Addiction to nicotine in tobacco remains the most deadly substance use disorder, resulting in more than 480,000 deaths each year from tobacco-related diseases including lung cancer. Lung cancer is the most common cause of cancer death, but it is also one of the most preventable.
Safe and effective pharmacotherapies and behavioral treatments already exist to help people quit smoking. Nicotine replacement therapies are available in several forms, including patches and over-the-counter gum that can ease nicotine craving without cancer-causing smoke. Varenicline and bupropion are prescription medications that can reduce nicotine cravings and withdrawal, and behavioral treatments like contingency management have been found to be effective at helping people quit. Combining behavioral treatments and pharmacotherapies may be most effective. And several promising new treatment approaches are also being studied and developed with NIDA funding.
For example, NIDA is working with Antidote Therapeutics, Inc. to complete preclinical studies of a human monoclonal antibody that binds to nicotine in the blood to prevent it from interacting with nicotinic receptors in the brain. Previous animal studies found that it reduced brain levels of nicotine and nicotine-induced increases in blood pressure.
Current NIDA-funded projects also include studies of noninvasive brain stimulation (transcranial magnetic stimulation, TMS) for tobacco cessation; a trial of the safety and efficacy of an infusion of the dissociative drug ketamine for tobacco use disorder; a multi-site randomized controlled trial of the psychedelic drug psilocybin for tobacco use disorder; and trials of compounds with novel mechanisms of action in the brain, including a compound that interacts with a type of glutamate receptor (mGlu2) to reduce nicotine’s reinforcing effects.
NIDA is also funding studies that could help identify individuals who would most benefit from targeted prevention interventions. They include studies of genetic factors underlying risk for nicotine addiction and other co-morbid mental health disorders, and studies to identify the role of vaping in combustible tobacco initiation. Research is also ongoing to assess how social determinants of health influence risk for smoking behaviors and nicotine addiction.
NIDA is prioritizing research addressing smoking-related health disparities and ways to promote quitting in diverse populations. These include a study of a Quitline texting program to promote smoking cessation among African Americans, a contingency management smoking-cessation intervention for pregnant women from ethnic minority groups, and TMS to promote smoking cessation in people with schizophrenia.
Smoking and its health consequences are most prevalent in American Indian/Alaskan Native (AI/AN) people, so NIDA is funding several projects focused on smoking cessation in AI/AN communities, including a family-based program that uses financial incentives to promote smoking cessation. A culturally tailored intervention called All Nations Breath of Life respects the sacredness of tobacco in AI/AN cultures as a way of discouraging recreational use, and NIDA is supporting research to adapt this intervention to being delivered via telephone.
Research is also needed to develop smoking cessation therapies for youth, since nicotine replacement therapies and bupropion are not approved for people under 18 and varenicline has not been approved for people under 16. The National Cancer Institute and NIDA have issued a funding opportunity announcement for initial studies that could lead to the design and development of behavioral smoking interventions for adolescents between 14 and 20 years old.
The science of whether vaping nicotine in e-cigarettes is effective in helping people quit smoking cigarettes is still evolving. A recent Cochrane review of 78 studies (with over 22,000 participants) found these devices to be more effective than nicotine replacement therapies in promoting quitting. A previous meta-analysis of real-world observational studies concluded that the use of e-cigarettes was not associated with smoking cessation, but results may have been affected by participants’ intention to quit.
The NIH, in partnership with the FDA Center for Tobacco Products, is currently funding several projects studying whether e-cigarettes are effective as potential harm reduction tools. NIDA is supporting studies to understand the effects on the body of exposure to e-cigarette vapor, including its effects on the lungs compared to standard cigarettes, and studies to measure other health indicators associated with switching from cigarettes to e-cigarettes, among other topics.
In the United States, smoking continues to decline in most groups. In 2021, just 12% of people were current smokers, down from 21% in 2005. But with one in five deaths each year attributable to smoking, we still have a long way to go. One of the aims of the Cancer Moonshot, launched by Joe Biden in 2016 when he was Vice President, is reducing the burden of preventable cancers, including those caused by tobacco. When the President and First Lady reignited the Cancer Moonshot in February 2022, they announced the bold goal to cut the cancer death rate in half within 25 years. As part of the 2023 State of the Union, the Biden-Harris Administration committed to expand smoking cessation services for Americans who want to access them. Developing new tools for smoking cessation and expanding access to and utilization of evidence-based interventions for nicotine addiction are central to this goal including that access to them is equitable.
Yesterday, the White House convened a Forum on Smoking Cessation, consisting of a diverse group of leaders from government, advocacy groups, and medicine who are well positioned to expand access to evidence-based smoking cessation interventions for all groups who could benefit from them. Participants discussed new initiatives and new ways to collaborate to help meet the President’s goal to eventually make cancer as we know it a thing of the past.
