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Summary Addiction is a major public health problem. Although great strides have been made in understanding the nature of addiction and its genetic, biological, psychological, and environmental factors, addiction is not well understood by the public or by policymakers, and addition research is often an undervalued and stigmatized area of inquiry. Overcoming these problems of stigma and misunderstanding will require educating the public, health educators, policymakers, and clinicians, highlighting progress made, and recruiting talented researchers into the field. Multiple definitions and confusing terminology constitute one barrier that promotes misunderstanding about addiction and the need for research. This and other Institute of Medicine committees have defined drug addiction as a brain disease similar to other chronic, relapsing conditions, such as heart disease and diabetes, and manifested by a complex set of behaviors that are the result of genetic, biological, psychosocial, and environmental interactions.1 The term ''addiction" has tended to be applied more frequently to use of illegal drugs than to legal ones; yet, addiction may occur as a consequence of using both socially acceptable, legal drugs or illicit drugs. Four major classes of drugs (nicotine, alcohol, opioids, and stimulants) are emphasized because they have the greatest economic impact on society and cause, or contribute to, many life-threatening disorders, including heart disease, cirrhosis, AIDS, and cancer.2
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PREVALENCE, COSTS, AND RESEARCH INVESTMENTS Drug abuse has been called the nation's number one public health problem. Of the nation's personal health care expenditures, $1 of every $12 is spent on prevention, diagnosis, and treatment of people suffering from addictive diseases. The measurable total economic costs of drug addiction clearly are enormous, totaling $256.8 billion in 1990. Alcohol use, abuse, and addiction, including the direct costs of crime, motor vehicle crashes, and other related costs, comes at the highest cost, estimated at $98.6 billion. The cost of nicotine addiction follows ($91.3 billion), and then addiction to illegal drugs ($66.9 billion). NEUROBIOLOGY OF ADDICTION: AN OVERVIEW Recent discoveries have turned addiction research into a field that should attract the very best scientists interested in both basic and translational research. Researchers have cloned the brain receptors (i.e., the immediate molecular targets) for all significant drugs of abuse and have defined their locations in the brain. Of great significance, there is now general agreement on the importance of the dopaminergic brain reward pathway as one of the key common sites of action of addictive drugs. Some aspects of treatment for all drugs are beginning to capitalize on the identification of this common pathway and the systems that regulate it. Researchers can now turn to the very difficult problems of understanding the precise brain mechanisms by which drugs alter brain function and come to dominate behavior. In the process, a great deal will be learned about the normal control of motivation and emotion in the brain. With such discoveries, understandings about other human diseases and illnesses can also be gained. For example, dopamine systems are not only the substrates of drug abuse and addiction, but are also involved in a variety of psychiatric disorders and some movement disorders, such as Parkinson's disease. The importance of these findings notwithstanding, it must be emphasized that drug addiction is the result of interacting biological, behavioral, social, and environmental factors. Thus, the development of successful treatments can come only from integrative, multidisciplinary research that may provide stronger connections between research and clinical practice. PSYCHOSOCIAL FACTORS AND PREVENTION How does the use of tobacco, alcohol, opioids, and stimulants begin? Virtually all Americans, some of whom may have a genetic vulnerability to drug abuse, are faced with the decision of whether to smoke, drink alcohol, or take illicit drugs. Why do some individuals say yes and others refuse? In addition to studies about genetic vulnerabilities, these and similar questions are the focus of behavioral, epidemiological, and social science research aimed at understanding
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and preventing drug addiction. Psychosocial factors include personality, as well as family, peer, and other environmental factors that either increase the risk of an individual developing an addictive disorder (risk factors) or decrease such risks (protective factors). Research indicates that beliefs and attitudes, many of which are learned by watching or listening to role models at home, in the community, or in the media, have a strong influence on drug use and abuse. As a result, changing the environmental conditions or cues associated with drug use or withdrawal can assist an individual's efforts to abstain from drugs. By using cognitive and behavioral research regarding the psychosocial factors related to drug initiation and use, prevention interventions have been and continue to be developed. Prevention interventions can be universal, selective, or indicated as defined by a previous Institute of Medicine (IOM) committee. Universal includes interventions aimed toward an entire population, such as warning labels on tobacco products and alcoholic beverages, advertising bans, smoke-free airline flights and buildings, taxes, and the role of primary care physicians and providers in inquiring about and providing information on smoking, drinking, and use of illicit drugs. Selective interventions are those aimed toward individuals who are members of a subgroup or population that is known to be at higher risk for a given disorder, for example, aiming interventions at teenagers to prevent drug abuse and