This op-ed was originally published by The Hill on September 12, 2022

Natalie struggled with a methamphetamine use disorder for more than 9 years.

She was one of the fortunate few to receive treatment to address her addiction, yet that help felt incomplete. Like many people trying to heal from substance use disorders, she eventually began taking meth again.

Eventually, Natalie was diagnosed with attention-deficit/hyperactivity disorder (ADHD), one of the most common mental disorders in youth. She started ADHD treatment in addition to treatment for her meth addiction, and it made her long-term recovery a reality.

“The addition of Adderall really changed my life,” she said. “Looking back, it makes sense that I was self-medicating ADHD that was undiagnosed. I found it very discouraging that a lot of people got their lives in order while I struggled to function with everyday tasks. In part, that is what led to my relapse.”

Recovering from drug addiction is notoriously difficult. Setbacks are common. Too often, a critical element is overlooked: co-occurring mental health conditions. Treating mental illnesses like depression, anxiety, post-traumatic stress disorder, ADHD, and others with medications or other therapies is crucial to address the addiction and overdose crisis that now claims over 100,000 lives annually.

Substance use disorders often accompany other mental illnesses. Individuals who experience a substance use disorder (SUD) during their lives may also experience another co-occurring mental disorder and vice versa.

For many people, drug and alcohol problems begin as self-medication: using substances to cope with temporary stress or to manage symptoms of chronic mental health problems they may not even know they have. Substance use, particularly alcohol, can be a socially accepted way of dealing with negative emotions.

Surveys show alcohol use rose during the COVID-19 pandemic, including increased use by stressed parents. Research has also tied problem alcohol use in college students to self-treatment of social anxiety. Similarly, people with untreated depression might discover that opioids or stimulants temporarily boost their mood and use them for that purpose.

Fragmented and hard-to-access mental health care means that these conditions and addiction often go untreated. In some communities, it is easier to get illicit drugs than adequate medical mental health care, making co-occurring addiction and other mental illness more likely.

But using substances to treat mental illness can begin a difficult cycle.  Substance use to manage mental illness can lead to addiction and can in turn worsen the original mental illness. Regularly taking drugs or alcohol causes the brain to adapt to that substance—known as dependence. Effectively, the brain dials down its own neurotransmitter systems upon which the drugs act. A person trying to relieve anxiety through substance use will feel worse anxiety most of the time, because their brain now depends on the drug for relief.

Racism and other forms of discrimination, isolation, childhood trauma, poverty and lack of access to education and healthcare can all play a role in increasing risk of developing mental illness and substance use disorders. The stigma that attaches to both substance use disorders and mental illness exacerbates these factors—making the person with mental illness and addiction even more isolated and vulnerable, and less likely to seek treatment.

The entanglement of mental illness and substance use disorders requires urgent action. Efforts to reverse the addiction and overdose crisis need to be multifaceted, taking mental illness into account. We have powerful, proven treatment tools for addiction, especially for opioid use disorder. Harm reduction strategies, when implemented, can staunch overdose deaths. But expanded screening and care for mental illnesses including depression, anxiety, PTSD, and others must be a component to successfully address the current addiction and overdose crises.

Prevention is possible if investments are made. Opportunities to reduce risk can begin early in life, since substance use disorders and other mental illnesses share common risk and protective factors. Interventions starting during the prenatal period and followed through adolescence and young adulthood can help avert a range of adverse outcomes later in life. Moreover, numerous studies of prevention’s return on investment show that communities could not only save lives but also money by investing in prevention programs.

Screening is equally important. Earlier this year, the U.S. Preventive Services Task Force recommended that primary care physicians screen all adult and adolescent patients for depression, given its low cost and potential for benefit. Screening for mental health conditions needs to become part of standard practice along with screening for substance use and substance use disorders to personalize interventions to treat patients’ unique needs and increase the likelihood of recovery.

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This week, NIDA released our strategic plan for FY 2022-2026. Strategic planning is a process all NIH Institutes perform every five years, to take stock of the current state of research and set priorities that are ambitious but achievable to advance an Institute’s particular mission. 

Drug addiction and overdose deaths are among the most pressing health crises of our times. NIDA’s new plan reflects our commitment to advancing all aspects of addiction science in the service of improving public health. It corrals the breadth of research we support—from basic neuroscience and pharmacology to epidemiology and prevention to therapeutics development and implementation, to research on the delivery of addiction treatment and other services—while remaining flexible and responsive to scientific innovations as well as to the rapidly shifting drug use and addiction landscape. Our plan for the next five years also prioritizes research that is informed by people with lived experience of addiction in themselves or their families, to best meet the needs of those most directly impacted by our science.   