NIDA research will continue to be an important part of this objective, including by identifying ways to advance the reach of existing treatments for smoking cessation and developing new approaches to help people end or reduce their use of tobacco products.
This blog was also published on HIV.gov.
Nearly 42 years ago, the Centers for Disease Control and Prevention (CDC) reported a rare pneumonia in five gay men, marking the recognized start of the HIV/AIDS epidemic. While we often hear about those men’s sexuality, we hear less often about their substance use. As the 1981 report notes, one of those five men injected drugs, and all five used drugs.
The history of HIV has long been entwined with substance use. In the United States today, more than 30,000 people acquire HIV every year while the drug overdose crisis cost the lives of nearly 107,000 people in 2021. Research shows people with HIV are more vulnerable to drug overdose than are those without HIV.
Because substance use plays such a significant role in HIV transmission and in health outcomes for people living with HIV, the National Institute on Drug Abuse (NIDA) is one of the largest funders of HIV research at the National Institutes of Health (NIH). We highlight the stories behind this essential research in the video series, “At the Intersection: Stories of Research, Compassion, and HIV Services for People Who Use Drugs.”
What is a syndemic?
Syndemics happen when two or more diseases interact to amplify each other—leading to an excess burden of disease and perpetuating health disparities. In a syndemic, environmental and social factors, like lack of quality healthcare, can make people more likely to be exposed to and experience worse outcomes from diseases. Having one health condition can also make people biologically or behaviorally more likely to acquire another illness. However, science shows that when we address syndemic diseases together, outcomes for both can improve—especially when we integrate a variety of medical and social services with community support programs.
Approaching HIV, substance use, and other health issues through this lens can identify new opportunities to intervene that are invisible when we look at each issue alone.
Methamphetamine use, HIV, and mental health issues
A 2020 NIDA-supported study showed that as many as one in three new HIV transmissions among sexual and gender minorities who have sex with men were in people who regularly use methamphetamine. Many participants reported using methamphetamine to enhance sexual experiences, sometimes called “partying and playing.” Other NIDA-funded research shows that individuals who use methamphetamine are more likely to have sex without HIV prevention; to have mental health issues like depression, anxiety, or bipolar disorder; and are more likely to have detectable HIV viral loads and less likely to take HIV treatment and prevention medication. Fortunately, approaches that emphasize compassion and flexibility over judgement show promise in helping people who use meth achieve their health goals, take medication, and reduce their drug use or stay safer when they are using.
Substance use, HIV, and syringe sharing
Since 2014, there have been at least nine HIV outbreaks associated with the sharing and reusing of syringes in communities of people who inject drugs. CDC- and NIDA-funded researchers have identified factors associated with such outbreaks, including higher rates of hepatitis C and drug overdose, poverty, and lower levels of education. Fortunately, decades of research show that syringe services programs are safe, effective ways to reduce syringe sharing—and with it, the risk of acquiring HIV. Today, many syringe services programs also offer the overdose antidote naloxone and medications for opioid use disorder (MOUD), as well as HIV testing, prevention tools and treatment.
Substance use, HIV, and stigma, criminalization, and violence
People with HIV and substance use disorder (SUD) struggle to access quality, evidence-based healthcare. Racism, homophobia, transphobia, and HIV- and SUD-related stigma in healthcare are serious problems. Policies that punish drug use and criminalize HIV status can lead to time in jails and prisons, where access to HIV and SUD services may be limited. Immediately after incarceration, people are at greater risk of overdose and of leaving HIV care.
These factors—plus high rates of intimate-partner violence (especially among transgender and cisgender women living with HIV), childhood abuse, and other trauma—mean many people face intersectional factors leading to poor HIV and substance use outcomes. But NIDA-funded research shows promising ways forward, including integrated care that addresses the totality of people’s lives. For example, “one-stop” clinics—like the mobile health units in the NIDA-supported INTEGRA trial—test the impact of offering comprehensive services delivered by trained peer navigators who can connect with participants’ diverse experiences.
Meeting people where they are to provide harm reduction and healthcare without stigma and treating the totality of people’s lives offers hope. And that hope is essential to ending the HIV epidemic.
This article originally appeared in the American Psychological Association’s Society for Psychopharmacology and Substance Use Division 28 Newsletter
A few years ago, I visited a methadone clinic in Baltimore and sat with several of the patients discussing the challenges they faced sticking with their treatment for opioid addiction. Every one of the individuals around the table told me the same thing: The biggest challenge was not having a place to sleep. Without housing, so much of their time was consumed arriving early enough to a shelter so that they could get a room, or other logistical challenges related to their basic life necessities—obtaining meals was another challenge—that they frequently could not make it to the methadone clinic on a given day.
