June 16–19, 2017
More than 200 participants from 46 nations attended the 22nd Annual National Institute on Drug Abuse (NIDA) International Forum, held June 16–19, 2017, in Montréal, Canada. International Program Director Steven W. Gust, Ph.D., chaired the meeting, which was cosponsored by the Canadian Centre on Substance Use and Addiction (CCSA). A joint NIDA International Forum/College on Problems of Drug Dependence (CPDD) poster session featured presentations on international research conducted by 140 scientists from the United States and 42 other countries. Plenary sessions addressed drug-related HIV/AIDS, kratom use, and marijuana policies, interventions, and research needs. Breakout sessions focused on preparing international research for publication, education and training opportunities, and conducting drug flows research using smartphone research applications to collect data that meet common core research standards.
Welcoming participants to Canada, CCSA Executive Director Rita Notarandrea described her organization’s efforts to provide evidence for coordinated Canadian action on substance use issues, particularly cannabis policy decisions and drugged driving regulation. She reported that the economic and social cost of collisions attributed to cannabis use was more than $1 billion CND in 2012. Dr. Notarandrea described CCSA partnerships with NIDA, the U.S. National Highway Traffic Safety Administration, the Royal Canadian Mounted Police, and university, government, and civic organizations in British Columbia. CPDD International Committee Chair Clyde McCoy, M.D., University of Miami Miller School of Medicine, reported that the committee’s survey of fellowship utilization found genuine interest in international research collaboration. The biggest barrier to international research fellowships seems to be a lack of applicants, not an institutional or researcher bias against international collaboration. Dr. McCoy surprised Dr. Gust with an award from the CPDD International Committee in appreciation of his more than 30 years of service at NIDA, 18 of them as director of the NIDA International Program. Dr. McCoy also introduced the 2017 CPDD International Traveling Fellow, Effat Merghati Khoei, Ph.D., Iran, and her research visit host, Bruna Brands, Ph.D., Health Canada.
Evaluation of Marijuana Policies and Interventions
CCSA Research and Policy Director Amy Porath, Ph.D., reviewed the cannabis research agenda her organization developed in response to Canadian government plans to regulate nonmedical cannabis use. A 2016 expert meeting identified six thematic areas where high-quality research was needed to inform policy decisions, assess the impact of the policy change, and facilitate monitoring to avoid negative impacts. The six thematic areas include (1) the endocannabinoid system; (2) neuroscience and cannabis effects on the brain and behavior; (3) mental health, dependence, treatment, and polysubstance use; (4) psychomotor performance, impaired driving, detection, and polysubstance use; (5) effective approaches for health promotion and harm prevention; and (6) social determinants of health, psychosocial impacts, and epidemiology. Dr. Porath outlined the need for funding and national coordination of the governance structure, interdisciplinary working groups, and surveillance of cannabis use trends. She also described next steps and preliminary reports, policy briefs, and partnerships CCSA has developed to address the research questions.
NIDA Epidemiology Research Branch Chief Marsha Lopez, Ph.D., M.H.S., reviewed NIDA cannabis research, noting that the Institute supports about 76% of National Institutes of Health (NIH) research on the topic. She reviewed NIDA-supported research findings on marijuana use and dependence, attitudes and dependence, availability and accessibility, health and social outcomes, and other drug use. Dr. Lopez suggested areas for focused research, including (1) the impact of marijuana products’ potency and composition on behavior, health outcomes, and treatment needs; (2) the impact of marijuana policies on use of other substances, particularly increases in tobacco use and harm reduction efforts; (3) defining impairment in drugged driving; and (4) prevention needs of youth who have greater access and exposure to marijuana use in the family environment, particularly second- and third-hand exposure or exposure during pregnancy. NIDA has established an Advisory Council workgroup or researchers and staff to provide advice and guidance on policy research needs. The Institute provides marijuana for research needs and supports policy surveillance resources such as the Prescription Drug Abuse Policy System (www.pdaps.org), LawAtlas Policy Surveillance Program (www.lawatlas.org), and the soon-to-be launched Drug Abuse Policy System.