NIDA’s 2022-2026 Strategic Plan has five priority scientific areas:

1. Understand Drugs, the Brain, and Behavior
2. Develop and Test Novel Prevention, Treatment, Harm Reduction, and Recovery Support Strategies
3. Accelerate Research on the Intersection of Substance Use, HIV, and Related Comorbidities
4. Improve the Implementation of Evidence-Based Strategies in Real-World Settings
5. Translate Research into Innovative Health Applications

Within each Priority Scientific Area, goals reflect targeted areas of emphasis to speed progress toward achieving our mission, as well as key focus areas that reflect specific research opportunities and other initiatives NIDA will undertake. Additionally, the plan describes seven cross-cutting themes that apply across the five priority areas:

The new strategic plan, which was developed with input from NIDA’s advisory council and the public, helps ensure that NIDA will continue to advance all domains of addiction science and disseminate new knowledge in ways that are measurable and that will have the greatest impact on people’s lives. The rapidly shifting drug landscape and the devastation of the drug overdose epidemic have enhanced public interest and drawn greater investment in our science, and it is our responsibility to help direct that investment in the most effective, equitable, and wise manner to prevent and treat drug addiction and its consequences. 

NIDA’s FY 2022-2026 Strategic Plan is a living document and a vital roadmap for our Institute and our field, and I thank all the NIDA staff and leadership who contributed to crafting it.

Read the 2022-2026 NIDA Strategic Plan, or read the Executive Summary. 

“…but more research is needed.” That’s often the refrain in science, and it includes addiction research. As the addiction and overdose crises continue to claim an unprecedented number of lives and fray communities, science is an essential part of the solution.

In the science-to-medicine pipeline, there is a point when a body of evidence is so well-established that to not put the science into action would be an abdication of responsibility. When it comes to the current crisis, there are at least five things that science has shown conclusively to be effective, where communities and healthcare providers can apply what we already know works.

We don’t need to keep asking if these things work. Instead, we must find ways to help providers, people, and communities overcome the barriers to implementing these valuable interventions.

1. Naloxone saves lives.

Opioids now claim 188 lives in the U.S. every day. Among their other effects, they attach to cells in the brainstem that control respiration, slowing down breathing to sometimes deadly levels. This is an overdose. Naloxone is a medication that can quickly reverse an opioid overdose by kicking opioid agonist drugs like fentanyl off opioid receptors and blocking them, which quickly restores breathing. It must be used promptly, and it requires another person to be nearby to administer it.

All over the country, putting naloxone in the hands of first responders has saved countless lives. And because it is such a safe drug, it can be put directly in the hands of people who use opioids, their loved ones and friends, and anybody else who may find themselves in a position to save the life of someone overdosing on an opioid.

Yet despite the safety and lifesaving value of this drug, there are impediments to widespread use. Naloxone is not available over the counter, which could ease access. Doctors don’t always prescribe it to patients who need it, pharmacies don’t always stock it, the price may be prohibitive when they do stock it. While many states now have standing orders allowing anyone to get it from the pharmacist without a prescription, people often do not know that. People who offer harm reduction in communities are also affected by costs and product shortages.

NIDA is supporting research to overcome regulatory and attitudinal barriers to wider use of naloxone and educating about its use. Opioid overdose education and distribution (OEND) programs have been implemented in some areas, with dazzling effectiveness at saving lives. Despite concerns of critics, having a naloxone kit has not been shown to increase a person’s opioid use. New methods of reversing overdoses with novel molecules and delivery techniques are also in the research pipeline.

2. Medications for opioid use disorder can work.

Decades of research has shown beyond doubt the overwhelming benefit of medication for opioid use disorder (or MOUD). The full opioid agonist methadone (in use for half a century) and the partial agonist buprenorphine (first approved two decades ago) have proven to be life-savers, keeping patients from illicitly using opioids, enabling them to live healthy and successful lives, and facilitating recovery. Naltrexone, an antagonist that prevents opioids from having an effect, is also effective for patients who do not want to use agonist medications and are able to undergo initial detoxification under medical supervision.

The efficacy of MOUD has been supported in clinical trial after clinical trial, and MOUD is now considered the standard of care in treatment of opioid use disorder, whether or not it is accompanied by some form of behavioral therapy. Yet even now, only half of addiction treatment facilities offer any FDA-approved medications, and only a tiny fraction offer all three. And while recovery supports like 12-step groups can be a useful adjunct to treatment, many continue to discourage participants from taking medication—a legacy of decades of misconception that medication substitutes one addiction for another.

Science is no longer needed to show that these medications are effective. Where we are directing efforts and dollars is toward research aimed at overcoming attitudinal barriers and, again, increasing the implementation of these effective treatments. Research is also needed for strategies to improve retention in MOUD treatment, since discontinuation of medication is high. Also, because the available medications are not right for everybody, we support research to determine which of these medications work best for whom and to develop additional treatments for opioid use disorder and other drug use disorders, including addiction to stimulants and addiction to multiple drugs (polysubstance use disorders).

3. Contingency management is an effective treatment for stimulant use disorders.

We don’t have an FDA-approved medication to treat stimulant use disorders. Although opioids, especially fentanyl, still cause the majority of overdose deaths, stimulants like methamphetamine and cocaine are increasingly showing up as contributors to overdose, in many cases in combination with opioids. Even without an FDA-approved drug to treat stimulant use disorders, there is an effective behavioral treatment available: Contingency management. But regulatory barriers—and unclarity about the regulations—have thus far limited its reach.