Talking to these patients demonstrated to me that treatment isn’t just about the delivery of a medication or some other intervention that works in ideal laboratory conditions. It is also about the social and economic factors that shape people’s real lives, day to day. Across many institutes of the NIH, research is increasingly focusing on social determinants of health: factors like work and housing instability, food insecurity, racism, class discrimination, immigration status, and stigma and their integral role in shaping risks and treatment outcomes for many health conditions. Understanding and finding ways to intervene in such factors are now also central priorities for my institute, the National Institute on Drug Abuse.
The NIDA and NIAAA -led nationwide longitudinal Adolescent Brain Cognitive Development study is already yielding striking new science on some of the neurodevelopmental mechanisms by which various forms of social adversity influence many aspects of mental health. Mitigating the adverse effects of environmental risk factors like social-economic disadvantage has long been a target of NIDA-funded substance use prevention research, and with projects like the HEALing Communities study, we are now bringing a similar mindset to addiction care and recovery. For instance, data is being gathered on how providing transportation to patients receiving medication for opioid use disorder increases retention in treatment.
Measuring social determinants of health can help researchers better design treatment interventions and services, as well as make addiction care more equitable. Research in other areas of medicine has already revealed the distorting effects of failure to take that step. For instance, a 2019 reanalysis of the data from a huge international clinical trial of hypertension medications found significant disparities in blood-pressure control, all-cause mortality, and various heart-related outcomes depending on whether participants had received their care in low-income versus high-income neighborhoods—differences not accounted for by the medications participants received or by their clinical characteristics, and ignored in the original analysis.
In clinical trials of new medications to treat addiction, it is crucial that we take into account social determinants that influence participants’ access to quality healthcare. Besides enhancing clinical science, measuring such factors could also help personalize our approach to addiction treatment, for instance by helping determine which patients in opioid addiction treatment might benefit from counseling or other services in addition to medications.
No aspect of health exists in a bubble, and this is especially true of substance use and addiction. Researchers keep in mind the diversity of people affected and how their different social contexts and circumstances affect their prospects, especially when those factors can be modified to make treatment more successful and recovery more likely.
This article originally appeared in the Milken Institute’s Power of Ideas series.
Our country remains in the grips of an opioid crisis claiming more than 100,000 lives every year. Rising mortality associated with drug addiction and excessive drinking is among the major factors contributing to declining life expectancy. And sadly, the treatments that exist—including medications, in the case of opioid- and alcohol-use disorders—help only a fraction of those who could benefit from them.
The need for new treatments is real and urgent. One aspect of hope amid the tragedy is that the crisis has spurred unprecedented resources and human ingenuity toward finding novel scientific solutions that may one day make addiction a thing of the past.
In the field of substance use and addiction, we have been careful to talk about the management of substance use disorders and the often-difficult road to recovery. Still, we seldom talk about curing these disorders. But recent discoveries and innovations are pointing to astonishing new possibilities for directly intervening in brain circuitry involved in addiction that, if realized, might amount to something like a cure.
Hereʼs an example. A year ago, a multinational team published a landmark analysis of people who smoked cigarettes and experienced damage to various parts of their brain as a result of strokes. Individuals with lesions in areas that had in common a specific pattern of connectivity to a region called the insula stopped smoking altogether after their stroke. This study helped delineate key nodes in the brain that were associated with remission from nicotine addiction. These nodes were also associated with reduced risk of alcohol addiction.
Technologies known as neuromodulation now enable us to alter activity in these and other brain areas without harming them. Transcranial magnetic stimulation (TMS), in which magnetic fields are applied to the scalp to affect activity in the cortex, is already FDA-approved for the treatment of major depression and migraine pain, and the FDA has cleared TMS devices for obsessive-compulsive disorder and smoking cessation.
TMS cannot reach some of the limbic areas (like the nucleus accumbens) that are implicated in addictive disorders, but another method called deep brain stimulation (DBS), which uses electrodes placed in more remote brain areas to deliver electrical current, can. Clinical trials are now ongoing or recruiting that apply DBS to the nucleus accumbens to treat addiction to opioids, alcohol, or methamphetamine.
Closed-loop brain-machine interfaces have been used successfully with DBS to treat movement disorders like Parkinson’s. Activity in movement-involved brain regions is recorded by an electrode, and a critical signal triggers an electric current to reduce tremors. A recent preclinical study used a similar responsive intervention in rats to control pain, and a model for using such an approach in addiction was provided in a recent small pilot study using deep brain stimulation in the treatment of two people with binge-eating disorders. Brain activity associated with food craving triggered the delivery of electrical current into the nucleus accumbens and quelled their cravings. Over six months, the participants experienced improved self-control over their eating, and they lost weight.
What if brain regions that control drug cravings could be targeted in real time, right when an individual recovering from an addiction was experiencing triggers and was in danger of relapsing? Better yet, what if we could do it without the need of planting electrodes?