Flavio Pechansky, who directs the Brazilian Center for Drug and Alcohol Research at the Federal University of Rio Grande do Sol, compared marijuana policies adopted by Brazil and Uruguay. In Brazil, there is widespread public support for medical marijuana use, despite health organizations’ warnings that cannabidiol should be used as a treatment medication only after established therapeutics fail. Current drug laws criminalize both drug traffickers and users, with vague definitions that contributed to a rise in drug-related incarceration from 9% in 2005 to 28% in 2014. The Brazilian Supreme Court suspended its review of the constitutionality of drug laws in 2017. In contrast, Uruguay adopted legislation in 2013 that permits production and distribution of cannabis for recreational use by adults. Users must enroll in a cannabis registry and choose one means of obtaining the drug: home cultivation; membership clubs; or retail pharmacies. Although prevalence of marijuana use increased between 2001 and 2014, the most recent data do not reflect the new policy. Early reports indicate that 40% of users are reluctant to enroll in the cannabis registry.
Dr. Porath and Doug Beirness, Ph.D., reviewed Canadian enforcement approaches for addressing drug-impaired driving. Roadside surveys indicate that Canadian drivers are more likely to test positive for drugs than alcohol, and cannabis is the most common illicit drug present in fatally injured drivers. Drs. Porath and Beirness reported on the CCSA research to validate standardized tests to document a driver’s level of impairment and develop devices law enforcement officers can use to confirm the presence of drugs. The Drug Evaluation and Classification (DEC) was 95% accurate when roadside conclusions were compared with analysis of urine, oral fluid, or blood. DEC was also reliable: different evaluators reached the same conclusion in 71% of cases. A Standardized Field Sobriety Test developed to detect alcohol-impaired drivers also has been validated to screen for drivers impaired by stimulants, depressants, cannabis, or narcotics. Drug screening devices that analyze oral fluid are the best option for roadside use; devices that analyze blood or urine are not practical, and those that analyze breath or sweat have not yet been developed.
Marijuana Research Issues
Dr. Gust reviewed a National Academy of Sciences report that conducted a modified systematic review of evidence regarding the health effects of cannabis and cannabinoid use and identified critical research questions. The expert committee reached 94 conclusions about 11 health end points, judging the level of evidence as conclusive, substantial, moderate, limited, or insufficient. The evidence was conclusive that cannabis or cannabinoids are effective treatments for chronic pain, nausea and vomiting due to chemotherapy, and multiple sclerosis spasticity. Evidence substantially supported nine other conclusions related to respiratory disease, injury, prenatal exposure, mental health, and problem cannabis use. Evidence was moderate, limited, or insufficient for 82 other health issues. The report recommended addressing gaps in clinical and observational health policy and health economics, and public health and safety research; improving research quality and surveillance capacity; and reducing barriers to research.
Mark A. Ware, M.B.B.S., M.Sc., McGill University, drew on his experience as a pain medicine specialist to review demand, regulations, medical professional perceptions, safety concerns, and priorities for medical marijuana research. He concluded that medical use of cannabis and cannabinoids deserves careful consideration, but that research may not follow conventional pharmaceutical drug development pathways. He predicted that changing policies and attitudes would facilitate improved understanding of medical cannabis use. He called for a global, integrated network of credible medical research that addresses safety; qualitative research documenting narratives, experiences, and case reports; and the role of industry. Dr. Ware recommended setting research priorities including efficacy and effectiveness, pharmacology, pharmacosurveillance, screening tools, driving and medical use, drug-cannabis interactions, laboratory testing capacity, drugs, devices, and technologies such as sequencing, extraction, isolation, and big data.