drinking. Indicated interventions are for those individuals who exhibit a known risk factor, condition, or abnormality that identifies them as being at high risk for developing a disorder. Indicated interventions include providing education about alcoholism to young people whose parents are alcoholics or monitoring drug and alcohol use in people with depression or other commonly co-occurring psychiatric disorders. All three types of interventions are employed to prevent drug abuse and the effectiveness of various approaches is the subject of ongoing research. TREATING ADDICTIVE DISORDERS One of the most enduring myths about addiction is that treatment for these disorders is ineffective. Although addiction involves a complex interplay of biological, social, and individual factors that complicates treatment, the same can be said about the treatment for diabetes, hypertension, or asthma, which are also complicated by an interplay of disease severity, the individual's motivation and ability to control diet or exercise levels, social support, and other factors. Yet, there are important differences between addiction and these other illnesses in the perception of the public, insurance companies, and physicians. Few would argue that retreatment for diabetes, hypertension, or asthma indicates treatment failure, or that retreatment should be withheld from or denied to these patients when they relapse and their symptoms reoccur. Such an argument, however, is commonly made about addiction.
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The general effectiveness of addiction treatment may be obscured by the tremendous variation in the types of services offered and in the amount of information available regarding the effectiveness of individual programs. In part, the variety reflects different approaches that have developed over time to address addiction to specific drugs (e.g., heroin vs. alcohol). In addition, not all strategies are possible to employ for specific addictions. For example, there are successful replacement pharmacotherapies available for herion and nicotine addiction (methadone and nicotine gum or patches), but not for alcohol or cocaine. Often, however, treatment approaches are based on underlying assumptions and viewpoints regarding the causes of addiction, ranging from addiction as a disease to addiction as a moral failure. It is important to keep in mind that success or failure in treatment involves both treatment factors (e.g., setting, length, intensity) and patient factors (e.g., severity of addiction, presence of other psychiatric and medical conditions, social support, education, and readiness for change). The interaction of specific treatment factors with specific patient factors, often called patient-treatment matching, is one area of great interest in research. Ongoing research in a variety of disciplines, coupled with a better base of interdisciplinary and health services and treatment outcomes research, can be expected to improve the quality and availability of treatment for addiction and, thus, reduce the attendant individual and societal costs. RECOMMENDATIONS Education and Training All secondary schools offer science courses, and many offer classes in psychology, sociology, and health education. The committee believes that strategies are needed to enhance the educational curricula in drug addiction. Students should be learning about the genetic and biological underpinnings of addiction, and how they interact with psychosocial and behavioral factors in the process of becoming addicted, overcoming addiction, and relapse. There is also a complementary need to improve the expertise of faculty so that well-qualified professionals who are capable of developing the necessary curricula are available to teach students about addicted individuals and addiction research. The committee recommends that: The U.S. Department of Education should provide incentives for schools to increase emphasis on the physiological and psychosocial aspects of drug abuse and addiction in science and health education classes at elementary, middle school, and high school levels; and Professional societies should facilitate expanding coverage of a science-based approach to understanding drug abuse and addiction at the
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university undergraduate level, especially in general psychology, sociology, and biology courses. Additional reviews should also be undertaken of related curricula in departments of social work, rehabilitation, and health education. Graduate schools offer relatively few courses in substance abuse. A survey of American Psychological Association (APA)-approved graduate programs in clinical psychology, as well as graduate programs in sociology, and pharmacy programs, revealed that students receive only minimal training in drug abuse, although some disciplines are beginning to improve their curricula in the area of addiction. It appears that there are more opportunities for training in drug abuse counseling than in research-oriented programs, and these opportunities are primarily at a less advanced educational level. This lack of attention to addiction research in the curricula at the graduate school level may discourage students who are interested in the field. The lack of instruction on drug abuse and addiction is a particular problem in medical schools. Less than one percent of curriculum time is spent on drug addiction in medical schools in the United States. The committee believes that the lack of emphasis on this important health and social issue is likely to convey to young medical professionals that this is not an important area of clinical work or research inquiry. Although opportunities in educational and training programs for addiction researchers exist, serious gaps remain. An effective medical training system must be both responsive to the differing needs of individuals at various stages of their careers and provide