One of the most exciting recent advances in neuromodulation is a method that uses low-intensity focused ultrasound instead of magnetic fields or electric current. Unlike those approaches, ultrasound can target areas deep inside the brain but is totally noninvasive. Focused ultrasound is already FDA approved in treating tremors associated with Parkinson’s, and trials are being conducted using low-intensity ultrasound to treat people with opioid-use disorder.
Closed-loop brain-machine interfaces utilizing ultrasound could potentially open up a whole new terrain of addiction management, one that could perhaps even involve wearable devices to deliver needed intervention in real time.
Could such an approach offer a potential cure for substance use disorders? Maybe, one day. And it is only one of many exciting avenues of research being pursued to address the current crisis. These novel technologies provide great hope for the millions of people who struggle with addiction in America and worldwide.
The addiction and overdose crisis in the U.S. continues unabated, with more than 46 million people having a substance use disorder (SUD) in 2021 and more than 100,000 people dying from drug overdose annually. And the crisis is increasingly hitting adolescents. Fentanyl, the main driver of overdose deaths, is now contaminating other illicit drugs including methamphetamine, cocaine, and counterfeit prescription pills, which may be taken by people, including young people, who have no prior exposure to opioids. Adolescent overdose deaths more than doubled from 2019 to 2021 (and deaths from fentanyl nearly tripled) after having held steady at relatively low levels for years.
The urgency of this public health crisis and the escalating danger of the illicit drug supply point to a need for a greatly expanded focus on prevention. Thanks to decades of research, we understand the environmental factors in childhood and adolescence that raise the risk for later substance use as well as the modifiable factors that can help protect against that risk and promote resilience. Effective interventions built on this knowledge range from nurse home visitation of disadvantaged first-time parents and pregnant women to various kinds of family- and school-based programs to build emotional regulation and self-control skills in preadolescents, teens, and young adults.
Many of these interventions have proven very effective in randomized trials—reducing later drug use, even in some cases by the children of the children who received the intervention. In fact, prevention interventions in childhood address risk factors for various psychiatric problems, not just SUD. Some interventions have been shown capable of mitigating the impacts of adverse social environments like poverty on brain development. Moreover, studies have shown that some evidence-supported prevention programs are extraordinarily cost-effective, an outstanding investment for communities over the long term.
The problem is, prevention interventions don’t get used enough. Important reasons include lack of will, as well as fiscal shortsightedness, since the benefits from prevention interventions are delayed from the time of implementation. But another major impediment is a lack of dedicated infrastructure and workforce for prevention. For example, school systems that wish to implement prevention programs turn to teachers who likely have not had any prior training in substance use prevention, and already have numerous competing needs. This is further exacerbated by other educational curriculum requirements taking precedence in time allocation over prevention.
And unlike substance use treatment, which may be covered by private insurance or Medicaid, there is little in the way of dedicated funding for prevention. A prevention program may need to be paid for by cobbling together funds redirected from other priorities. It severely limits the reach of potentially effective interventions and means they are unlikely to be sustained over time if they are ever taken up in the first place.
Policy changes that would place increased priority on preventing substance use and its consequences and increase public funding for it could help increase the reach of prevention and help mitigate drug crises like the one our country is currently experiencing. But as my NIDA colleagues Drs. Amy Goldstein, Barbara Oudekerk, and Carlos Blanco highlight this month in Psychiatric Services, prevention researchers can also do more to ensure that interventions they design can find a home in the various systems that could implement or pay for them. That means developing and testing interventions in the settings where they are intended to be delivered and designing prevention programs that meet criteria that would qualify them for funding under the Patient Protection and Affordable Care Act (ACA), child welfare, or federal prevention dollars administered by the Substance Abuse and Mental Health Services Administration.
For instance, the ACA requires that preventive services be completely covered by insurance as long as they meet certain standards of evidence set by the U.S. Preventive Services Task Force (USPSTF), but those standards are currently only met by a small handful of prevention interventions. The USPSTF identifies gap areas in the evidence, so NIDA’s prevention research is now funding research that could generate the evidence needed to redress those gaps.
Greater collaboration between prevention researchers and those in a position to fund prevention programs could facilitate developing interventions that have greater promise of being paid for and sustained and that are more responsive to community needs. It could also spur innovation and even the development of new interventions in less traditional settings like justice systems and new strategies that take advantages of virtual tools and wireless devices.
As a society, we must do much more to foster mental health and resilience in young people as well as screen patients at all ages for potential or emerging drug problems before addiction becomes their reality, and before drug experimentation escalates, creating havoc in a person’s life or even claiming it. Prevention, if properly implemented in universal and tailored settings, could play a much larger role in reducing the numbers of Americans with drug addiction and stemming the tide of overdoses. For that to happen, the science of prevention should tackle strategies that address the challenges of paying for and delivering prevention services in a world with competing public health priorities.
This blog was also published in STAT on February 8, 2023.