Addiction is a disorder that profoundly affects motivation: Through repeated use, seeking the drug prevails over other goals (social connection, career, school) in part by reorienting the brain’s reward system. Even when people want to quit, they have a hard time finding the motivation to pursue a life free of the drug, since they don’t have alternative reinforcing stimuli to motivate them. Contingency management provides such reinforcement, encouraging positive behavior change with small prizes—usually, the opportunity to win a small gift card, movie pass, or similar small monetary gift—for negative drug tests, adhering to medications regimens, and other healthy behaviors.

It sounds strange that small rewards would help keep people experiencing addiction from using drugs, but when they want to quit, these token prizes can boost their incentive enough that they can do it and experience the growing benefits of a life without drugs. Contingency management has been shown in trial after trial to be especially effective for people with addiction to stimulants (including people with both stimulant and opioid use disorders), outperforming other behavioral approaches.

However, too-stringent interpretation of regulations put in place to prevent medical fraud (coercive inducements or kickbacks) have limited the dollar value of rewards to trivial amounts that often are not very effective. And providers unsure about the legality of contingency management often do not provide it at all.

We don’t need more science to show the effectiveness of contingency management. We need more treatment centers to implement it. For this to happen, there needs to be greater clarity from regulators that it is a legitimate medical treatment, not an inducement with potential legal penalties. And raising the dollar caps will greatly enhance the treatment’s effectiveness. 

4. Syringe services programs (SSPs) greatly mitigate harms of opioid use.

Syringe services programs or SSPs are another harm-reduction approach backed by massive scientific research showing their effectiveness at reducing the transmission of infectious diseases like HIV and hepatitis C among people who inject opioids and other drugs.

SSPs also have a range of additional benefits, including linking clients to SUD treatment and other needed healthcare that they may be reluctant seeking elsewhere. Staff at SSPs, who are often in recovery themselves, treat clients with dignity, a positive experience of healthcare engagement when they may experience stigma from most others.

Critics have worried that dispensing sterile injection equipment implicitly sanctions or encourages drug use, and it has led to their limited utilization. But studies show SSPs do not increase drug use or negatively impact surrounding neighborhoods. They are a win for communities and a good investment. History has shown that disease outbreaks can result when communities fail to implement SSPs. For instance, a 2018 modeling study suggested that an earlier public health response including timely implementation of an SSP might have blunted or prevented the 2014-2015 HIV outbreak in Scott County, Indiana.

SSPs are among the most-studied of harm-reduction techniques, and now we need to write the next chapter: build the evidence base to see what other harm-reduction approaches could help in the current crisis and how they can be adapted to diverse communities.

5. Prevention interventions can have broad and lasting impact.

With the current addiction and overdose crisis, our country has been playing catch-up, ramping up treatment and harm-reduction services to staunch the tide of deaths and devastated lives. What is also needed is prevention, and this is another area where research shows us the way to go.

Decades of research on periods of developmental vulnerability and the kinds of social-environmental factors that raise the risk of early drug experimentation and addiction have led to the development of numerous evidence-based prevention interventions that mitigate the risk factors as well as strengthen protective factors. These interventions, ranging from nurse-home visitation of low-income first-time parents (such as Nurse-Family Partnership) to family-based pre-teen/teen programs (Strengthening Families Program: For Parents and Youth 10-14) or school-based interventions to strengthen self-control skills (such as Life Skills Training) show multiple benefits including, in some cases, reduced or delayed drug experimentation in adolescence and young adulthood.

Some of these interventions show benefits in reduced drug use decades out—even across generations. Children of parents who received an elementary-school intervention called Raising Healthy Children showed improved outcomes too. And since many of the risk factors for substance use are shared with other mental illnesses, prevention interventions reap a wide range of mental-health benefits. Best of all, benefit-cost analyses show prevention to be an extremely good investment for communities, averting many direct and indirect costs of substance use and other related problems.

Yet such interventions are seldom adopted. Short-term thinking, unwillingness to invest in long-term solutions, plays some role. But there are real challenges in scaling up interventions that work in small trials and effectively implementing them in the real world, adapting them to the specific characteristics and needs of unique communities. It’s an area where NIDA is investing in research to find ways to bring effective evidence-based prevention interventions to scale.

A year ago in this blog, I called for radical change to solve the opioid crisis. It remains true. But radical measures are really not that radical: If we are guided by science, they are actually conservative and commonsensical, undoubted wins in any kind of benefit-cost calculus. We just need the collective will to put the science into action, and research to find ways to do it most effectively in the real world.

Video: What Radical Change Means

IN AN EMERGENCY:

• Are you or someone you know experiencing severe symptoms or in immediate danger? Please seek immediate medical attention by calling 9-1-1 or visiting an Emergency Department. Poison control can be reached at 1-800-222-1222 or www.poison.org.
• Are you or someone you know in crisis? Please call the Substance Abuse and Mental Health Administration (SAMHSA) National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or visit suicidepreventionlifeline.org/chat. The call or web chat is free and confidential. Trained crisis workers are available 24/7 to help you.

