presented by Nora D. Volkow, M.D. Director, National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services
Testimony Before the House Subcommittee on Labor-HHS-Education Appropriations
Statement for the Record
Mr. Chairman and Members of the Committee:
I am pleased to present the President's Budget for the National Institute on Drug Abuse (NIDA) of the National Institutes of Health (NIH). The Fiscal Year (FY) 2009 budget of $1,001,672,000 includes an increase of $972,000 over the FY 2008 appropriated level of $1,000,700,000. As one of the 27 Institutes and Centers that make up the National Institutes of Health, NIDA supports a broad array of research to improve the treatment and prevention of drug abuse and addiction, and increase our understanding of their medical consequences.
Drug abuse and addiction are preventable diseases, yet continue to cause immeasurable human suffering, with associated societal costs estimated to exceed half a trillion dollars annually in the United States. NIDA's efforts over the years have led to continued declines in both licit and illicit drug use, particularly among our Nation's youth. Our latest Monitoring the Future survey of drug use patterns and trends among 8th, 10th, and 12th graders shows a 24-percent decline in drug use among the three grades combined between 2001 and 2007 (figure). Cigarette smoking also shows a positive downward trend - at its lowest rate in the survey's history. Challenges remain, however, with new forms of drug abuse always emerging, the latest threat coming from the non-medical use of prescription and over-the-counter medications. Growing misuse and abuse of prescription opioid analgesics (e.g., painkillers) and cognitive enhancers (e.g., stimulants prescribed for ADHD) by young adult and older populations sounds a warning. NIDA stays on top of such trends, winning important battles over the years by helping to bring about smart and effective prevention and treatment strategies.
Responding to a New Reality and New Opportunities
The current scientific landscape profoundly changes the kinds of questions we can ask and how we go about answering them. Biomedical research is being transformed, as the traditional approach to data collection is displaced by a vigorous drive to combine knowledge and expertise from multiple domains. The rapid buildup of integrated knowledge across different disciplines allows for a far more meaningful translation of that knowledge. This new scientific paradigm is better equipped to evaluate the many complex facets of a person, opening up incredible opportunities to revolutionize our approaches to promoting, preserving, and restoring health.
NIDA has fully embraced this new paradigm, increasing its stake in investigations that combine many of the different aspects of an individual's life that could impact his or her vulnerability to abusing drugs and becoming addicted to them. This commitment has been a major force in shaping our interdisciplinary approach to evaluating the combined contributions to risk stemming from biological (e.g., genetics, development, neurophysiology) and environmental (e.g., social, cultural) factors, as well as from their interactions. Thus, NIDA's research programs are poised to foster a more predictive, personalized, and participatory kind of medicine.
Indeed, the complex interactions between biological, social, environmental, and developmental factors that underlie this disease demand a "whole systems" approach to treating it. NIDA is taking advantage of recent discoveries of an expanded range of possible targets within interconnected brain systems to potentially affect craving, euphoria, motivation, learning, memory, and inhibitory control - key contributors to addiction and relapse. One strategy in this context is to develop medications that block priming and prevent relapse in people trying to remain abstinent; another is to develop medications that strengthen executive function and allow addicted individuals to exert inhibitory control over their urges to take drugs. Findings from genetic studies are helping us identify new molecular targets for developing these medications. NIDA is also supporting the development of vaccines designed to stimulate the body into producing antibodies against a specific drug and prevent it from entering the brain. Vaccines against nicotine and cocaine have already been developed and are currently in advanced stages of testing, while research is now being conducted to evaluate the feasibility of a similar strategy for the treatment of methamphetamine addiction.
Working Across Domains: Genes, Environment, Epigenetics
The public health impact of integrating knowledge and data across domains is perhaps nowhere more evident than in the field of genetics. Because genes influence substance abuse vulnerability, knowing an individual's genetic code will help identify new avenues to prevent and cure disease. This knowledge will further our understanding of the basic mechanisms underlying the disease of addiction, and of its frequently associated comorbid conditions.
Recent genome-wide association studies of nicotine addiction, for example, have yielded many previously unsuspected genes whose products may be involved in the addiction process. Such findings offer exciting opportunities to develop novel addiction pharmacotherapeutics and herald the advent of more personalized interventions based on a patient's genetic profile.