Though it may be hard for many to fathom, even pregnant people and new parents can have active substance use disorders. They need support, not criminalization.
The addiction and overdose crisis, which now claims more than 100,000 lives a year, shows little sign of abating, and emerging data highlight its startling impact on pregnant people: Overdose is now a leading cause of death during or shortly after pregnancy.
Columbia University researchers recently reported that drug overdose deaths among pregnant and postpartum people increased by 81% between 2017 and 2020. In September 2022, the Centers for Disease Control and Prevention released data showing that deaths related to mental health conditions, including substance use disorders (SUDs), account for 23% of deaths during pregnancy or in the year following it. This outstrips excessive bleeding, cardiovascular conditions, or other well-known complications of pregnancy.
These stunning data highlight just how important it is to ensure access to substance use disorder treatment for pregnant and postpartum people, including the need to eliminate barriers that interfere with this treatment.
In the United States, quality addiction treatment is notoriously hard to come by, especially in rural areas and especially for people from some racial and ethnic groups. Even for those with health insurance, addiction treatment is not covered equitably, so getting care may be expensive. And fewer than half of addiction treatment programs prescribe effective medications like buprenorphine for opioid use disorder.
People seeking treatment for addictions face additional obstacles, especially if they have children. Only a small minority of treatment facilities provide child care, creating yet another obstacle on top of securing transportation, housing, food, and other necessities, all of which can be more difficult for people who are also supporting children.
The barriers get even higher for pregnant people. In one recent study using a “secret shopper” approach, callers to addiction treatment providers in 10 states were 17% less likely to receive an appointment if they said they were pregnant. Pregnant Black and Hispanic people experience even greater challenges accessing addiction treatment, including being less likely to receive medication for opioid use disorder, a proven and cost-effective treatment.
Fear of criminal punishment deters many pregnant people from seeking help for drug or alcohol problems. Many U.S. states have punitive policies in place related to substance use in pregnancy, which may include regarding it as potential child abuse, or grounds for commitment or being charged with a criminal act. Penalties for substance use in pregnancy can include fines, loss of custody, involuntary commitment, or incarceration.
Between 2011 and 2017, the number of infants placed in foster care grew by 10,000 each year; at least half of those placements were associated with parental substance use. Children in states with punitive policies are less likely to be reunited with their parents than those in other states. Moreover, there are considerable inequalities within the child welfare system. Pregnant Black people are more likely to be referred to child welfare and less likely to be reunited with their infants than pregnant white people, and Black and American Indian/Alaska Native children are overrepresented in this system.
It’s no surprise that punitive policies cause pregnant people to fear disclosing their substance use to their health care providers or to avoid seeking treatment for a substance use disorder. These policies may also cause them to avoid or delay getting obstetric care.
Decades of research show that addiction is a chronic but treatable condition that drives people to use substances even if it harms their health, careers, and relationships. Punitive policies are not effective at addressing substance use disorder and, if anything, only exacerbate its societal risk factors, including worsening of racial health disparities. Punitive approaches also lead to more negative outcomes for parents and their children.
In states more likely to criminalize pregnant people with opioid use disorder, fewer receive medications for it. A 2022 analysis found that women living in states with punitive policies for substance use in pregnancy had a lower likelihood of receiving timely or quality care, both before and after pregnancy. In states with such policies, or which require doctors to report their patients’ substance use, prenatal care tends to be sought later in pregnancy. States with punitive policies toward pregnant people with substance use disorders have higher rates of infants born with neonatal abstinence syndrome.
In addition to increasing a mother’s risk of overdose, untreated opioid use disorder during pregnancy can cause fetal growth restriction, placental abruption (separation of the placenta from the uterus), preterm labor, and other problems, and sometimes even the death of the fetus. Treatment with methadone or buprenorphine reduces the rates of preterm delivery, low birth weight, and placental abruption. Treatment also helps people with substance use disorders stay employed, take care of their children, and engage with their families and communities.
Like other medical conditions, substance use disorders require effective treatment. Science is poised to help as ongoing research develops more safe and effective interventions, as well as better implementation models tailored to the needs of those seeking substance use disorder treatment during pregnancy.
Punitive policies toward substance use reflect the entrenched attitude that addiction is a deviant choice rather than a medical disorder. A shift away from criminalization will require a shift of societal understanding of addiction as a chronic, treatable condition from which people recover, underscoring the urgency to treat and not punish it.
Having a substance use disorder during pregnancy is not itself child abuse or neglect. Pregnant people with substance use disorders should be encouraged to get the care and support they need — and be able to access it — without fear of going to jail or losing their children. Anything short of that is harmful to individuals living with these disorders and to the health of their future babies. It is also detrimental to their families and communities, and contributes to the high rates of deaths from drug overdose in our country.
Nora D. Volkow is a psychiatrist, scientist, and director of the National Institute on Drug Abuse, which is part of the National Institutes of Health.