FIND TREATMENT:

• For referrals to substance use and mental health treatment programs, call the SAMHSA National Helpline at 1-800-662-HELP (4357) or visit www.FindTreatment.gov to find a qualified healthcare provider in your area.
• For other personal medical advice, please speak to a qualified health professional. Learn more about finding a doctor or medical facility at www.usa.gov/doctors.

DISCLAIMER:

The emergency and referral resources listed above are available to individuals located in the United States and are not operated by the National Institute on Drug Abuse (NIDA). NIDA is a biomedical research organization and does not provide personalized medical advice, treatment, counselling, or legal consultation. Information provided by NIDA is not a substitute for professional medical care or legal consultation.

This blog was also published on the NIH Director's Blog on July 11, 2022.

During the COVID-19 pandemic, we have seen unprecedented, rapid scientific collaboration, as experts around the world in discrete, previously disconnected fields, have found ways to collaborate to face a common cause. For example, physicists helped respiratory specialists understand how virus particles could spread in air, leading to improved mitigation strategies. Specialists in cardiovascular science, neuroscience, immunology, and other fields are now working together to understand and address Long COVID. Over the past two years, we have also seen remarkable international sharing of epidemiological data and information on effects of vaccines.

Science is increasingly a team activity, which is true for many fields, not just biomedicine. The professional diversity of research teams reflects the increased complexity of the questions science is called upon to answer. This is especially obvious in the study of the brain, which is the most complex system known to us.

The NIH’s Brain Research Through Advancing Innovative Neurotechnologies® (BRAIN) Initiative, with the goal of vastly enhancing neuroscience through new technologies, includes research teams with neuroscientists, engineers, mathematicians, physicists, data scientists, ethicists, and more. Nearly half (47 percent) of grant awards have multiple principal investigators.

Besides the BRAIN Initiative, other multi-institute NIH research projects are applying team science to complex research questions, such as those related to neurodevelopment, addiction, and pain. The Helping to End Addiction Long-term® Initiative, or NIH HEAL Initiative®, created a team-based research framework to advance promising pain therapeutics quickly to clinical testing.

In the Adolescent Brain Cognitive Development (ABCD ) study, which is led by NIDA in close partnership with NIH’s National Institute on Alcohol Abuse and Alcoholism (NIAAA), and other NIH institutes, 21 research centers are collecting behavioral, biospecimen, and neuroimaging data from 11,878 children from age 10 through their teens. Teams led by experts in adolescent psychiatry, developmental psychology, and pediatrics interview participants and their families. These experts then gather a battery of health metrics from psychological, cognitive, sociocultural, and physical assessments, including collection and analysis of various kinds of biospecimens (blood, saliva). Further, experts in biophysics gather information on the structure and function of participants’ brains every two years.

A similar study of young children in the first decade of life beginning with the prenatal period, the HEALthy Brain and Child Development (HBCD) study, supported by HEAL, NIDA, and several other NIH institutes and centers, is now underway at 25 research sites across the country. A range of scientific specialists, similar to that in the ABCD study, is involved in this effort. In this case, they are aided by experts in obstetric care and in infant neuroimaging.

For both of these studies, teams of data scientists validate and curate all the information generated and make it available to researchers across the world. This makes it possible to investigate complex questions such as human neurodevelopmental diversity and the effects of genes and social experiences and their relation to mental health. More than half of the publications using ABCD data have been authored by non-ABCD investigators taking advantage of the open-access format.

Yet, institutions that conduct and fund science—including NIH—have been slow to support and reward collaboration. Because authorship and funding are so important in tenure and promotion decisions at universities, for example, an individual’s contribution to larger, multi-investigator projects on which they may not be the grantee or lead author on a study publication may carry less weight.

For this reason, early-career scientists may be particularly reluctant to collaborate on team projects. Among the recommendations of a 2015 National Academies of Sciences, Engineering, and Medicine (NASEM) report, Enhancing the Effectiveness of Team Science , was that universities and other institutions should find effective ways to give credit for team-based work to assist promotion and tenure committees.

The strongest teams will be diverse in other respects, not just scientific expertise. Besides more actively fostering productive collaborations across disciplines, NIH is making a more concerted effort to promote racial equity and inclusivity in our research workforce, both through the NIH UNITE Initiative and through Institute-specific initiatives like NIDA’s Racial Equity Initiative.

To promote diversity, inclusivity, and accessibility in research, the BRAIN Initiative recently added a requirement in most of its funding opportunity announcements (FOAs) that has applicants include a Plan for Enhancing Diverse Perspectives (PEDP) in the proposed research. The PEDPs are evaluated and scored during the peer review as part of the holistic considerations used to inform funding decisions. These long-overdue measures will not only ensure that NIH-funded science is more diverse, but they are also important steps toward studying and addressing social determinants of health and the health disparities that exist for so many conditions.