But genes do not act in isolation but rather in tandem with developmental and environmental factors. Therefore, NIDA supports research to define and measure relevant aspects of the social environment - culture, neighborhoods, schools, families, and peer groups - to understand how genes might mitigate or amplify social influences, known to powerfully affect individual choices and behaviors related to substance abuse.
Conversely, environmental elements, such as parenting quality, home conditions, stress, diet, pollutants, and, of course, exposure to drugs of abuse, can regulate gene expression. Discovery of the underlying mechanisms driving some of these effects, known as epigenetic modifications, presents a path to moderate and perhaps even override a genetic predisposition by adjusting environmental influences. Epigenetic knowledge also lays the groundwork for next-generation pharmaceuticals: the recent discovery of histone demethylases - a new family of genome modifying enzymes - has far-reaching implications for the development of epigenetic medications.
Integrating Biological Databases and Disciplines
Advances in our ability to identify, characterize, and treat complex diseases require research and development of new computational platforms and databases for the storage, integration, retrieval, and sharing of biological, behavioral, and environmental data. This enhanced infrastructure will be necessary to enable the integration of knowledge across diverse levels of analysis. NIDA leads the NIH Bioinformatics Roadmap initiative, which calls for research on software design, construction, and implementation that will extend the applicability of existing software to a broader biomedical research community. The goal is to expand and integrate the massive amounts of multimodal biological data for the benefit of all complex disorders.
At present, many scientific disciplines are going through their own radical transformations. Modern neuroimaging tools, for example, are allowing us to study the complex responses of a living human brain in experimentally controlled environments. This technology provides an unprecedented level of detail about brain function in health and disease, and offers incredible opportunities for investigating the individual characteristics at the root of behavioral vulnerabilities to abuse and addiction. The accelerating rate of discoveries is driving the research and development of smarter medications and behavioral interventions to counteract drug-induced changes in the circuits responsible for normal behavioral, cognitive, and emotional functions. As a direct result of these developments, clinicians will be better positioned to match particular therapies with a patient's changing needs over time, allowing people to regain their cognitive abilities and capacity to enjoy life.
Integrating Knowledge to Promote Public Health/Safety
It is now clear from our research that drug abuse cannot be treated in isolation from other associated issues, such as criminal behavior, mental health status, physical health, family functioning, employment status, homelessness, and HIV/AIDS. A robust and consistent effort to tap into and integrate different sources of knowledge will be needed to design and implement effective interventions in the future.
This rationale underlies NIDA's efforts to incorporate evidence-based treatment principles into criminal justice settings. Our current system affords treatment to only a small percentage of inmates who need it, and even these services are generally inappropriate to the needs of this population. Making effective treatments more broadly available to criminal justice offenders will help successfully transition drug-addicted prisoners back into society and bring about significant reductions in drug abuse and criminal recidivism. Every $1 invested in addiction treatment programs yields about $7 in savings, mainly from reduced drug-related crime and criminal justice costs. 1
NIDA is revamping its HIV/AIDS research strategy to better address the critical need for new therapies for drug abusers with HIV, and to learn more about the complex medical consequences, such as neuroAIDS, that plague this population. For example, recent developments using a combination of nuclear and magnetic resonance spectroscopy techniques to identify and track specific neurons in a living human brain could greatly enhance our ability to investigate the effects of AIDS on cognition. Another NIDA initiative will help elucidate the effects of genetic variations on disease progression, and on how drugs of abuse and medications (for drug addiction and HIV) interact with both host and viral genes. To further such innovations, NIDA has established the Avant-Garde Award for exceptionally inspired researchers offering transformative approaches to major challenges in biomedical and behavioral research on drug abuse and HIV/AIDS.
In sum, the health of our Nation and our leadership role in furthering biomedical progress around the world depend on our collective ability to recognize the changing face of biomedical research and the long-lasting impact of our choices today. Thank you for this opportunity, and I will be pleased to answer any questions you may have.
1Ettner SL et al. Benefit-cost in the California Treatment Outcome Project: Does substance abuse treatment pay for itself? Health Services Research 41(1):193-213, 2006