Appearance and performance enhancing drugs (APEDs) are most often used by males to improve appearance by building muscle mass or to enhance athletic performance. Although they may directly and indirectly have effects on a user’s mood, they do not produce a euphoric high, which makes APEDs distinct from other drugs such as cocaine, heroin, and marijuana. However, users may develop a substance use disorder, defined as continued use despite adverse consequences.
Anabolic-androgenic steroids, the best-studied class of APEDs (and the main subject of this report) can boost a user’s confidence and strength, leading users to overlook the severe, long-lasting, and in some cases, irreversible damage they can cause. They can lead to early heart attacks, strokes, liver tumors, kidney failure, and psychiatric problems. In addition, stopping use can cause depression, often leading to resumption of use.
Because steroids are often injected, users who share needles or use nonsterile injecting techniques are also at risk for contracting dangerous infections such as viral hepatitis and HIV.
Steroids are popularly associated with doping by elite athletes, but since the 1980s, their use by male non-athlete weightlifters has exceeded their use by competitive athletes.1 Their use is closely associated with disordered male body image—most specifically, muscle dysmorphia.
The need to save lives and reduce negative health outcomes from drug use is unprecedented. In 2021 alone, the overdose epidemic took the lives of more than 107,000 people in the U.S., according to provisional data from the Centers for Disease Control and Prevention. These deaths were largely driven by fentanyl, sometimes contaminating or taken in conjunction with other drugs. This includes stimulants as well as opioids. There are many other health consequences of addiction, including the transmission of infectious diseases like HIV and hepatitis C.
Enabling people to access treatment for substance use disorders is critical, but first people need to survive long enough to have that choice. Other consequences of drug use, such as infectious disease transmission, must also be mitigated. The United States’ overdose crisis requires bold, evidence-based actions to save more lives, which is why NIH is announcing a $36 million, five-year investment in research to reduce the overdose epidemic and improve care access for people who use drugs through the establishment of a harm reduction research network. The network, funded by the NIH Helping to End Addiction Long-term Initiative (NIH HEAL Initiative) through the National Institute on Drug Abuse, begins this year with nine research grants and one grant to establish a coordinating center.
The projects funded by these grants will test harm reduction interventions so that we can develop evidence-based actions to help prevent overdoses and save lives. Research projects will also assess how well some existing harm reduction programs work, with concrete endpoints like overdose rates. And they will test novel harm reduction approaches meant to gather data on what works, what doesn’t, and acceptability in communities.
Harm reduction is a crucial part of our overall strategy to address the addiction and overdose crises. We know that overdose education and naloxone distribution programs and provision of naloxone to people who take drugs and to first responders saves lives. And, nearly 30 years of evidence shows that access to syringes and other injection equipment helps reduce the spread of diseases like HIV and hepatitis C. People who encounter harm reduction services during active use are often more likely to take steps toward treatment and recovery and stay in better health – saving long-term healthcare dollars and protecting the overall community’s health, too. Other harm reduction techniques such as fentanyl test strips show promise as well, but we need additional data to evaluate their effectiveness and to know more about how to best deploy new tools. The bottom line is that investing in more harm reduction research and tools is key to saving lives.
In addition to overdose prevention, harm reduction programs often have additional benefits, such as linkage to treatment with medications for opioid use disorder (MOUD) as well as other healthcare services provided onsite. Harm reduction programs can be an important way of delivering services to people who otherwise might be afraid of seeking care because of the stigma they encounter in most settings, including traditional treatment settings.
Harm reduction is an important part of reducing the impact of stigma because these services are often staffed by people in recovery or with lived experience of addiction, and thus clients are treated with dignity. This can open doors that lead to treatment, recovery, increased employment, education, and stronger family bonds, as well as reduced drug use.
Several of the studies funded by the new grants will target populations disproportionally affected by drug use and its negative impacts, including Black and Latino/Latina communities, women, and people in rural areas of the country. Multiple projects will examine the efficacy of providing harm reduction services and tools via mobile vans and other on-the-ground outreach.
This is particularly needed in rural areas, where people may need to travel great distances to receive services. Harm reduction techniques must be examined in or adapted to rural settings to see if they can work and are desirable. Overdose deaths involving psychostimulants were higher in rural counties than in urban counties from 2012 through 2020, so some grantees will specifically be investigating harm reduction for people in rural areas who use stimulants.
Projects will also study barriers to accessing harm reduction services more broadly, which can include the physical inaccessibility of services that are located far away from those who need them, and other factors like clinician attitudes that can discourage use.
Some projects are assessing implementation of the evidence-based approach of employing peer counseling and referral, which has been found to increase the ability of programs to reach the hardly reached. All projects will have a community advisory board and/or people with lived experience will have paid positions to support the research. Greater involvement of people with lived experience in all aspects of research is one of the themes of NIDA’s 2022-2026 Strategic Plan.