CCSA researchers Anna McKiernan and Katie Fleming reported on a series of focus groups with youth aged 14 to 19 conducted in four Canadian provinces to assess prevention, treatment, and policy information needs. Facilitators explored perceptions about why youth smoke cannabis, the effects of alcohol and cannabis use on driving, the effects of cannabis use on brain development, cannabis addiction, legality of cannabis possession and use, and media portrayals of cannabis use. CCSA concluded that youth need more information about the growing evidence on the positive and negative effects of cannabis. Targeted prevention efforts should provide evidence-informed facts about the use of cannabis by adolescents. As regulations change, youth need facts to inform their decisions to use or abstain from cannabis. Building on these regulations, CCSA has developed tools for parents and teens, such as videos, online learning modules, event guidelines, and teachers’ guides on drug-impaired driving.
Dr. Beirness reported on tests to develop standards for oral fluid screening devices in Canada. The devices were effective in identifying cocaine, methadone, opioids, and the active ingredient in cannabis, THC; they were less effective at identifying amphetamine and not at all effective in identifying benzodiazepines. He stressed that oral fluid testing devices screen for a small number of drugs and rates of false positive or negative results must be examined carefully. In Canada, the results of oral screening may not be submitted as evidence, but serve as probable cause for arresting suspects and conducting additional biological tests. Rachel Huggins of Public Safety Canada reported on a pilot study of two oral fluid devices conducted in seven Canadian jurisdictions to assess their acceptance by law enforcement officers working in a variety of settings, including extreme climates, and the adequacy of training guidelines, standard operating procedures, and device standards. The pilot revealed that officers were comfortable using the devices, but training procedures need to be improved and operating procedures standardized.
Research on HIV and Substance Use Disorder and Kratom
Speakers presented the results of NIDA-supported research testing HIV interventions among drug-using populations. Todd Korthuis, M.D., M.P.H., Oregon Health & Science University, reported on pilot studies to determine the acceptability and feasibility of integrating substance use disorder treatment with HIV treatment. The studies demonstrated that prescribing extended release naltrexone or buprenorphine was acceptable to HIV clinic physicians and patients. Scale-up trials are testing the effect of addiction pharmacotherapy on HIV treatment engagement and HIV viral suppression. In an ongoing study, researchers investigating integrating buprenorphine care in Vietnamese HIV clinics found that Vietnamese stakeholders required multiple addiction medicine training sessions and peer review of national buprenorphine and naloxone treatment guidelines. Cultural differences in family structure meant that in Vietnam, peers and family members play a larger role in recruiting and retaining patients in treatment than their counterparts do in North America.
British Columbia Centre on Substance Use Director Evan Wood, M.D., Ph.D., described the center’s development, which was prompted by an unusual outbreak in HIV infection among a drug-using population served by interventions such as needle exchange programs and safe injection spaces. A donor-funded, purpose-built research building facilitates centralized HIV treatment and data collection. The epidemic’s unique characteristics helped the center qualify for funding through the NIDA International Program Announcements and collaboration with other NIDA-funded studies. The British Columbia Centre on Substance Use has three core functions: education, providing clinical care guidance, and research and evaluation. The center emphasizes research productivity and integrates educational opportunities and mentorship with interdisciplinary research and clinical care. Educational programs include workforce training, licensing, diploma programs, an addiction medicine research fellowship for clinicians, and public education programs. The multidisciplinary research programs are affiliated with the Canadian Research Initiative in Substance Misuse, which conducts social and community-based research, and the NIDA Clinical Trials Network (CTN), which conducts clinically and patient-oriented research. In clinical care guidance, the center has issued new guidelines for addiction treatment.
Frederick L. Altice, M.D., M.A., Yale University, reported lessons learned from three implementation science partnerships in Ukraine: implementing medication-assisted therapies (MAT) in criminal justice settings; expanding MAT in 22 regions; and integrating MAT, HIV, and tuberculosis services in primary care clinics. He recommended that partners commit to the same ideals and that work needs to be locally meaningful, involving fully informed stakeholders and outside experts. He warned partners that situations do not change quickly and anything that can go wrong will. Dr. Altice’s Ukrainian partner is former NIDA Hubert H. Humphrey and INVEST/CTN Fellow Sergii Dvoriak, M.D., Ph.D., Ukrainian Institute on Public Health Policy.