expertly trained professionals capable of addressing the health consequences related to addiction. The committee recommends the following: Accreditation and certifying entities [e.g., Liaison Committee on Medical Education (LCME), American Psychological Association (APA)] should review curricula in medical schools, and in psychology, social work, and nursing departments for the adequacy of drug addiction courses and should require basic competence in these areas for certification and recertification on medical specialty board examinations and in other relevant disciplines; Deans, administrators, and professional societies should undertake systematic evaluation of existing curricula to assess how they encourage or discourage training in addiction research and develop curricula tailored to different levels of schooling and specialty. Incentives should be provided to recruit and train faculty to teach courses in addiction research and to serve as role models. Mentors are needed at all stages of research training as well as for different groups of students, such as women and minorities. There is no single strategy
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that could increase and sustain the number and quality of mentors; several different efforts are needed. To enable appropriate mentoring experiences, the committee recommends that: Ph.D. programs in the behavioral and social sciences should be included among the degrees eligible for M.D./Ph.D. (MSTP) support; NIDA and NIAAA should increase the number of mentors by promoting interdisciplinary research through the establishment of funding mechanisms for mentoring teams composed of investigators from different disciplines in the Academic Centers of Excellence programs; NIDA and NIAAA should emphasize innovative mentoring programs through the K05, K07, and other K award mechanisms; and NIDA and NIAAA should consider reviving the Career Teacher Training Program. Although the focus of this report is on addiction research, the issues of treatment and research are often intertwined. Faculty who have expertise in treating addicted individuals can stimulate faculty who have expertise in conducting basic or applied research on addiction. Likewise, the availability and quality of treatment are dependent on innovative research findings. Furthermore, many graduate students, medical students, postdoctoral students, and medical residents will be exposed to the field of addiction research while being supervised in treatment settings. The committee recommends that: All treatment professionals should have some knowledge of basic neuroscience and how alcohol, nicotine, and other drugs work on brain pathways, influence behavior, and interact with diverse conditions. Treatment professionals should include physicians, nurses, clinical psychologists, social workers, drug abuse peer counselors, and other health care providers who work in conjunction with one another in treating patients with an addictive disease; Continuing education courses to update treatment professionals' knowledge base on addiction should be instituted systematically and widely; and Competence-based documentation of treatment professionals' knowledge base on addiction should be sought in licensing and recertification examinations. The committee identified several problems with the mechanisms that support careers in addiction research. These include insufficient numbers of traineeships and fellowships, insufficient research career development and sustaining awards, varying applicant success rates, and a low percentage of training support
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as a percentage of extramural funding. For example, fellowship training time is often insufficient for clinical researchers, who need to accommodate their clinical responsibilities with sufficient time for research training. Changes in this system need to be established as a government priority because there is limited support for career development from industry, universities, and private foundations. Resources Needed for Young Investigators Young investigators trained in the disciplines relevant to addiction research seek postdoctoral fellowships or salaried positions in universities, academic medical centers, or pharmaceutical companies. Those who seek academic careers usually apply for positions where the salary is at least partly secure, but their ability to conduct research is often dependent on research funding that has been obtained by a colleague (e.g., a senior researcher who is in charge of the postdoctoral training program) or funding that they must obtain by writing or assisting in the writing of a successful research grant application. The launching and sustained development of a research career is therefore dependent upon the availability of fellowship programs, research grants, and other mechanisms to support such careers. To meet the challenges for developing careers in addiction research, the committee recommends that: The number of research career development awards should be increased, greater flexibility in duration and time-to-start of awards should be provided, and the funding priority of such awards should be advanced; The use of the B/START (Behavioral Science Track Award for Rapid Transition) mechanism now at NIMH and NIDA to provide seed money for young investigators should be expanded; Programs for student-directed summer research should be established by NIDA and NIAAA; Industry and private foundations should cooperate with universities to provide supplemental funds for career development and research support of young investigators, especially during transition periods between awards, or to provide partial salary support for clinical researchers; Increases should be made in the percentage of NIDA and NIAAA extramural research funding spent on training programs to reach the NIH institute average (currently 5 percent to 6 percent), funds for which should not be redirected from the research budgets of these institutes; Jointly sponsored programs (e.g., government, industry, private foundations, academia) to support research training should be established
