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 Senate 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 Fiscal Year 2010 Budget request for the National Institute on Drug Abuse (NIDA) of the National Institutes of Health (NIH). The Fiscal Year (FY) 2010 budget includes $1,045,384,000, which is $12,625,000 more than the FY 2009 appropriation of $1,032,759,000.
Drug abuse and addictions are preventable conditions, yet continue to cause immeasurable human suffering, with associated societal costs estimated to exceed half a trillion dollars annually in the United States. Tobacco use alone is responsible for more than 400,000 deaths per year, and is the leading cause of preventable death in the United States. NIDA's budget request and its research projects are consistent with the President's multi-year commitment for Cancer . For example, NIDA has active programs to hasten the development of new, more effective treatments for nicotine addiction that can dramatically reduce the prevalence of diseases like lung cancer and emphysema, which mean an early death for many smokers.. Other NIDA-supported research advances have contributed to steady declines in both licit and illicit drug use over the years, particularly among our Nation's youth. Our latest Monitoring the Future survey of drug use patterns and trends among 8th, 10th, and 12th graders reveals, for example, that tobacco use has declined continuously since its peak in the mid-1990's, and is presently at its lowest level since the first MTF survey in 1975 (figure). However, if we are to fully eradicate drug abuse and addictions, we must find novel approaches to prevent drug abuse (including smoking) among the significant fraction of youth who, because of strong genetic and/or environmental propensity, appear refractory to current efforts. Additional challenges include the growing abuse of prescription medications, including opioid analgesics (e.g., painkillers), stimulants (e.g., ADHD medications), and CNS depressants (sleep and anxiety medications). NIDA is committed to closely monitoring these trends and to furthering the development of innovative strategies to counter them, including the widespread dissemination of screening and early intervention tools for medical settings to increase the medical community's participation in identifying and treating substance abuse disorders.
Addiction Medications: Changing the Culture of Treatment
NIDA's accelerating rate of discovery is beginning to spur the advent of better medications and behavioral interventions to counteract drug-induced changes in brain function. Among the strategies NIDA supports for medications development are those to: counter stress responses, which frequently trigger relapse to drug use; strengthen executive function and inhibitory control so that drug abusers can better control their urge to take drugs; and interfere with drug-conditioned memories to prevent relapse when drug abusers are exposed to environments they associate with drug use. Other research includes development of vaccines, or antibody-based approaches, which can block both illicit and licit drugs (e.g., nicotine) from ever reaching the brain, thereby inhibiting their rewarding effects. In the context of nicotine addiction, this approach may help prevent smokers from escalating to addiction and/or facilitate abstinence in those who seek to quit. It also complements ongoing efforts to discover new, more effective medications through conducting screens of novel compounds and chemical libraries and applying promising findings to help people achieve abstinence from tobacco and other addictive substances.
To accelerate progress in combating substance use disorders, there must also be social change to recognize that people who suffer from addiction require medical treatment. Presently, addiction treatment occurs largely outside of mainstream medicine, even though drugs undermine overall health, frequently appearing alongside other medical and psychiatric conditions. To help change this culture, NIDA is providing knowledge of associated brain dysfunctions and developing and deploying effective addiction medications. As these efforts succeed, the consequent medicalization of drug abuse and addiction will allow (1) clinicians to respond to their patients' needs more effectively and in a more personalized fashion; (2) insurance companies to become increasingly responsible for the coverage of treatments that can dramatically improve overall health; and (3) pharmaceutical companies to be incentivized to develop novel addiction medications. As the stigma of addiction wanes, the dissemination of proven treatments will expand to include the populations that need them the most, such as those involved in the criminal justice system, half of whom meet the criteria for drug abuse or dependence, according to estimates from the Department of Justice. Broader treatment access for drug-addicted offenders will help them to successfully transition back into society, dramatically reducing not just drug abuse, but also criminal recidivism.