Increasingly, scientific discovery is as much about exploring new connections between different kinds of researchers as it is about finding new relationships among different kinds of scientific databases. The challenges before us are great—ending the COVID pandemic, finding a solution to the addiction and overdose crisis, and so many others—and increased collaboration between scientists will give us the greatest chance to successfully overcome these challenges.

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By the time someone reaches out for addiction care, they may have already have suffered numerous painful losses in their lives. Addiction can steal a person’s happiness, job, friends and family, and can erode their freedom.

Far too often, the expectation is that someone must hit “rock bottom” before treatment can work. But this is a myth that can have dire consequences. By then the damage is consequential and a much harder road to recovery. Factually, the best time to get help is as soon as possible. Yet frequently when a person asks for help early on, society – friends and family, coworkers, health care systems – do not recognize it as a serious issue. They may ignore or deny it.

In a commentary published today in JAMA Psychiatry, Tom McLellan of the Treatment Research Institute, National Institute on Alcohol Abuse and Alcoholism Director George Koob, and I raise the possibility of moving toward a plan for better detection and support of those in the early stages of substance use disorder that, if untreated, may lead them to develop a severe health condition – addiction.

To define this early stage that we refer to as “pre-addiction,” we propose considering the criteria of mild or moderate substance use disorder (SUD). Identification of “pre-addiction” as an early condition of addiction could motivate greater attention to the risks associated with early-stage substance use disorder and help marshal the policies and healthcare resources that will support preventive and early intervention measures.

We are proposing the term “pre-addiction” because it gives a readily understandable name to a vulnerable period of time in which preventive care could help avert serious consequences of drug use and severe substance use disorders. This is akin to how we counsel and provide for care to prevent chronic diseases like heart disease or diabetes for patients who demonstrate higher risk of developing those conditions.

Healthcare in the U.S. is notoriously bad at delivering preventive medicine. Despite the well-known conventional wisdom that an ounce of prevention is worth a pound of cure, the system has always been set up to treat diseases and disorders once they manifest, not avert them. This has started to change for some conditions, however. For instance, it is now standard to monitor risk factors like cholesterol, blood pressure, and BMI during routine checkups, so that steps can be taken to avert heart attacks or stroke through some combination of lifestyle changes and medications.

The same mentality could be applied to substance use disorders. It is no longer necessary or reasonable to make people with drug or alcohol problems “hit rock bottom” before a substance use disorder is recognized and addressed. Nor is it true that people will only contemplate treatment when their disorder reaches that point. It is possible, through screening and early intervention—including brief intervention during routine checkups—to alert people to problematic patterns of drug or alcohol use that do not (yet) meet the threshold of addiction, sometimes defined as severe substance use disorder.

One of the definitions of addiction is inability to control drug use despite adverse health consequences and even despite a desire to change. For those meeting the criteria of severe substance use disorder, treatment and external recovery supports are often needed. Unfortunately, just 10 percent of people who could benefit from treatment get it. Prior to reaching this point, however, it is easier for people to exert control, including by setting limits and being more mindful of their substance use.

Increased awareness of the harms of heavy drinking and binge drinking even outside of a diagnosed alcohol use disorder, for instance, has alerted people to unhealthy patterns that in an earlier era escaped attention because the crucial addiction criterion—inability to control use—was not met. A diagnosis of pre-addiction could similarly serve as an alert to the individual about a behavioral pattern with potentially major—but also very preventable—health and life consequences down the road. It could create a different inflection point, one that recruits the patient more actively as an agent in their own health and wellness.

It could also save lives. Today’s extremely hazardous drug landscape is dominated by fentanyl, which is increasingly contaminating or being sold in place of non-opioid drugs. Even people who only take drugs occasionally, and even people who do not knowingly take opioids, run the risk of a fatal overdose. Some lever is needed to enable routine healthcare to serve as a screening and teaching opportunity about the danger of drug contamination that people who use illicit drugs face, even those who only use them occasionally.

For a renaming of mild to moderate substance use disorders as pre-addiction to be meaningful, it would require measures to define and detect substance use that is clinically significant and amenable for early intervention. Existing DSM criteria for mild to moderate substance use disorder are a starting point, as are existing screening tools used in primary care that ask about frequency of substance use. But research is needed to better characterize the kinds of substance use and the kinds of individual risk factors that would raise concern for future addiction and other health problems.

There is a need for a wider range of evidence-supported and reimbursable interventions for individuals meeting pre-addiction criteria, and clinicians would need to know how to deliver them or refer patients to the appropriate specialists. NIDA is already directing substantial funding, including via the Helping to End Addiction Long-term® Initiative, or NIH HEAL Initiative®, to increase the range of addiction treatments, but a diagnostic framing of mild to moderate substance use disorder as pre-addiction could create a market and thus incentive for greater development of interventions to prevent addiction from developing in the first place. This could potentially even include devices and over-the-counter aids that people could use on their own initiative without a doctor’s supervision.

