2021 NIDA International Forum: Building International Collaborative Research on Drug Abuse

June 21–24, 2021
Virtual Meeting

NIDA International Program Director Dr. Steve Gust chaired the 2021 NIDA International Forum, which was held in conjunction with the College on Problems of Drug Dependence (CPDD) Annual Scientific Meeting. More than 80 researchers from more than 35 countries presented their findings in the NIDA International Poster Gallery on the CPDD virtual meeting platform. Three virtual plenary sessions featured presentations by researchers from 18 nations and 12 time zones. In lieu of travel awards, the NIDA International Program and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) supported CPDD meeting registrations for Forum presenters.

Dr. Gust chaired the opening plenary session, which reviewed NIDA efforts to support graduate, professional development, and technology transfer programs that promote adoption of evidence-based innovations and educate addiction researchers and treatment providers. The opening plenary also examined the short- and potential long-term impacts of COVID-19 on substance use around the world, presenting data from EMCDDA and the NIDA-supported Global Study of Stress and Resilience in the Face of COVID-19.

Ms. Anja Busse, program officer at the Prevention, Treatment and Rehabilitation Section of the United Nations Office on Drugs and Crime (UNODC) Drug Prevention and Health Branch, chaired the second plenary session, which described the development, field-testing, quality assurance testing, and implementation of drug use disorder treatment standards. Speakers included scientists from UNODC, the World Health Organization (WHO), the U.S. Department of State, and six nations: Australia, Chile, Indonesia, Nigeria, Pakistan, and Spain. Dr. Gust also chaired the final plenary session, which featured rapid research reports from 11 researchers in nine countries. Speakers from Brazil, Canada, Georgia, Mexico, Palestine, and Romania discussed the impact of COVID-19 on substance use in their countries. Other topics included service dogs as complementary therapies for Canadian veterans with post-traumatic stress disorder (PTSD) and problematic substance use; cannabis use by female students in Ecuador; implementing the Universal Prevention Curriculum among drug demand reduction practitioners in Nigeria; and translating a standard stigma scale in Pakistan.

NIDA Support to Develop the Addiction Workforce

Dr. Kimberly Johnson, University of South Florida and executive director of the International Consortium of Universities for Drug Demand Reduction (ICUDDR), described the global network of universities working to improve education for substance use prevention and treatment professionals. The U.S. Department of State Bureau of International Narcotics and Law Enforcement Affairs (INL) worked with the Colombo Plan and the Organization of American States to create the network, which has grown to include 270 universities in 72 countries. ICUDDR focuses on developing the network; encouraging academic and continuing education programs for addiction prevention and treatment professionals; advancing applied research in addiction prevention and treatment; enhancing partnerships between universities, addiction professionals, and addiction researchers; and advocating for policy changes to enhance addiction prevention and treatment services, within universities for academic programs in addiction studies, and within the profession for evidence-based standards in providing services. There are 27 new addiction studies programs in development that are expected to be launched in 2022 or 2023.

Dr. Johnson described two NIDA-supported ICUDDR initiatives: a joint project between ICUDDR and the International Society of Addiction Journal Editors (ISAJE) to create an academic course in writing for peer-reviewed journals and two learning collaboratives of 23 faculty members learning how to use the ISAJE materials in their own writing and adapt the experience to teach their students. The learning collaborative will be evaluated on whether any of the 23 faculty members publish papers and to what extent participants use what they learned in their own classrooms. For the course development project, universities in Albania, Indonesia, Kenya, South Africa, Uganda, and Ukraine submitted competitive applications. The ICUDDR/ISAJE review committee unanimously selected Kenyatta University in Nairobi, Kenya, with Beatrice Kathungu as principal investigator for the project. Work began in January on a three-credit course on scientific writing that will become a mandatory element of the postgraduate diploma in addiction science and will be open to master’s and doctoral students in the psychology department. The course development project will be evaluated on four criteria:

  • Success in developing an effective curriculum
  • Success in obtaining university approval to offer the course
  • Success in encouraging students to take the course
  • Success in encouraging other universities to adopt or adapt the course.

