THC
delta-9-tetrahydrocannabinol
DHHS
Department of Health and Human Services
DMT
dimethyltryptamine
DNA
deoxyribonucleic acid
DoD
Department of Defense
DOM
dimethoxymethylamphetamine
DOT
Department of Transportation
DSM-III-R
Diagnostic and Statistical Manual of Mental Disorders—Third Edition Revised
DSM-IV
Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition
DWI
driving while intoxicated
F30
Individual Predoctoral National Research Service Award for M.D./Ph.D. Fellowships
F31
Individual Predoctoral National Research Service Award for Fellows
F32
Individual Postdoctoral National Research Service Award for Fellows
FAS
fetal alcohol syndrome
FDA
Food and Drug Administration
FHN
familial high-alcohol nonpreferring
FHP
familial high-alcohol preferring
FUN
Faculty for Undergraduate Neuroscience
GABA
gamma-aminobutyric acid
GAO
General Accounting Office
HCFA
Health Care Financing Administration
HCl
hydrochloride
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HDL
high-density lipoprotein
HIV
human immunodeficiency virus
HRSA
Health Research and Services Administration
ICD
International Classification of Disease
IOM
Institute of Medicine
IRB
institutional review board
IRG
initial review group
K01
Mentored Research Scientist Development Award
K02
Independent Scientist Award
K05
Senior Scientist Award
K07
Academic Career Award
K08
Mentored Clinical Scientist Development Award
kcal
kilocalories
LAAM
levo-alpha-acetylmethadol or levomethadyl acetate, trade name: Orlaam®
LCME
Liaison Committee on Medical Education
LRP
Loan Repayment Program
LSD
lysergic acid diethylamide
LTA
latent transition analysis
MATCH
Matching Alcohol Treatment to Client Heterogeneity
MDA
methylenedioxyamphetamine
MDD
Medications Development Division
MDMA
methylenedioxymethamphetamine
mg
milligram
mm
millimeter
MMWR
Morbidity and Mortality Weekly Report
MOU
memorandum of understanding
MSTP
Medical Sciences Training Program
NAc
nucleus accumbens
NAMA
National Alliance of Methadone Advocates
NAMI
National Alliance for the Mentally Ill
NARSAD
National Alliance for Research on Schizophrenia and Depression
NAS
National Academy of Sciences
NBCC
National Breast Cancer Coalition
NCHGR
National Center for Human Genome Research
NCHS
National Center for Health Statistics
NCI
National Cancer Institute
NCRR
National Center for Research Resources
NEI
National Eye Institute
NHLBI
National Heart, Lung, and Blood Institute
NIA
National Institute on Aging
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NIAAA
National Institute on Alcohol Abuse and Alcoholism
NIAID
National Institute of Allergy and Infectious Diseases
NIAMS
National Institute of Arthritis and Musculoskeletal and Skin Diseases
NICHD
National Institute of Child Health and Human Development
NIDA
National Institute on Drug Abuse
NIDCD
National Institute on Deafness and Other Communication Disorders
NIDDK
National Institute of Diabetes and Digestive and Kidney Diseases
NIDR
National Institute of Dental Research
NIEHS
National Institute of Environmental Health Sciences
NIGMS
National Institute of General Medical Sciences
NIH
National Institutes of Health
NIMH
National Institute of Mental Health
NINDS
National Institute of Neurological Disorders and Stroke
NINR
National Institute of Nursing Research
NMDA
N-methyl-D-aspartate
NRC
National Research Council
NRSA
National Research Service Awards
OER
Office of Extramural Research
ONDCP
Office of National Drug Control Policy
OTA
Office of Technology Assessment
OTC
over-the-counter
PCP
phencyclidine
PET
positron-emission tomography
PTSD
posttraumatic stress disorder
QTL
quantitative trait loci
R01
Investigator Initiated Research Project
R03
Small Grant
R21
Exploratory/Developmental Grant
R29
FIRST Award—First Independent Research Support and Transition Award
R37
MERIT Award—Method to Extend Research in Time Award
RFA
request for applications
RFP
request for proposals
RI
recombinant inbred
RWJF
Robert Wood Johnson Foundation
SAMHSA
Substance Abuse and Mental Health Services Administration
SOAR
The Society of American Recovery
SPECT
single photon emission computed tomography
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T32
National Research Service Award Institutional Research Training Grant
T35
National Research Service Award Short-Term Institutional Research Training Grant
THC
tetrahydrocannabinol
TOPS
Treatment Outcomes Prospective Study
VTA
ventral tegmental area
WHO
World Health Organization
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