As is also true of recovery support services, development and implementation of harm reduction over the years has often been driven by peers and people in recovery from substance use disorders—responding nimbly, creatively, and compassionately to the needs of people who are seeking help in their communities. NIDA can help by supporting research that builds on their work, finding out which strategies work, and ways to implement these most effectively for all who need them.
NIH is committed to addressing the overdose crisis with urgency and precision. The number of deaths we are seeing requires us to expand our thinking with evidence-based, scientific action that can meaningfully save more lives. These grants will help us achieve that mission.
For more information about the new harm reduction research network, read the NIH press release. NIH is not providing funds for the purchase of pipes, syringes or needles.
On World AIDS Day, December 1, we remember those lost to the HIV epidemic, take stock of how far we have come, and map the way forward. In the past decades, scientific and community leadership have achieved great things in helping people with HIV live long, healthy lives, as well as reducing HIV transmission through prevention. Yet as the United States grapples with the dual epidemics of HIV and drug overdose, people who use drugs continue to be left behind—especially sexual and gender minorities who are disproportionately impacted by HIV.
But even with multiple forms of HIV prevention now available, including pre-exposure prophylaxis (PrEP) pills for people who are HIV-negative and antiretroviral therapy that can help people with HIV maintain an undetectable viral load and thus not transmit the virus, HIV transmission rates remain frustratingly elevated. Increased methamphetamine use over the past decade may play an overlooked role. A 2020 study in the Journal of Acquired Immune Deficiency Syndromes (JAIDS) showed that a third of new HIV transmissions among sexual and gender minorities who have sex with men were in people who regularly use methamphetamine.
Methamphetamine use is more prevalent among gay and bisexual men than among other men, and it often accompanies sex (sometimes called “partying and playing” or “chemsex”). While in previous decades the mixing of methamphetamine and sex was mainly associated with White gay men, Black and Hispanic men who have sex with men are increasingly using methamphetamine too.
The disinhibiting effects of methamphetamine can increase certain sexual behaviors that make transmission of HIV more likely. There is also evidence that methamphetamine may make the body more vulnerable to HIV acquisition and contribute to HIV disease progression. Methamphetamine use can also lead to other serious health concerns, including addiction and fatal overdose.
In a new NIDA video, “Sex, Meth and HIV,” we highlight that to end the HIV epidemic with the effective tools at our disposal requires that we first recognize and respect the complexity and needs of sexual and gender minorities who use drugs. Like other drugs, methamphetamine may help individuals cope with mental health challenges like depression, anxiety, and trauma. Some gay and bisexual men use methamphetamine to enhance sexual experience and sense of connectedness. It can also temporarily boost self-confidence among individuals who may experience stigma and shame surrounding sexuality or other aspects of their lives.
For clinicians working to educate patients about health at the intersection of HIV and drug use, understanding the role that methamphetamine plays in an individual’s life is critical to providing quality care.
As Sarit Golub, a City University of New York (CUNY) Hunter College psychologist researching HIV and stigma, says in a companion video for clinicians, “Trust, Stigma and Patient Care,” telling gay and bisexual men about risks of combining drugs and sex can come across as instilling fear and shame, and may alienate rather than empower. As Dr. Golub notes, such communication can disregard the totality of an individual’s needs—for connection, for pleasure, and for confidence in a world that judges and shames.
Even in healthcare settings, people commonly experience stigma around drug use and sexuality, as well as racism and other forms of discrimination. A history of encountering stigma and discrimination in these settings often leads people to avoid disclosing their substance use and sexual practices with their providers. Clinicians must work with patients to rebuild that lost trust by listening to patients’ concerns rather than imposing their own.
“Meeting people where they are”—that is, providing care regardless of substance use or other behaviors that confer some health risk—has become the guiding philosophy of harm reduction. But it should also apply to prevention and treatment of both HIV and substance use disorders. We cannot hope to reach communities with effective prevention measures such as PrEP without recognizing and accepting the totality of people’s experiences, wants, and needs. Listening and acceptance from others help people take control of their own health. Equally important is to ensure that access and coverage for HIV prevention and treatment are accessible to all who can benefit from them.
Research to find better ways to reach people who use drugs with HIV prevention tools like PrEP, as well as to guide policymakers and insurance providers in ensuring the coverage of these tools, is a key focus area in NIDA’s 2022-2026 Strategic Plan. Expanding education regarding drugs and HIV, reducing stigma, and overcoming other barriers to care are also crucial. Carrico and CUNY School of Public Health researcher Christian Grov (lead author of the JAIDS study) are currently conducting NIDA-funded research on strategies to increase the use of PrEP among sexual minority men who use stimulants, including use of telehealth and incentives (contingency management) to facilitate adherence.