Genes and Environment: High Pay-Off Research
A steady flow of genetic discoveries is uncovering previously unsuspected genes whose products may be involved in the addiction process and therefore present good candidates for medication development. They also herald the advent of more personalized interventions based on a patient's genetic profile. And, because genes influence both vulnerability and resilience to substance abuse and other mental disorders, genetic data will further our understanding of the basic mechanisms underlying the disease of addiction, as well as its frequently associated comorbid conditions.
But genes do not act in isolation; rather, they work in tandem with developmental and environmental factors to determine a person's drug abuse vulnerability. Therefore, NIDA is encouraging more research to understand how genes might mitigate or amplify social influences that 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. Uncovering the mechanisms behind these so called epigenetic effects, offers a path to alleviate and perhaps even override a genetic predisposition by adjusting environmental variables.
One approach NIDA is pursuing is the merging of genomic and brain morphology (i.e., brain structure) data in order to understand how genes influence human brain development. Such data would be invaluable as a basis for understanding the contribution of specific genes to neuropsychiatric disorders and how exposure to certain environmental factors can trigger disease in those who are genetically vulnerable. This research would, in turn, open the door to next-generation pharmaceuticals that could target and perhaps even prevent or reverse disease processes. The recent discovery of histone demethylases - a new family of genome modifying enzymes - is just one example of a set of proteins that could be targeted for medications development.
Also critical to substance abuse prevention and treatment is the development of reliable assays for drug exposure and addiction vulnerability. Although tests of bodily fluids or hair and surveys using self-report questionnaires are used routinely, their value is compromised by their limited reliability, low sensitivity, and narrow scope. NIDA will encourage research to find reliable biomarkers - or indicators of a biological response/vulnerability to drug exposure - for assay development. The ability to quantify thousands of biomarkers in a consistent, expeditious, and affordable manner will yield revolutionary new approaches to the prevention and personalized treatment of substance abuse.
The Relevance and Impact of Comorbid Conditions
NIDA research has demonstrated that drug abuse cannot be treated in isolation from associated concerns, such as criminal behavior, mental and physical health status, social functioning, 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 will be particularly important for members of the military and their families, who may be facing difficult challenges related to substance abuse in the coming years. Many are returning from active duty with post traumatic stress disorder (PTSD) and/or chronic pain conditions, both of which can be comorbid with drug abuse and require comprehensive treatment interventions. In response to these projections NIDA will increase our research investment in this area and collaborate with the Veteran's Administration, the Substance Abuse and Mental Health Administration (SAMHSA), and other NIH institutes - NIMH, NCI, NIAAA, and NHLBI - in developing a responsive and forward-looking research agenda.
Understanding the Dynamics of Drug Abuse and HIV
NIDA's recent revamping of its HIV/AIDS research strategy better addresses the critical need for new therapies for drug abusers with HIV and for research designed to uncover more about the complex medical consequences, such as neuroAIDS. Initiatives in this area 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 creative researchers offering transformative approaches to major challenges in biomedical and behavioral research on drug abuse and HIV/AIDS. Awardees are undertaking diverse approaches, such as evaluating the effectiveness of expanded access to highly active antiretroviral therapy in decreasing new cases of HIV infection among injection drug users. Evidence to date suggests the utility of this approach for injection drug users and their partners; if widely adopted, it could also help stem the HIV epidemic around the world. In addition, NIDA is promoting research on HIV screening and on how to best integrate testing and counseling into drug abuse treatment settings, among criminal justice populations, and in other countries that have been hit especially hard by the epidemic. Learning one's HIV-positive status reduces risk behaviors and, when linked to HAART, makes the person a less efficient vector for spreading the disease.
In sum, the health of our Nation and its leadership role in bringing science to bear on drug abuse and addiction depend on our ability to continue to support promising biomedical research that can bring with it enduring and transformative public health changes not just to this country but to the rest of the world. Thank you for this opportunity, and I will be pleased to answer any questions you may have.