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
Mr. Chairman and Members of the Committee:
I am pleased to present the President’s budget request for the National Institute on Drug Abuse (NIDA) of the National Institutes of Health (NIH). The Fiscal Year (FY) 2013 NIDA budget of $1,054,001,000 includes an increase of $1,887,000 over the comparable FY 2012 level of $1,052,114,000.
The President’s Budget for FY13, which has just been released, offers a timely opportunity to review NIDA’s research priorities for bringing the power of science to bear on drug abuse and addiction and reducing their burden on the public’s health.
A Technological Revolution
The technologies of biomedical research are advancing at unprecedented rates ushering in scientific breakthroughs that are providing a deeper understanding of human genetics, chemistry, and brain circuitry. The emerging picture has the potential to transform how we prevent and treat drug abuse and addiction and its health consequences, and involves new techniques for capturing and analyzing vast and diverse datasets on everything from genetics to neuroimaging to social networks.
NIDA is poised to harness complete genome and “deep” sequencing tools and a growing portfolio of epigenetic initiatives to elucidate how biological processes and environmental factors like chronic stress and drug exposure can alter the expression of genes that influence brain organization and function and the expression (or not) of substance use disorders. For example, the recent finding in an animal model that nicotine can trigger epigenetic processes that make the brain more susceptible to the effects of cocaine could have important policy and practice implications, if it occurs also in humans.
Epigenetic research is also shedding critical new light into the mechanisms that govern the disease progression of HIV, the spread of which is closely intertwined with injection and non injection drug use behaviors. A cure for HIV has been elusive because the virus is able to "hide" in a latent form in resting CD4-T cells. This allows HIV to persist for years, even with prolonged exposure to antiretroviral drugs. Understanding this "latency" effect could enable researchers to reactivate the virus and use current or future therapies to rid the body of it altogether.
The overlaying of neuroimaging data will further accelerate discovery by linking molecular and cellular data with human behavior. For example, a new functional magnetic resonance imaging (fMRI)-based approach can probe the resting brain (i.e., one not performing any specific task) to illuminate circuit-level functions that may prompt behavioral responses, including those related to diseased states or vulnerability. Individual differences found in these images could provide useful biomarkers (neural signatures) of illness risk, course, and treatment response.
The amount and diversity of data being generated by genetic, epigenetic, and imaging studies call for harmonization standards that will allow data integration across laboratories. Thus, our continuing efforts to train the next generation of addiction researchers must now take into account the urgent need for a new cadre of interdisciplinary scientists capable of developing modern analytical tools for integrating and managing large pooled data sets and for modeling and analyzing complexity.
To help those already suffering from addiction, we need to expand the tools available to treat substance use disorders and their health consequences. To this end, NIDA will continue to invest in the development of addiction medications and to seek public-private partnerships with pharmaceutical companies still reluctant to play an active role due to perceived stigma and financial disincentives. Success demands both adaptable and novel approaches.
Among the “low-hanging fruit” are already-approved drugs, which NIDA is seeking to repurpose for addiction indications, saving enormous amounts of research and development time and cost. Notable in this category are: buspirone, which blocks action at the dopamine (D3) receptor (among its other effects) and may be useful in treating stimulant addiction, based on well-established findings in the animal literature; and cytisine, which acts on nicotinic receptors and has recently been shown to be about 3.5 times more effective than placebo in a smoking cessation trial.
NIDA also continues to support research to increase the effectiveness of various vaccines being tested against nicotine, cocaine, heroin, and methamphetamine. Efforts aim to increase these vaccines’ immunogenicity—that is, their ability to stimulate the production of antibodies capable of blocking a drug’s entry into the brain.
Finally, NIDA is actively pursuing a strategy that involves the use of medication combinations, an approach that has proven effective for treating many diseases (e.g., HIV, cancer) and one starting to show success with addiction. For example, the combination of lofexidine (a hypertension medication) and marinol (a synthetic form of marijuana’s THC) has shown promise in treating withdrawal symptoms (which can trigger relapse) among marijuana-addicted individuals.
Improving Public Healthcare: Delivery and Performance
NIDA will harness every opportunity to translate scientific knowledge to improve strategies for combating drug abuse and addiction. This commitment includes engaging physicians as “frontline” responders and providing them with tested tools, including a Web-based screening tool that generates specific clinical recommendations. The broad availability of these resources is an important step toward integrating substance abuse screening, brief intervention, and referral to treatment (SBIRT) into routine medical care, which will enable better healthcare decisions and outcomes.
NIDA will also capitalize on the Affordable Care Act to study how innovations in service delivery, organization, and financing can improve access to and use of effective prevention and treatment interventions. Because so few people access treatment, coupled with the >$600 billion that drug abuse and addiction cost society each year, even a marginal increase in treatment use and retention could have a sizeable public health impact—for individuals, families, and society as a whole.
To help get evidence-based treatments to providers in a variety of settings, NIDA uses collaborative research infrastructures designed to deploy proven strategies rapidly and effectively. For example, NIDA’s Criminal Justice-Drug Abuse Treatment Studies (CJ-DATS) network promotes multilevel collaborations to test proven treatment models in the criminal justice system, disproportionately affected by both drug abuse and HIV. One example, called “Seek, Test, Treat, and Retain,” expands access to HIV testing and treatment, ultimately reducing HIV spread.
Staying Ahead of the Curve
NIDA continues to monitor drug abuse trends across different populations. Particularly worrisome are the trends pertaining to marijuana use, on the rise after about a decade of decline; the emergence of an ever-evolving array of synthetic drugs (e.g., spice and bath salts) that are sending users to emergency rooms nationwide; and the continued high rates of prescription drug abuse, which have resulted in a quadrupling in unintentional overdose deaths in this country since 1999. NIDA is addressing all these problems through both broad-based prevention efforts and targeted initiatives.
Prescription drug abuse is one such targeted area that demands a multifaceted approach. NIDA’s long term strategy to help reverse this trend includes: (1) research to understand the factors that influence an individual’s risk, treat those already addicted, and develop pain medications with reduced abuse potential; (2) physician education to improve pain treatment while minimizing prescription drug abuse; and (3) community engagement exemplified by NIDA’s leadership of a multiagency effort to create a Surgeon General Call to Action to reduce prescription drug abuse among youth.
In closing, NIDA pledges to continue to tackle the emerging and significant public health needs related to drug abuse and addiction, taking advantage of unprecedented scientific opportunities to close the gaps in our knowledge and develop and disseminate more effective strategies to prevent and treat drug abuse and addiction.