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with clear roles and responsibilities for the participation of each institution; and NIDA and NIAAA should explore the possibility of providing bridging support for promising young investigators to assist in the transition from K01 and R29 to R01 funding. To encourage clinical research on the problems of addiction, the committee recommends that: The federal government should establish a debt deferral or forgiveness program for scientists conducting clinical research in drug addiction or treating persons with drug abuse in publicly funded settings; and Federal funds should be made available from NIH, SAMSHA, HRSA, or AHCPR to provide training for primary care physicians (e.g., obstetricians, family physicians, and internists) to recognize, treat effectively, or refer patients with drug abuse problems. In light of the recent advances in the field and the importance of collaborative and integrative research efforts to address the problems of addiction and relapse, the committee recommends that: Funding institutions, such as the government and private foundations, should develop program funding mechanisms (e.g., Requests for Applications [RFAs], annual conferences, symposia) to foster collaborative exchanges of information and research, such as the scientific breakthroughs that occur during drug development; Universities with faculty engaged in addiction research should undertake a comprehensive review of the support and resources available for collaborative efforts within and outside the university, particularly those collaborative efforts which involve multiple disciplines; administrators should develop a plan to share resources and facilities both within and across institutions and specify criteria for access; Funding agencies, such as the government and private foundations, should focus on new integrative opportunities (e.g., drug addiction etiology and medications) through using the combined strengths of the participating institutions, including government, industry, private foundations, multidisciplinary centers, and Academic Centers of Excellence; NIH should review the composition of Initial Review Groups (IRGs) to ensure that there is appropriate representation across necessary disciplines; NIDA and NIAAA should consider establishing additional mechanisms or expanding R03 awards for individual investigator awards that support innovative, high-risk, interdisciplinary research; and
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Additional sources of resources to increase and support integrative and collaborative efforts in addiction research should be considered by Congress. For example, the percentage of the budget of the White House Office of National Drug Control Policy earmarked for research should be increased substantially as part of a coordinated strategy to make drug abuse and addiction research a national priority. Public Perceptions and Public Policy Although there have been many scientific advances in our knowledge about drug addiction, the public's perceptions and understanding lag far behind. If the goal is to increase interest in and support for careers in addiction research, it is essential to communicate the current scientific knowledge base in an effective way to the public at large. Educating the public begins in schools and is carried further through the media and other mechanisms. To help inform the public and build advocacy for destigmatizing addiction research, the committee recommends that: Public education campaigns should be based on an interdisciplinary view of addiction and emphasize treatment effectiveness, as well as include descriptions of the role of brain physiology and function (e.g., pain systems, anxiety circuits, mood systems, and behavioral and psychosocial aspects). Consumer and other advocacy groups should be encouraged to strengthen their focus on the need for research on the causes, prevention, and treatment of addictive disorders. Liaison relationships and joint activities should be explored among advocacy groups to increase public understanding of addictive disorders. Activities could include meetings of representatives of provider groups, state and local health departments, and established grassroots advocacy groups to develop cohesive, workable strategies to accomplish change. All of these efforts will contribute to the long-term goals and strategies that the committee deems essential to resolve the broad problems found in this scientific area. NOTES 1. One committee member, Dr. Satel, disagreed with this definition. She believes that, "The concept of addiction as a brain disease is somewhat limited and potentially misleading. Many workers find it more instructive to define addiction as a complex behavioral
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condition that is accompanied by organic changes in the brain but which is not inevitably sustained by them. In conventional brain disorders such as schizophrenia or Parkinson's disease, symptoms of disturbed mentation and action are the result of brain pathology. In compulsive drug use, conversely, the brain changes are a result of that behavior. These changes, it is true, likely predispose to craving and rapid re-habituation in individuals who have been drug free, thus making them vulnerable to relapse. Yet it is important to emphasize that the course of addiction can be modified by its consequences and that biological urges can be overridden. The addiction as a brain disease model tends to obscure this clinical reality." 2. The class of opioids includes heroin, codeine, morphine, and synthetic opioids, while the stimulants include cocaine, amphetamine, methamphetamine, and methylphenidate.
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