Drug abuse: Robert Brooner, PhD, researches, teaches and treats it.

"I have a diverse set of responsibilities that keep my day-to-day experience interesting, challenging and sometimes a bit overwhelming," says the 49-year-old Johns Hopkins professor of medical psychology.

As principal investigator for the Mid-Atlantic Node of the National Institute on Drug Abuse Clinical Trials Network (CTN), Brooner spends almost half his time providing overall administrative and scientific leadership to the project. In addition, he oversees the Addiction Treatment Services program of the Johns Hopkins Bayview Medical Center, a job that entails mentoring faculty and postdocs, supervising senior clinical and research staff and delivering direct clinical services to patients in his treatment program. In the spaces between this "sometimes hectic schedule," Brooner writes and edits research reports, collaborates with colleagues on grant proposals, and serves as a reviewer for several scientific journals.

Each and every day.

A typical day for Brooner starts off with fielding calls from funding agencies and CTN members. The network encompasses 14 nodes--or regions centered around an academic institution--and 80 community-based treatment centers nationwide. From advice on managing a problematic patient to suggestions for raising staff morale in what is often a sobering setting, Brooner finds the answer. "I then take about three hours to write reports associated with my research activities and status reports on the program from my administrative and budget perspectives," he says.

During the time most of us step out for lunch, Brooner meets with clinical staff and academic researchers to discuss new treatment ideas and review research data. From late afternoon until 8 p.m., he treats patients "and I grab a few moments to try to write."

"Then, I try to be with my family at home," says this husband and father of two with another on the way. But once the family goes to bed, he goes back to work until 3 a.m., he admits. "I write the manuscripts that as a professor I still have to produce, or edit my advisees' work." He also routinely clocks in six to eight hours on the weekend.

Brooner's hard work has paid off. He believes no case carbon copies another, and applies a variety of approaches accordingly; his recognition of each drug abuser as an individual with unique problems has proven the best recipe for recruitment and retention, he says.

"Patients who found their way to us after failing in psychiatric and other drug abuse clinics have been doing very well here," he notes.

Bringing together the best treatments

Before assuming leadership in the CTN two years ago, Brooner had already dedicated 13 years to the development of his community-based treatment center at Johns Hopkins University, which offers 15 residential spaces and 700 outpatient slots.

To participate in the CTN studies, Brooner selected nine clinics, most located in the Baltimore-metropolitan area. Some are methadone maintenance, others provide only counseling, others cater to adolescents. This diversity is key to upholding CTN's experimental purpose and allows Brooner to measure the benefits of innovations such as introducing medications to drug-free heroin treatment centers.

"Bringing together medicine and counseling," he believes, "improves the scope of services and thus maximizes outcomes."

The experiment has worked thus far, Brooner believes, because the constant component to such specialized care is consistency. The clinics combine a flexible program with behavioral reinforcement to ensure attendance at both counseling and medical appointments.

Reinforcements are as unique as patients' needs, but commonly include availability of medication to calm cravings, or assistance with family or employment problems--benefits contingent upon patients showing up for treatment. The behavioral reinforcement therapy appears to work well. In fact, Brooner's reinforcement tactics have boosted patient retention; his programs in Baltimore have the lowest rate of drug use of all funded programs in the city, with 80 to 90 percent of random urine tests negative for evidence of cocaine and heroin.

"Over time, patients say they come to enjoy counseling," Brooner says, "and then start volunteering for more counseling per week. When we provide a good service, patients recognize its value and seek it out."

Brooner also believes the key to treating drug abuse is addressing the co-occurring conditions--from mood disorders to schizophrenia--with which he says about 40 to 50 percent of his patients present. He operates on the paradigm that "interventions that integrate different elements of treatment for different conditions offer better outcomes." Determining what a patient needs, then, is "a dose response issue," Brooner explains. The flexibility to recognize and make adjustments for each person is a requisite, he believes, for making substance abusers well.

Walking the wire

Brooner finds treading the tightrope between service delivery, academia and personal life an interesting challenge.

"While my work has always provided great personal satisfaction," says Brooner, who was made a full professor of medical psychology at Johns Hopkins School of Medicine at the same time he took charge of the CTN, success has not been won without "some sacrifice in other aspects of my life." After his promotion, Brooner says he grew "acutely aware of the pace at which I built a set of responsibilities that I enjoy, but also are of great magnitude." Today, one of his chief goals is "to learn how to better balance competing demands for time."

He is grateful for the partnerships he has forged within the CTN, which he calls an opportunity to "add novel interventions that have proven effective in research settings to community programs." It is thus that Brooner does his part to calm the scourge of drug abuse, one patient at a time.