A concept of pre-addiction would also require—but in turn could facilitate—greater public and clinical advocacy about addiction and how it develops. Currently the genetic and behavioral risk factors for diabetes are well-known, as are the clinical indicators of “pre-diabetes,” which can facilitate early intervention. Greatly needed is improved training in medical schools for recognizing and addressing all levels of substance use disorder, including low-severity substance use disorder that is nevertheless a risk for becoming more severe.

There are many questions, however, and such a paradigm change requires hearing multiple perspectives and diverse voices. We want to hear from the public, including people with lived experience, and from clinicians about the potential advantages as well as drawbacks of a pre-addiction framing. Above all, it is critical that changes to clinical practice alleviate, rather than exacerbate, harmful stigma.

Rebranding mild to moderate substance use disorder as a common and addressable behavioral health pattern could normalize and thus destigmatize potentially unhealthy substance use that does not merit the specialized interventions required to treat addiction, while also raising awareness of the potential health risks of such a pattern. However, interventions should ensure that the pre-addiction label does not lead to stigmatization of the people to whom it is applied. In particular, this will require legal protection when disclosing drug use to physicians. Unless drug use is decriminalized, fear of disclosure presents an obvious challenge to screening for and medically addressing non-disordered substance use in general medical settings.

Whether it comes with a “rebranding” or sparks renewed thinking, it is important that we understand addiction not as a disease that appears overnight, but as a condition with a backstory: a history of escalating substance-taking, often exacerbated by environmental and personal historical circumstances and by genetic risk factors. A greater awareness of the potential negative trajectories from substance use disorder and opportunities to prevent them will empower those in the early stages of a substance use disorder to arrest its escalation.

You can’t put a dollar value on the losses American families have suffered due to the addiction and overdose crisis. A life lost to overdose is irreplaceable, and the costs to happiness, success, and well-being of those living with addiction are similarly overwhelming and incalculable. Yet, funds are finite, and public health decisions do carry cost implications. When policymakers and community leaders can translate the human benefits of effective treatment and prevention measures into some quantifiable return on that investment, it can be a lever to shift public health policies.

Recently in the journal Prevention Science, a group of researchers funded by the National Institute on Drug Abuse (NIDA) published an analysis of the costs to North Carolina healthcare payers for hospital charges potentially relating to higher-risk behaviors in patients aged 9-18 (i.e., pre-adolescents and adolescents) in 2012. Charges included care for injuries from violence, accidents, or poisoning; care relating to sexual activity, substance use, or psychiatric disorders; and charges related to suicide or self-inflicted injury.

The researchers found that these charges totaled more than $327 million, accounting for more than 10 percent of all hospital-related charges. The higher-risk behaviors associated with these costs are preventable with psychosocial interventions, including family-based prevention programs. Pediatricians and family therapists surveyed in the study supported screening and referral to prevention, but cited possible challenges to reimbursement for these services as well as lack of training and lack of referral networks to/from each other. Pediatricians also cited concerns over patients not following through with referrals, suggesting that having family therapists working in pediatric clinics could help.

Primary prevention—including screening and intervention before negative health outcomes occur—is relatively inexpensive, and the higher-risk behaviors it is designed to reduce are so costly to the healthcare system that it is staggeringly wasteful not to make sure that screening and treatment referral are readily implemented and faithfully reimbursed by insurers and that interventions are convenient for parents and their children.

Reducing higher-risk behaviors would lessen burden across many sectors of society, not just healthcare, which was the sole focus of the newly published analysis. Greater investment in preventing such behaviors in youth would yield savings across public safety and the criminal justice system, behavioral health, education, and so on.

This is a common theme in the research on the benefits and costs of prevention. Some programs designed to prevent teen substance use and other behavioral problems have been found or estimated to be stunningly good investments. For example, an early childhood intervention called Nurse Family Partnership, in which specially trained nurses periodically visit first-time mothers during their pregnancy and first two years of their child’s life, was shown in an analysis by the Washington State Institute for Public Policy to save taxpayers $2.88 for each dollar invested; the same analysis found that a component of an elementary-school-based intervention called the Good Behavior Game saved taxpayers $25.92 for each dollar.

Another example is the Communities That Care prevention system, developed three decades ago and the subject of many randomized trials that follow participants well into adulthood. Communities That Care is not a single prevention intervention but a structured approach that helps communities utilize their resources most effectively to address identified risk factors for substance use, aggression, and other problems in youth. One recent analysis showed that an approximately $602 investment in each child (adjusted to 2017 dollars) had yielded an estimated $7754 in savings by the time participants were age 23—a $12.88 return for each dollar invested. The researchers estimated that those savings were distributed among individuals/families themselves, taxpayers, and other stakeholders. The return was well over twice as great when the downstream economic benefits of completing college—more likely among those receiving interventions—was factored in.

Prevention is needed now more than ever. Fentanyl is permeating the illicit drug supply and causing ever-greater numbers of overdose deaths. It is increasingly found in counterfeit prescription pills, which are liable to be taken by youth and other people with no previous exposure to opioids. In 2020, for the first time, fentanyl overdose deaths in teens spiked to nearly double the rate it had been in previous years.  

