Questionnaire

Drug addiction is seen as many different things: a social ill, a personal vice, a genetic frailty. Nora Volkow, MD, wants people to know that, above all, it's a brain disease.

Volkow, the great-granddaughter of Bolshevik revolutionary Leon Trotsky, has served as director of the National Institute on Drug Abuse in Bethesda, Md., since 2003. She emphasizes addiction's disease nature because it helps destigmatize addiction and encourages research into both behavioral and medical therapies. For her efforts, Time magazine included Volkow in its list of 100 influential people in 2007.

The Monitor asked Volkow about the changing landscape of drug addiction in the United States, new trends in treatments, and what works when combating addiction.

How is drug use in this country evolving?

There is a preference nowadays for prescription medications. These drugs are much more widely available than they were 10, 15 years ago. Secondly, there's a much greater diversity of prescription products (such as OxyContin, Vicodin and Xanax) with respect to these types of drugs than there was in the past. And third, there's a misconception that because these drugs are prescribed by physicians, they are less risky than classic illicit substances. But when used inappropriately, they are just as dangerous and addictive.

What's new in terms of treatments for addiction?

We're excited about the many new compounds under development for stimulant addiction, and more being developed for addiction to marijuana, opiates and other drugs. One new strategy involves using "vaccines," or immunotherapies, which target the drug itself—rather than the implicated neural pathways or receptors—by binding to the drug and blocking its entry into the brain. Cocaine and nicotine vaccines are both under study, and one for methamphetamine addiction is under development. Also, cognitive behavioral therapy shows good outcomes with substance abuse dependent patients, but it remains underused. A NIDA-supported clinical trial showed that patients who received computer-delivered cognitive behavioral therapy (called CBT4CBT) used fewer drugs and had longer continuous periods of abstinence than standard treatment alone.

Are there any emerging addiction trends psychologists should be aware of?

National surveys have long documented the high prevalence of drug abuse among people diagnosed with psychiatric disorders, such as ADHD and PTSD. We've supported research focusing on genetic and gender vulnerabilities, similar brain regions involved in co-morbid disorders, and environmental and developmental influences. That's been underscored lately in the emerging mental health needs of our returning military members and other veterans, many of whom suffer from co-morbid substance abuse problems and PTSD, as well as chronic pain.

NIDA recently released a report stating that marijuana use has dropped substantially in young people. Did anything else drop, too?

For the last eight years, we've seen significant decreases in the rate of substance use, period, both licit and illicit. It's not just marijuana that has gone down—actually, the most dramatic decrease in drug abuse among young people is in cigarette smoking. In eight years, we've seen close to a 50 percent reduction in the rate of smoking behavior in high school students.

How do you explain that remarkable drop?

Initially, anti-smoking campaigns targeted older adults, and there was a lot of frustration in the field because people were saying, "But we're not reaching the young people." Twenty years ago, it was thought that it was harder to change patterns of behavior in young people. But that's not true. We've learned that it's important to tailor prevention interventions for a particular age group. I would say that the American Legacy Foundation's advertising campaign against cigarette smoking has been particularly good [the popular "Truth" anti-smoking ads that showcase cigarette ingredients and visually demonstrate the numbers of people harmed by smoking-related illnesses]. Studies on the efficacy of this campaign have been able to directly ascribe some of the decline to the advertisements that have come out of it. They've created anti-smoking as a brand itself and made it cool not to smoke. Whereas normally young people use drugs as a way of rebelling, the campaigns are saying, "No, rebel against these cigarette companies that actually represent what's negative about the system and are just interested in making money at the expense of the well-being of individuals." It's targeted at that rebelliousness, and I think that's been very successful.

How do you reach people who don't fall within a campaign's target demographic?

One thing that's interesting is that you can affect one person, and that one person, through his or her social network, can affect behaviors in other people. There was a paper published in May (New England Journal of Medicine, Vol. 358, No. 21) that found that if one of your friends stops smoking, and you're a smoker, that will increase the probability of you[r] stopping smoking between 36 percent and 43 percent. It is a pretty dramatic effect that these social systems have on your behavior. If your spouse stops smoking, that increases your likelihood of stopping smoking by 67 percent. So you can do an intervention that targets one person, and that will have downstream effects on those close to that individual.