Dr. Mary Loos, programme director for the International Programme in Addiction Studies (IPAS), described the unique online postgraduate degree and certificate program, which features an international perspective for both faculty and students. Adelaide University in Australia, King’s College London in the United Kingdom, and Virginia Commonwealth University in the United States created the program in 2006 with support from NIDA and input from WHO. The goal was to increase research capacity and focus on addiction policy and public health issues. IPAS currently offers three nested graduate program options:

  • Graduate Certificate in International Addiction Studies: Intermediate Concentration
  • Graduate Certificate in International Addiction Studies: Advanced Concentration (known as a postgraduate diploma in the United Kingdom and Australia)
  • Master of Science in Addiction Studies.

The IPAS faculty includes substance use and addiction experts from around the world, who focus on the biological basis of addiction, public health approaches, addiction policy, and critical issues in treating substance use disorders, including psychosocial and pharmacotherapeutic interventions. Master’s degree graduates complete a unit on research methods and an independent research project. Degrees and certificates are jointly awarded by all three universities. The 120 master’s degree graduates and 12 certificate recipients represent 28 nations on six continents. Graduates work in medicine, nursing, counseling, social work, advocacy, law enforcement, research, and policy. About 10% entered or have completed doctoral programs and 20% continue to conduct addiction research, often collaborating with fellow IPAS students or faculty members. Dr. Loos added that the Virginia Commonwealth University campus also hosts the NIDA Hubert H. Humphrey Fellowship Program as part of the larger U.S. Department of State Humphrey Program, which introduces NIDA Humphrey Fellows to the IPAS program. Some Humphrey Fellows take IPAS courses during their fellowship year; four have received their IPAS master’s degree and three more are enrolled in the master’s program.

Ms. Laurie Krom, director of the International Technology Transfer Center (ITTC) Network Coordinating Office at the University of Missouri–Kansas City, described the newly launched ITTC network. Technology transfer is the process of accelerating the diffusion of what is known (research) to what is done (practice). Ms. Krom discussed how ineffective or insufficient implementation of evidence-based interventions can lead to unsustainable, poor, or inconsistent outcomes. The ITTCs help ensure that proven innovations in research, standards, and policies are successfully implemented and incorporated into regular practice. They are based in universities to draw on academic expertise and to provide continuity and sustainability while serving as neutral conveners for individuals, governments, community-based organizations, researchers, and service providers. ITTCs manage a continuum of processes—development, translation, dissemination, adoption, and implementation—to disseminate innovations using transdisciplinary, integrative, and dynamic approaches. The goal is to build capacity across individuals, organizations, networks, and systems to provide high-quality substance use prevention, treatment, and recovery services.

Ms. Krom added that ITTCs are currently operating in South Africa, Ukraine, and Vietnam. She said the United Arab Emirates was scheduled to launch an ITTC in late June, followed by Peru in July and Indonesia in August. With partial support from INL, the ITTC network is a branch of ICUDDR. The new ITTCs are based on the 30-year-old Addiction Technology Transfer Centers established domestically by the Substance Abuse and Mental Health Services Administration (SAMHSA). The President’s Emergency Plan for AIDS Relief and SAMHSA originally supported the ITTC program to address drug-related HIV/AIDS.

 Global Impact of COVID-19 on Substance Use

Mr. Paul Griffiths, scientific director EMCDDA, described how the organization launched a series of Trendspotter studies using a flexible but structured rapid assessment process to provide preliminary data on the impact of the COVID-19 pandemic on drug use in the European Union. Assessments used a variety of mixed methods; wastewater analysis proved particularly useful. The first assessment was issued within 5 weeks of the first report of COVID-19 cases. Mr. Griffiths described how the pandemic highlighted the need to assess information quickly and sensitively at a systems level, answering questions that changed over time. He suggested that moving forward, adapting information gathering might be more important than precisely documenting the past.

The EMCDDA Trendspotter reports identified increased use of intermodal containers and sea routes to smuggle drugs, temporary shortages and higher prices for drugs in some areas during lockdown, disruptions in distribution and retail sales due to social distancing measures, and the move toward digital drug markets. Retail drug markets proved resilient, adapting quickly to offer online options such as social media and encrypted apps, with distribution using postal services, impersonated legitimate delivery services, and espionage-like dead drop techniques. Mr. Griffiths warned that these digital drug markets may have significant long-term effects on the retail drug market. Demand for cocaine, MDMA, and other stimulants dropped significantly during lockdown but bounced back rapidly after restrictions eased. Although the pandemic had no impact on the availability of cannabis, regular users reported using the drug more frequently while occasional users reported using the drug less frequently. Use of psychedelics and dissociative drugs increased due to boredom and escapism.

EMCDDA also documented how the pandemic forced drug services to rethink their operations, as they addressed challenges in delivering treatment as usual for individual clients and prevention, health promotion, and harm reduction services in community settings. For the most part, existing clients continued to receive medication-assisted therapies, but service was disrupted, and new treatment demands increased during the second half of 2020. Patients and providers now view telemedicine as a valuable tool, but concerns remain about quality of treatment, patient retention, and access for marginalized groups. Illicit drugs were less available in criminal justice settings because most drugs used in prisons are delivered by visitors, and visitors were banned during the pandemic. This increased concerns about prisoners’ mental health and the need to increase use of treatment medications in criminal justice settings.

Mr. Griffiths identified potential warning signs in drug use trends, including the impact of rebound demand on drug-related deaths, adulterated or synthetic cannabis that was linked to 21 deaths, increasing reports of crack cocaine and benzodiazepine use, and the economic impact of increased availability of smaller, cheaper doses of crack cocaine, heroin, and benzodiazepines. He added that increased benzodiazepine use might be an indicator of the pandemic’s psychological impact.

Dr. Mustafa al’Absi, University of Minnesota Medical School, reported on the results of the Global Study on Stress and Resilience in the Face of COVID-19. The study captured ongoing challenges experienced during lockdown by 5,123 men and women age 18 and older. The online study was available in English and eight other languages; participants were recruited through multiple approaches including social media and professional contacts. Preliminary findings showed increases in self-reported levels of depression, anxiety, stress, social isolation, uncertainty about the future, and financial worries. Higher levels of depression, stress, social isolation, uncertainty, and poor sleep quality during the pandemic predicted increased nicotine and alcohol use. Resilience did not seem to buffer these relationships for nicotine use, but lower levels of resilience and social support during the pandemic were associated with increased alcohol use. Increased cannabis use was predicted by higher levels of depression, anxiety, and stress. Alcohol sales rose by more than 25% during the pandemic. An analysis of 500,000 urine drug tests showed an increase of 32% for nonprescribed fentanyl; 20% for methamphetamine; and 10% for cocaine. Some states reported an 18% increase in drug overdoses.

Dr. al’Absi noted that many researchers have reported increased drug use during other societal changes, such as economic downturns, or major life events. The COVID-19 pandemic affected individuals from around the world, causing deteriorated mood; increased stress, uncertainty, and social isolation; and reduced access to treatment for substance use dependence either due to fear of contracting COVID-19 or because access to services was limited or eliminated during lockdowns. He predicted that the pandemic may impact mental health, substance use, other behavioral risk factors, and cognitive health for decades.

UNODC/WHO International Standards for the Treatment of Drug Use Disorders

Ms. Giovanna Campello, chief of the Prevention, Treatment and Rehabilitation Section of UNODC, opened the session by thanking the NIDA International Program for continuously providing a platform for collaboration and exchange among researchers from around the world. “We use the platform a lot,” she said, “and we hope to continue doing so for a long, long time.” Thanking INL for supporting development of the International Standards for the Treatment of Drug Use Disorders, Ms. Campello said the standards are an example of how WHO and UNODC work collaboratively to develop technical guidance that is directly relevant to UN member states, civil society, and people with drug use disorders. She urged participants to promote COVID-19 vaccination plans that prioritize people with drug use disorders, who are more susceptible to adverse effects from the virus.

Dr. Andrew Thompson, INL narcotics science advisor, said that stigma against people with drug use disorders is one of the most pernicious challenges facing substance use prevention, treatment, and recovery support professionals. The international treatment standards will help combat attitudes that people with substance use disorder are responsible for their own suffering, that they aren’t deserving of quality care, or that the resources being spent on their treatment would be better spent elsewhere. The treatment standards use a radically different approach: Individuals with substance use disorders deserve nothing less than ethical and science-based standards of care similar to those adopted for other chronic diseases.

Ms. Anja Busse, program officer in the UNODC Prevention, Treatment and Rehabilitation Section, chaired the session and introduced the global situation with drug use: About 35.6 million people who use drugs suffer from drug dependence, and only 1 in 8 has access to treatment. The quality of treatment is often low, with many commonly used treatments ineffective, harmful, or not in line with public health principles. Patient outcomes are a key measure of treatment quality. Treatment should show evidence of symptom reduction; contribute measurably to physical, psychological, and social functioning improvements; and decrease the risk for negative health and social consequences from drug use. International treaties call for all nations to provide drug use prevention and treatment programs. The Commission on Narcotic Drugs, the UN General Assembly Special Session on the World Drug Problem, and the Sustainable Development Goals have all supported development of evidence-based, effective, and ethical standards of care. The first draft of those standards was released in 2016 and field-tested by 1,200 professionals around the world.

Dr. Dzmitry Krupchanka, medical officer in the Alcohol, Drugs and Addictive Behaviors Unit at WHO, described the development and field-testing of the first draft of the international treatment standards. Beginning with a rough outline, WHO and UNODC convened experts to build consensus, conducted literature reviews, and incorporated previously issued WHO recommendations and standards. Field-testing included key informant surveys, focus groups, external expert reviews, and site visits in nine countries: Australia, Brazil, Chile, China, India, Indonesia, Iran, Mexico, and Thailand. Each country rated the standards on utility, appropriateness, comprehensiveness, and feasibility of implementation. Feasibility raised the most issues, with numerous bottlenecks to adoption within the varied national treatment systems. Following these field tests, the standards were restructured, primarily to add new sections and adopt more user-friendly language.

Researchers from Indonesia and Chile reported on how field-testing for the 2016 draft of the international treatment standards was conducted in their countries.

Dr. Eva Suryani, a psychiatrist at the School of Medicine and Health Science at Atma Jaya University in Indonesia, described the results of a key informant survey, focus groups, and an expert review committee. All groups found the standards useful and comprehensive, but expressed reservations about implementation. Issues identified included stigma, funding, inadequate health facilities, lack of competent personnel, limited access to services in remote areas, cultural resistance to family-based interventions, and restrictions imposed by national labor, health care, and criminal justice policies. Expert reviewers sought more detailed guidelines on treating withdrawal, serving vulnerable populations, and prescribing appropriate medications at adequate dosing levels.

Dr. Carlos Ibáñez Piña, a psychiatrist and chief of the addiction unit at the School of Medicine at the Universidad de Chile, also described the opinions from a key informant survey, focus groups, and an expert review committee. The groups found the 2016 draft standards comprehensive, adequate, and useful, but thought it was only 50% feasible to implement them in Chile. The primary criticisms were an overemphasis on opiates and a neglect of alcohol and smokable cocaine. Other barriers were insufficient financial resources and lack of trained personnel.

Dr. Wataru Kashino, a program officer in the UNODC Prevention, Treatment and Rehabilitation Section, described the revised international treatment standards and the mechanisms for implementing them. He explained that the goal is to offer the most effective, least invasive, and lowest-cost drug treatment intervention first while also understanding the necessity of personalizing treatment to match individual needs. The standards describe drug use disorder interventions such as screening, brief intervention, and referral to treatment; evidence-based psychosocial and pharmacological therapies; overdose identification and management; and recovery support. The standards are designed for use in a wide variety of settings, including community-based outreach; nonspecialized settings (mental health services; general hospitals; emergency services; welfare and social service agencies; and sexual health, infectious disease, HIV, hepatitis, or TB clinics); and specialized outpatient, short- or long-term inpatient, and residential treatment facilities. In addition to drug use disorders, the standards address co-occurring psychiatric and physical health conditions, vulnerable populations, and drug policies.

Dr. Kashino added that quality assurance tools have been developed to help implement the standards for treatment systems and services. There are five standards and 19 criteria to evaluate treatment systems and 34 standards and 134 criteria to evaluate treatment services in six general categories. UNODC conducted full pilot tests of the treatment services quality assurance standards in Afghanistan and Nigeria, delivered training programs in 12 countries, and launched on online train-the-trainers program. A treatment systems quality assurance project has launched in Pakistan and others are being developed in 11 Latin American and Caribbean nations.

Dr. Auwal Sani Salihu, head of the department of psychiatry at the Aminu Kano Teaching Hospital in Kano, Nigeria, described how quality assessment teams evaluated programs at the service level. Two or three team members toured each of 13 pilot test sites, interviewing key informants and patients and reviewing case studies. The team members assessed each site, then harmonized their individual scores and wrote a report on their visit. The full quality assurance team reviewed these reports and developed a consensus opinion for each site. Only three of the sites were designated drug use treatment sites. Dr. Salihu reported that all of the sites “required tremendous improvement” in areas ranging from staff training and provision of mental health services to basic hygiene and abuse of patients. The quality assurance teams helped site managers and government agencies to identify training and resources necessary for developing and implementing improvement plans. In turn, the quality assessment teams revised the assessment tools and identified capacity building and resources needed to sustainably expand the program.

In Pakistan, quality assessment focused on federal and provincial systems to support evidence-based treatment for substance use disorders. Mr. Sabino Sikander Jalal, senior joint secretary in the Pakistani Ministry of Narcotics Control, reported on the quality assurance survey of key informants and a feasibility study that identified numerous areas of needed improvement in the country’s health, education, social welfare, judicial, and criminal justice systems to meet the international treatment standards. As part of the government commitment to address these gaps, Mr. Jalal described a 5-year plan to create a “groundbreaking regulatory framework” to improve government policies, establish a drug monitoring system, and institute accreditation and accountability measures for drug treatment and prevention providers. The Drug Demand Reduction Quality Assurance Technical Committee has prepared draft legislation to achieve this goal.

Overdose prevention is one area within the international treatment standards. Professor Paul Dietz, director of the behavioral and health risk program at the Burnet Institute in Australia, described the UNODC/WHO multisite study on community management of opioid overdose, including emergency naloxone, that was conducted in Kazakhstan, Kyrgyzstan, Tajikistan, and Ukraine. The Stop Overdose Safely (S‑O‑S) study explored the feasibility and impact of community management of opioid overdose, including the use of take-home naloxone. The study focused on people likely to witness opioid overdose, hoping to train 90% of the target audience, give doses of take-home naloxone to 90% of individuals who have been trained, and have 90% of those people carry the naloxone. About 35% of the cohort reported witnessing an overdose in the 6 months since they were trained, and 89% of those individuals reported administering naloxone at the overdose they witnessed. Importantly, in 98% of those instances, the victim survived. The study concluded that take-home naloxone can be implemented, at scale, using the S‑O‑S protocol in these countries; the S‑O‑S training protocol works to improve responses by overdose witnesses, and S‑O‑S participants administer naloxone at witnessed overdoses in line with expected targets. Future studies will examine sustainability in the original countries and expanding S‑O‑S to other countries.

Dr. Marta Torrens, head of the addiction program at the Universitat Autónoma de Barcelona in Spain, used her clinical perspective from treating pregnant women diagnosed with drug use disorders to discuss the international standards chapter on populations requiring special treatment and care. The standards were field-tested in Argentina, Ecuador, and Ukraine, with good results in all three countries.

The standards stress that pregnant women with drug use disorders have the right to both drug treatment and pregnancy care, and they have better long-term outcomes when they receive treatment that focuses on issues more commonly found among women with drug use disorders. Guidelines address screening and intake, assessment, treatment planning, and treatment approaches. When entering drug treatment, all women of childbearing age should be screened for pregnancy as well as acute medical conditions, risk of withdrawal, need for withdrawal management or detoxification, and risk of harm to self or others. Assessment must be accurate to ensure proper diagnosis and treatment placement.

Individual treatment plans should consider the woman’s preferences and fully involve her in planning and setting goals. Given the rapid changes that occur throughout pregnancy and following delivery, treatment plans should be reviewed regularly, involve collaboration with obstetricians and gynecologists, and closely monitor fetal development. Treatment approaches must be evidence-based, appropriate for the level and pattern of drug use, include psychosocial and relevant pharmacological interventions, and use comprehensive women-centered interventions. The treatment plan also must anticipate delivery, postpartum, and breastfeeding concerns for the mother as well as postnatal concerns, including neonatal withdrawal syndrome, for the baby. Dr. Torrens stressed that not only medical staff, but also secretarial and managerial staff who have contact with patients, must be trained to avoid stigmatizing pregnant women with drug use disorders.

Ms. Busse ended the session by describing additional dissemination tools and strategies under development. UNODC is developing a quality assurance toolkit for opioid medication-assisted treatment services and, with WHO, is improving dissemination and implementation of the International Standards for the Treatment of Drug Use Disorders. She invited participants to join the network on quality assurance in drug treatment established on the International Society of Substance Use Professionals website (https://www.issup.net).

Rapid Research Reports From Around the Globe

Eleven researchers presented 5-minute summaries of their research. Seven presentations examined the impact of COVID-19 around the world.

  • João Maurício Castaldelli-Maia, a NIDA INVEST Fellow with Dr. Silvia Martins at Columbia University, discussed a retrospective study of substance use in 1,000 Brazilian patients with mild cases of COVID-19. Researchers assessed frequency of substance use at three time points: the month before getting COVID, the month just after having COVID, and the month just before the online survey. Levels of alcohol and tobacco use decreased in the month just after COVID, and the levels of nonmedical use of analgesics increased in the month just after COVID. For tobacco use and nonmedical use of analgesics, use levels reverted to pre-COVID levels, whereas levels of alcohol use were higher than in the post-COVID period but lower than pre-COVID levels. There were no specific associations between previous substance use and COVID symptoms or severity, nor between COVID severity and post-COVID substance use. There were, however, new pathways for substance use: People who had used nonmedical analgesics prior to COVID reported using benzodiazepines and cannabis during the month before the survey; cannabis use also was reported during that period by people who had used tobacco prior to COVID; and people who reported alcohol or benzodiazepine use prior to COVID reported nonmedical use of analgesics during the month before the survey. A follow-up study is underway to assess substance use, depression, and anxiety.
  • Anna Goodman, a research and policy analyst at the Canadian Center on Substance Abuse and Addiction (CCSA), described Canadian perceptions and experiences with virtual services. CCSA conducted a quantitative survey with 1,000 respondents who had substance use disorders or comorbid conditions, a survey of the general public, and qualitative interviews with 14 service providers. Among clients, two-thirds were satisfied with the services, but slightly less than half said they would prefer to continue using virtual services. Service providers felt virtual care was not as effective as in-person care, reported a steep learning curve for both patients and providers, and noted that marginalized populations could not access technology. Comfort with technology strongly influenced views of virtual services, as did gender, age, race, and geography. More men endorsed virtual services; respondents aged 34 to 55 reported privacy was a barrier to virtual service; and those over aged 55 had less faith that they could build rapport with a provider virtually. The researchers recommended developing a hybrid approach to providing services, including considering providing technology and internet access to populations without access.
  • Sarah Moreheart, a doctoral student at Simon Fraser University, presented preliminary work on the impacts of the COVID-19 pandemic and the opioid poisoning epidemic on overdose prevention and risk among sex workers in Vancouver, Canada. A questionnaire asked about health, safety, changes to working conditions, and substance use during the pandemic by participants enrolled in an open-perspective, community-based cohort of more than 900 indoor, street-based, and online sex workers. A total of 179 sex workers completed the survey; more than 60% reported a negative change to their illicit drug supply, including decreased availability, quality, or accessibility of illicit drugs. Just more than 20% had accessed Safer Supply, the government-regulated prescription program, which in bivariate analysis had a statistically significant association with reports of accessing overdose-prevention sites, experienced barriers to health care in the last 6 months, and injection drug use in the last 6 months. In multivariate analysis, there were higher odds for reporting negative changes to illicit drug supplies among women who inject drugs, as well as those reporting barriers to health care. Marginally higher odds were associated among women accessing overdose-prevention sites. Harm reduction and other health- and safety-related spaces tend to be male-oriented and are especially dangerous for women facing the overlapping stigmas of substance use and sex work. Ms. Moreheart stressed that a major consequence of both COVID and the ongoing opioid poisoning epidemic is that the illicit drug supply market is tainted, and people simply do not know what’s in the drugs that they’re buying in the illicit market. She added that mitigating the negative impacts of the overlap in the COVID-19 and opioid overdose public health crises requires informed policy decisions and critical investment in sex-worker and women-led interventions.
  • Ada Beselia, a research assistant at the Alternative Georgia Addiction Research Center, discussed a study examining trends in illicit drug sales on the darknet Matanga website during COVID-19 restrictions. The research team used locally developed software to scrape and export data from 22,000 Matanga transactions worth $4.5 million between April and September 2020. Nineteen categories of substances were sold, with an average of 132 daily transactions. Cannabis was the most frequently purchased substance in both volume (48.5%) and number of transactions (67.1%), followed by cocaine and MDMA/Ecstasy. Cannabis also accounted for the largest share of revenue, followed by cocaine and crystal methadone. Other substances sold in relatively large amounts included MDMA/Ecstasy, heroin, the synthetic cathinone alpha-PVP, methamphetamine, and the synthetic hallucinogen NBOMe. Ms. Beselia noted that continuous monitoring of online platforms for illicit drug sales can provide useful data to better understand the dynamics of the illicit drug market, can help identify emerging drug supply patterns, and can be an important source of data for a national early warning system.
  • Judith Ferrer-Alarcón, a psychologist with the Mexican Observatory of Mental Health and Drug Use at the National Commission Against Addictions, presented the results of an online survey of 17,267 people; 62% were female, and the average age was 40.9 years. The Organization of American States Inter-American Drug-Abuse Control Commission designed the 27-question survey. Since the pandemic began, 48.3% of the respondents worked or studied from home and 39% were required to work in person. During the past 12 months, the most common substances used were alcohol, cannabis, and tobacco. Illegal drugs were obtained by 9.6% of respondents; however, 5.4% of respondents mentioned that it was difficult to obtain illegal drugs. During lockdown, 59% of illegal drug users reported that they had stopped using drugs; however, 10.4% increased cannabis use. Anxiety, stress, and self-isolation motivated participants who increased drug use. Patterns of alcohol and tobacco use remained unchanged. A follow-up survey is planned for September and October 2021.
  • Ahmed Farhoud presented the results of a study conducted under the direction of Dr. Basma Damiri, an associate professor at the National University in Palestine. Researchers investigated the prevalence of depression and its association with use of cognitive enhancers and psychostimulants among medical and nonmedical university students in West Bank Palestine during the COVID-19 pandemic. Cigarette smoking was highly prevalent among university students—39.3% of males smoked cigarettes—and was associated with all levels of depression: severe (OR = 4.5, p= 0.001), moderate (OR = 3.3, p < 0.001), and mild (OR = 2.3, p = 0.002). Medical students were less likely than nonmedical students to have severe depression, and males were less likely than females to have moderate or mild depression. Waterpipe smoking, e-cigarettes, and energy drink consumption were all highly prevalent among university students; the gender gap between males and females in waterpipe smoking was narrower than that in cigarette smoking. No association was found between depression and waterpipe smoking, e-cigarettes, energy drinks, coffee, tea, or chocolate. The most prevalent motivations for substance use were curiosity for cigarette smoking and energy drink consumption; fun for waterpipe smoking; and increasing wakefulness and improving vigilance and attention for energy drinks, coffee, and tea consumption. About 10% of smokers said COVID-19 was a motive for smoking.
  • After the first 6 months of the pandemic, Dr. Adrian Abagiu noticed that the percentage of COVID infections was lower among patients receiving methadone maintenance therapy (MMT; 0.87%) or attending needle and syringe exchange programs (NSEP, 1.2%) when compared to the general population of Romania (3.7%) or residents of Bucharest (5%). Similar findings were reported by participants in the November 2020 meeting of the International Society of Addiction Medicine. Among Romanian MMT patients, 96% were receiving less than 60 mg of methadone; 65% of NESP participants combined psychostimulants and heroin. Drawing on work published by Luigi Attademo and Francesco Bernardini, Dr. Abagiu described how gene co-expression and co-regulation between angiotensin-converting enzyme 2 (ACE2)—which encodes the main receptor for the spike of COVID-19—and dopa decarboxylase (DDC)—which encodes the enzyme that catalyzes the biosynthesis of dopamine, serotonin, and histamine—may protect individuals with fewer dopamine receptors, such as children and people with Parkinson’s disease or drug use disorders. Dr. Abagiu is a former NIDA Humphrey Fellow, senior physician at the Romanian National Institute for Infectious Diseases, and medical coordinator of the ARENA Opioid Maintenance Therapy Center.

Four researchers addressed issues in addiction treatment, epidemiology, capacity building, and adapting standardized instruments for use in other languages and cultures.

  • Colleen Dell, a professor and the Centennial Enhancement Chair in Health and Wellness at the University of Saskatchewan, discussed a pilot study examining whether and how service dogs assist veterans diagnosed with PTSD in addressing problematic substance use. The quantitative analysis measured substance use in five veterans with PTSD at six points—at baseline and at 1, 3, 6, 9, and 12 months. Comparing baseline and 12-month means for the PCL-5 PTSD Checklist and the Drug Use Screening Inventory (DUSI), the Reliable Change Index suggested a clinically significant decrease in scores and symptoms. The interviews echoed the quantitative findings: Three of the five veterans attributed fewer nightmares, less hypervigilance, and more focus to their relationship with their service dog. The DUSI revised substance abuse scale changes were not significant. In interviews, the veterans reported decreased use of opioids and alcohol; some reported increased use of medical cannabis. Some veterans reported increased PTSD symptoms and substance use as they began bonding with the service dogs. Dr. Dell noted that this study suggests that service dogs can be a complement for treatment and provide some benefits to veterans diagnosed with PTSD. She added that standardized instruments do not adequately capture the human/animal bond, so qualitative research is needed to assess the impact of nonjudgmental support provided by service dogs for veterans, criminal justice populations, or other individuals who are struggling with problematic substance use.
  • Daniela Ocaña-Gordillo, a sociologist and former NIDA Humphrey Fellow, described correlates of marijuana use and problems of use in a nationally representative sample of female students, aged 11 to 18, in Ecuadorian secondary schools. The more than 34,000 surveys were administered in 2016. Measures included lifetime and problematic use of marijuana; risk factors such as ease of access to marijuana and peers’ use of alcohol, tobacco, and marijuana; and protective factors such as parental monitoring, familial engagement, and perceived security around schools. Once the girls started using marijuana, the sole predictors for problematic use were peer use of marijuana and frequency. Ms. Ocaña-Gordillo noted that tailored prevention interventions must be developed for girls who have started using marijuana, specifically addressing their needs and their experiences with use of marijuana and other substances.
  • Martin Agwogie is the founder and executive director of the Global Initiative on Substance Abuse, a nongovernmental organization that coordinates training on Universal Prevention Curriculum in Nigeria, as well as substance abuse treatment, capacity building, and policy. He is also a former NIDA Humphrey Fellow and former Distinguished Humphrey Leadership Fellow. Dr. Agwogie assessed the implementation of the Universal Prevention Curriculum among drug demand reduction practitioners in Nigeria, using three instruments: a pre- and post-knowledge assessment, a qualitative post-training survey, and a trainer proficiency survey. The outcomes were feasibility, success in meeting training objectives, fidelity, trainer proficiency, and connections between Wenger’s communities of practice model and essential components of the implementation process. Of 202 participants, 96% demonstrated objective gains in foundational knowledge. All participants agreed that the curriculum was implemented as designed, objectives were met, and the course is relevant to their practice. All facilitators were ranked “proficient” in subject knowledge, ability to engage participants in the learning process, supervision of the training environment, time management, and demeanor. The practitioners who participated in the study work in varied professional environments and came from locations that include diverse ethnic groups across Nigeria with very different languages and traditions. Dr. Agwogie concluded that they all agreed that the relevance of the training demonstrates the feasibility of implementing a standardized curriculum of substance use prevention in Nigeria.
  • Salman Shahzad, associate professor in the Institute of Clinical Psychology at the University of Karachi, Pakistan, another former NIDA Humphrey Fellow, described the process of translating and validating a standardized instrument for use in Pakistan. First, the Perceived Stigma of Substance Abuse Scale (PSAS) was forward and backward translated into Urdu. Dr. Shahzad recruited 200 male patients with substance use disorders. Participants’ mean age was 29 years, and 82% had completed the 10th grade. Heroin was the most commonly used substance (39%), followed by polydrug use (37%) and hash and methamphetamine (11% each). The internal consistency, test-retest reliability, and validity analyses of the PSAS suggest that perceived stigma has a significant negative relationship with self-esteem and perceived social support in Pakistani patients with substance use disorder. Dr. Shahzad added that the findings have implications for clinicians, mental and medical health care professionals, and public health experts to develop evidence-based, culturally sensitive interventions to reduce stigma and discrimination and improve the mental health, social support, and well-being of patients with substance use disorders.