Communities, schools, and healthcare systems already have scientifically well-supported tools at their disposal to help prevent substance use and other related mental illnesses and risk behaviors in adolescence, but sadly they are seldom implemented. Even if an intervention can be shown in a trial to produce benefits, it cannot be expected to make a positive impact if it is not easily scaled up in a variety of real-world settings adaptable to the needs of different communities. For this reason, developing and testing interventions that can be adopted and sustained is an important part of NIDA’s prevention research portfolio.

While investment in prevention doesn’t show immediate returns, playing the long game and investing in prevention interventions can save lives and dollars.

Racism is rampant in the US with effects that are pervasive and wide-ranging, including in the areas of science and health. In 2020, in response to events like the murder of George Floyd that highlighted once again how far our society is from real racial equity, leaders from across the country stepped forward to provide their commitments to making a difference, NIH leadership included. Francis Collins and Larry Tabak announced the NIH-wide UNITE Initiative to end structural racism in biomedical sciences, and in parallel NIDA established the Racial Equity Initiative (REI) to work toward eliminating racism and racial bias from (1) the NIDA workplace, (2) the larger workforce of scientists and staff supported by our Institute, and (3) the portfolio of addiction-related research NIDA funds.

Since establishing the REI, workgroups composed of NIDA staff volunteers have held numerous listening sessions to solicit input from our staff on the three goals of the initiative, and we held a scientific meeting in February 2021 on enhancing research in health disparities associated with substance use and addiction. The meeting was open to the public and featured leaders in the addiction research community with expertise in social determinants of health. The result of these and other activities is a draft Racial Equity Initiative Action Plan to focus our efforts in eliminating racism and racial bias over the coming years.

The draft Action Plan consists of Goals and Objectives designed to further the missions of the three workgroups: Workplace, Workforce, and Research Gaps and Opportunities. Before finalizing and implementing the Action Plan, we are now seeking input from the public in all three areas, including input from the scientific community, healthcare professionals, and people who use drugs or have addiction, and their families.

The aim of the NIDA REI Workplace Workgroup is to create opportunities for safe and regular communication among staff and between staff and management about concerns related to racial bias and harassment and take measures to promote racial equity, inclusion, and diversity—both in NIDA’s headquarters in Bethesda, Md., and at its Intramural Research Program in Baltimore. Special focus will be given to providing ongoing opportunities for sharing and obtaining feedback from NIDA staff about the workplace climate and implementing measures to keep that climate free from harassment and discrimination.

The NIDA REI Scientific Workforce Diversity Workgroup aims to increase racial and ethnic diversity, equity, and inclusivity in the wider community of addiction researchers. It requires identifying disparities and systemic barriers to workforce diversity, increasing engagement among students and those scientists, and taking measures to ensure that groups historically underrepresented in addiction science are fostered throughout their education, incentivized to pursue an addiction science career, and retained in that career path. The latter goal may entail continuing to implement policy changes in grantmaking with the goal of recruiting and retaining a more diverse community of scientists studying addiction. Objectives include addressing factors such as racial imbalance on review committees that perpetuate the bias in favor of white grant applicants and holding principal investigators and their institutions accountable for diversity and inclusivity. 

Inevitably, lack of diversity and imbalances in the research community are self-perpetuating, contributing to blind spots in the kinds of topics that receive the most attention. The aim of the NIDA REI Research Gaps and Opportunities Workgroup is to increase support for research on social determinants of drug use, addiction, and related conditions and the ways these contribute to racial health disparities in our society. Although social determinants are already a research priority for NIDA, a key focus of this Initiative will be to identify topics (such as stigma) that have not been given adequate priority in the past and to test and implement sustainable remediation strategies to address them. Developing tools to measure social determinants and ensuring the inclusion of underrepresented minorities in clinical trials are among the many objectives of this part of the Action Plan.

By sharing this draft plan with the research community, stakeholders, and others, we ask for input and perspectives that can inform our work. We are listening, and we are particularly interested in listening to those who have been directly or indirectly impacted by structural racism or racial bias in NIDA practices or research. Sharing your thoughts and views will help ensure that the plan is comprehensive, realistic, and meets the needs of those most affected by racial discrimination and unconscious bias.

The draft Action Plan can be read here and instructions on how to submit feedback can be found in the Request for Information (RFI) (NOT-DA-22-052). Your input will make our field more diverse and improve the important science that we do.

This essay was also published by Health Affairs on January 3, 2022.

Last year saw drug overdose deaths in the U.S. surpass an unthinkable milestone: 100,000 deaths in a year. This is the highest number of drug overdoses in our country’s history, and the numbers are climbing every month.

There is an urgent need for a nationwide, coordinated response that a tragedy of this magnitude demands. Recent data from 2020 shows that only 13 percent of people with drug use disorders receive any treatment. Only 11 percent of people with opioid use disorder receive one of the three safe and effective medications that could help them quit and stay in recovery.

The magnitude of this crisis demands out-of-the-box thinking and willingness to jettison old, unhelpful, and unsupported assumptions about what treatment and recovery need to look like. Among them is the traditional view that abstinence is the sole aim and only valid outcome of addiction treatment.

While not using any drugs or alcohol poses the fewest health risks and is often necessary for sustained recovery, different people may need different options. Temporary returns to use after periods of abstinence are part of many recovery journeys, and it shouldn’t be ruled out that some substance use or ongoing use of other substances even during treatment and recovery might be a way forward for some subset of individuals.

Reduced number of heavy drinking days is already recognized as a meaningful clinical outcome in research and medication development for alcohol addiction. Clinical endpoints other than abstinence, such as reduced use, are now being considered in medication trials for drug use disorders. This could facilitate the approval of a wider range of medications to treat addiction, as well as open the door to medications that address symptoms associated with it, such as sleep disorders and anxiety. The existing medications methadone, buprenorphine, and naltrexone have proven to be effective at reducing relapse risk and improving other outcomes in patients with opioid use disorder, but more options could benefit more patients. And medications to treat other drug use disorders are needed.

Temporary returns to drug use are so common and expected during treatment and recovery that addiction is described as a chronic relapsing condition, like some autoimmune diseases. Yet these setbacks may still be regarded by family, friends, communities, and even physicians as failures, resetting the clock of recovery to zero. Patients in some drug addiction treatment programs are even expelled if they produce positive urine samples.

Healthcare and society must move beyond this dichotomous, moralistic view of drug use and abstinence and the judgmental attitudes and practices that go with it.

There are still many unknowns about the different trajectories that recovery may take, but stereotypes should not guide us in the absence of knowledge. Research in the field of nicotine addiction shows that a person’s first cigarette after a period of abstinence raises the risk of returning to their pre-treatment use pattern but does not always have that outcome. Research on the consequences of returning to opioid, stimulant, or cannabis use after a period of non-use is still needed, but there is little evidence to support the assumption—reinforced in movies and TV shows—that a single return to drug use following on a one-time loss of resolve will automatically lead the individual straight back to their former compulsive consumption.

Medicine can perhaps learn from the recovery world, where a distinction is increasingly made between a one-time return to drug use, a “slip” or “lapse,” and a return to the heavy and compulsive use pattern of an individual’s active addiction—the more stereotypical understanding of relapse. The distinction is meant to acknowledge that a person’s resolve to recover may even be strengthened by such lapses and that they need not be catastrophic for the individual’s recovery.

A return to substance use after a period of abstinence may also, in some cases, lead to less frequent use than before treatment. Such a trajectory has been identified in research on drug and alcohol treatment outcomes in adolescents. For some drugs, any reduced use is likely beneficial: Less frequent illicit substance use means less frequent need to obtain an illicit substance and fewer opportunities for infectious disease transmission or fatal overdose. It may also increase the likelihood that a person can be a supportive family member, hold a job, and make other healthy choices in their life.  

But as long as treatment is only regarded as successful if it produces abstinence, then even one-time lapses can trigger unnecessary guilt, shame, and hopelessness. If an individual feels like they are bad, weak, or wrong for taking a drink or drug after a period in recovery, it could potentially make it more likely for those slips to become more serious relapses. As it now stands, even a slip can produce a positive urine sample or force the honest patient to self-report a return to drug use, which can then trigger the judgment and punitive policies of their treatment program or the law as well as trigger the personal sense that they have failed again and there is no hope for their recovery.  

Another deleterious effect of equating treatment success with abstinence and drug use with treatment failure is that some people with SUDs are unready to give up substances completely. In fact, this is one of the main reasons people who could benefit from addiction treatment do not seek it. Although it may not be ideal or optimal, treating an opioid or methamphetamine use disorder even while a person continues to use cannabis or alcohol would be a net individual and public health benefit.

Realistically and pragmatically addressing addiction requires that we not let the perfect be the enemy of the good. Right now, we need all the good we can get. It also means offering supports for people with SUD that protect against the worst consequences of drug use. Syringe-services programs reduce HIV transmission and offer people an entry point into treatment; naloxone distribution to people who use opioids and their families reduces overdose fatalities. Neither of these measures increase drug use in communities that implement them, as critics often worry.

Other harm-reduction modalities being studied include personal drug-testing equipment like fentanyl test strips, as well as overdose prevention centers—places where people can use drugs under medical supervision, which are in operation in other countries and, as of late November, are available in New York City. Such services could potentially help mitigate some of the risks associated with lapses and relapses, such as heightened risk of overdose due to lost tolerance. The latter currently accounts for many fatal overdoses after people with an untreated opioid use disorder are released from prison, for example.  

Drug addiction is a chronic but treatable disorder with well-understood genetic and social contributors. It is not a sign of a person’s weakness or bad character. Continued or intermittent use of drugs, even by people who know they have a disorder and are trying hard to recover from it, must be acknowledged as part of the reality of the disorder for many who struggle with it. Just as we must stop stigmatizing addiction, we must also stop stigmatizing people who use drugs as being bad or weak, and instead offer them support to help prevent addiction’s most adverse consequences.