The new videos are the latest in NIDA’s series, “At the Intersection: Stories of Research, Compassion, and HIV Services for People Who Use Drugs.”
As NIH honors World AIDS Day, we particularly remember the people lost to the dual epidemics of HIV and overdose. For those grieving loved ones, NIDA stands among you. Through scientific advancement, NIDA is committed to saving lives. Recovery and healthy, long lives are possible through the use of evidence-based treatments alongside social support.
I often talk about how substance use and substance use disorders (SUDs) change the brain, but that malleability (plasticity) is multifaceted. While drugs change the brain, lived experiences, aging, and treatment change it too.
Cessation or potentially even reduction of substance use, for example through treatment, can heal the brain and in doing so drive positive changes in emotion, cognition, and behavior that can facilitate recovery. When people enter treatment for an SUD, it should be with the knowledge and understanding that recovery is achievable.
But while treatments such as medications for opioid use disorder (MOUD) or behavioral approaches like cognitive behavioral therapy or contingency management address the biological and behavioral dimensions of an SUD, changes in the brain and behavior take time, as does resolving the radiating impacts of an SUD on an individual’s life. Those impacts may include job loss, loss of housing, fractured relationships with family and friends, and involvement in the criminal justice system. People may need ongoing support and help with these issues to maintain and sustain their recovery.
A wide range of services and supports have been developed, including recovery housing, recovery high schools (for adolescents and young adults), as well as the many community- and faith-based organizations such as mutual aid groups that have long augmented and in many cases substituted for treatment when the latter was not available or desired. These services not only provide essential social connection with peers who understand and support their recovery, they may also make it easier for people to continue with treatment or reenter treatment when needed.
Unfortunately, much less is known about recovery supports than about treatment, such as which kinds of services are most effective, how they work, and how they are best adapted to the needs of different people. Without that knowledge of efficacy, insurers and other payers may not cover these potentially useful components of the care spectrum, and people may not know which to choose.
NIDA has been supporting research on peer and community-based recovery supports, active recovery communities, and recovery modalities that integrate multiple services, such as recovery residences. But more focus is still needed on this topic, to build foundational knowledge of these services and thus better advance this part of the U.S. Department of Health and Human Services Overdose Prevention Strategy. To that end, the Helping to End Addiction Long-term® Initiative, or NIH HEAL Initiative®, with funding from NIDA, is supporting several additional research projects that will add to our knowledge of recovery residences, clinical continuing care, linkage to recovery community centers, and peer interventions to increase retention in treatment with MOUD.
Three of the new grants will develop resources to study recovery support services. One will establish a collaborative Peer Recovery Innovation Network (PRIN) that will develop resources for training and mentoring, as well as infrastructure to advance the science on facilitating continuation of care through these services after people are initiated on MOUD, as well as on such services delivered via technology, specifically for Hispanic/Latino/a people near the US-Mexico border and in other underserved areas. Another project will develop a network of researchers, recovery support specialists, and young adults (ages 18-25) in recovery, to advance our understanding of recovery support services for people in that age group who take MOUD, especially those with co-occurring mental disorders and polysubstance use. Another project will focus on developing tools and methods to better study the effectiveness of recovery residences for individuals who take MOUD.
Three grants will support trials of the effectiveness of recovery supports or the planning of such trials. One will develop an integrated intervention involving peer recovery coaching and cognitive behavioral therapy for opioid use disorder to enhance retention in MOUD treatment. Another will study the effectiveness of peer recovery support in helping people living in recovery residences remain in MOUD treatment or reengage in treatment after dropping out or after being discharged from a recovery residence. And another grant will support the planning of a multi-site trial to examine the effectiveness of recovery community centers serving Black communities to support people using MOUD.
A supplement to an existing grant will develop a coordinated infrastructure and a research agenda for the Consortium on Addiction Recovery Science (CoARS), which was initiated by five research teams previously funded by NIDA that will be expanded with funds from HEAL. This supplement provides sufficient resources to help the researchers coordinate their research and training efforts, harmonize their data and metrics, support diversity in the consortium, and ensure its sustainability, as well as organize the first national meeting on recovery support services science.
One of the themes that has emerged from the NIDA focus on recovery and recovery supports is the impressive ingenuity and proactiveness of people working in the field to develop novel solutions to address the rapidly evolving addiction and overdose crisis. Many of these researchers and other participants in these projects are themselves in recovery or have lived experience of addiction.
One of the cross-cutting themes of NIDA’s new FY 2022-2026 Strategic Plan is greater involvement of people with lived experience in research design, and the science of recovery supports is emblematic of how successful that mindset can be.
It is people on the front lines of the addiction and overdose crisis, peers finding innovative ways to help peers. NIDA’s role is to support research to determine which new approaches are most effective, and these new grants will facilitate the translation of that knowledge into interventions to help individuals with SUDs achieve recovery.