Discussant David S. Metzger, Ph.D., University of Pennsylvania, called the three research teams among the most productive in the world. He stressed that services need to be available, accessible, and affordable. Dr. Metzger urged international research teams to think strategically about how to continue funding and support of international projects after initial grants end.
Turning to kratom, Marek Chawarski, Ph.D., Yale School of Medicine, summarized research conducted by his Universiti Sains Malaysia partners on kratom. Dr. Chawarski briefly outlined findings on kratom pharmacology, pharmacokinetics, toxicity, neurobiology, use patterns, and cognitive and behavioral effects. He reported that current data are insufficient to establish a safety profile of substances found in kratom and that human laboratory studies are in the planning stages. Research is needed to establish a safety profile and evaluate the potential efficacy of kratom to manage pain and opioid withdrawal symptoms. Research challenges include preparing kratom formulations with stable, measurable, and calibrated properties, preparing placebos for blinded studies, and ethical concerns related to cultural and legal contexts of kratom use.
Drug Education and Training Opportunities
Speakers described ways to promote adoption of evidence-based drug abuse education, interventions, and policies through professional development organizations, community education programs, and fellowships. U.S. Department of State Senior Foreign Service Officer Charlotte Sisson described the International Society of Substance Use Professionals (ISSUP), a global network of treatment professionals and prevention specialists supported by the U.S. Department of State Bureau of International Narcotics and Law Enforcement and the Drug Advisory Programme of the Colombo Plan. Partners include the United Nations Office on Drugs and Crime, the World Health Organization, the African Union, and the Organization of American States. ISSUP is mapping treatment capacity, disseminating universal treatment and prevention curricula, and coordinating an international credentialing system. ISSUP Executive Director Riva Setiawan described ISSUP’s approach to promoting ethical, evidence-based practice through online resources, an annual international training and networking meeting, and national chapters to improve local access to knowledge, networks, and information exchanges.
The National Drug and Alcohol Facts Week, supported by NIDA and the National Institute on Alcoholism and Alcohol Abuse, has become an international success, with events in 16 nations featuring community programs, youth volunteers, students, poster contests, lectures, and training programs for health care professionals. The 2018 events will be held January 22–28. International coordinators can download free materials from NIDA and register their events at http://teens.drugabuse.gov/national-drug-facts-week. Former NIDA Humphrey Fellow Mariana Azcárraga-Quiza, M.D., described how she arranged for Mexico City high school students to become the first international participants in Drugs and Alcohol Chat Day, where NIH scientists answer questions submitted online by high school students. Students in Mexico City submitted nearly 200 questions; participation increased when they realized they could submit questions in Spanish and receive answers from Spanish-speaking scientists at NIH. Dr. Azcárraga-Quiza reported that the majority of the students’ questions were related to alcohol (22%), followed by nicotine (8%), cannabis (8%), and cocaine (5%). She suggested that Chat Day questions might indicate drug use trends.
Three former NIDA International Program fellows described how their fellowship experiences helped them advance their careers. Former Humphrey Fellow Adrian Abagiu, M.D., Romania, described how his Humphrey experience helped him expand opioid dependence treatment options, including establishing a needle exchange program, obtaining insurance coverage for addiction treatment, increasing treatment capacity, and collaborating with national, regional, and international colleagues to host scientific meetings and publish reports. He stressed the need to teach junior scientists, expand continuing education programs, and build networks through international societies. Tetiana Kiriazova, Ph.D., Ukraine, discussed how her Humphrey Fellowship professional affiliations helped her win a Humphrey Alumni Impact Award to develop a clinic-based training program for nurses on safety procedures to limit HIV and hepatitis exposure and establish post-exposure prophylaxis treatment. The course improved safety, perceptions of risk, and attitudes toward caring for people living with HIV. Fernanda de Conto, M.S., Brazil, described a research partnership she developed with NIDA-funded researchers during her Humphrey Fellowship. The project compared clinical and psychosocial characteristics of males and females with substance abuse or mental health problems.
More details about the 2017 NIDA International Forum are available online: