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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health Podicy. I'm your host, Rob Lott. Friends, it's another very special episode of A Health Podicy, the kind of episode we do about once a month with a step away from our typical focus on the authors of the latest papers published in Health Affairs. And instead, we reach out to some of the luminaries in our field to hear their story and get their take on the health policy landscape today. This month at Health Affairs, our work is all about the opioid crisis.
Rob Lott:In September, we published a special theme issue looking at the latest research and evidence shaping the public policy response to this urgent national and global health challenge. And so for our special guests, we've turned to none other than Doctor. Nora Volkov, Director of the National Institute on Drug Abuse at the National Institutes of Health. We typically refer to this institute as NIDA, and it's the world's largest funder of scientific research on the health aspects of drug use and addiction. Doctor.
Rob Lott:Volkov is a research psychiatrist whose work has documented how changes in the dopamine system affect the brain regions involved with reward and self control in addiction. She has also made important contributions to our understanding of neurobiology as it relates to fields like obesity, ADHD, and aging. And I'm thrilled to have her here today. Doctor. Nora Volkov, thank you so much for joining the podcast.
Nora Volkow:Well, very much for having me. It's a pleasure.
Rob Lott:Well, let's just jump right in. In a moment, I want to ask you about your work leading Naida, but first I'd love to hear briefly about your own research. I know you've pioneered the use of brain imaging to investigate how substance use affects brain functions, and I was hoping maybe you could say a little bit about how that field has changed over the years. What did it look like when you entered it? And what does it look like today?
Nora Volkow:Yeah, it has changed dramatically and it has transformed it. And I actually, I have always been extremely interested on understanding how is it that a drug can modify the function of our brain to the extent that we no longer follow the behaviors that are more likely to lead us to succeed, but instead become literally slaves of drugs. And to me, that's fundamental because it's the notion of losing your free will to do something. And as a researcher, my perspective was to study the changes in the brain could give us an insight about how we made decisions and priority and our capacity to do them. And that's how I got immediately saw the power of imaging technologies.
Nora Volkow:And when I was a medical student, imaging was just emerging, and we could only look in terms of the brain with structural changes. And towards the end of my medical school, beginning of my residency, we started to have imaging that allow us to look at function, and that blew my brain. Because I realized that it would be possible when you look at the brain and you try to understand how it leads to behavior is like looking at a car and trying to understand how it's going to perform. If it's not moving, if you're not driving it, you'll never know. And by looking at function and seeing how the brain responds to different type of stimuli, it was obvious that this would be a transformative tool, and it has been.
Nora Volkow:So, therefore, I jumped right away into using it for understanding changes in the brain, brain activity of people that have psychiatric diseases that had never been understood, and including addiction. And so I went into actually favoring the study of addiction because it allows us to focus and target very specifically the whole mechanisms by which we exert self regulation and make decisions of what is most important. So that's how my career went on into research. How has the field changed since then? Well, the tools that we have were limited initially, as I mentioned, just to structural imaging like CAT scan, and then we developed technologies that allow you to look not just at brain function, but also biochemistry.
Nora Volkow:Positron emission tomography was the technology that allows us to do that, and it's still the main important technology for brain neurochemistry. But in the meantime, MRI started to emerge as an extremely promising technology. And with as it was launched, our researchers started to realize that what the signals that we were deriving of the brain, whether it was doing a task or resting, thinking of nothing in specific, which we were obtaining, like when you look at the television set and there's all of this noise, it's exactly the way that you would look at these images, and there were all of these points planking back and forth, and they were dismissed as noise. But researchers at Wisconsin figured out that this was not noise, that it had certain frequencies that could be predicted and that these oscillatory frequencies were corresponding together, were similar in certain areas of the brain and very different from others. And they put two and two together, and they view the potential of using these signals as a mean of understanding how different regions of the brain work together to perform a task, a process.
Nora Volkow:And then everything changed. Because fMRI, which is functional magnetic resonance imaging, which is basically the utilization of these early awareness that these signals that actually reflect oscillatory activity that connotes information about brain organization, has enabled us to look at a much higher temporal and spatial resolution of what happens in the human brain than what we had had with technologies like positive transmission tomography, or PET scan. So that's how it has. So it went from being very limited to a few technologies and a very few sites in The United States and in the world that could do it, to now having MRI available for fMRI studies across many, many places in The United States and in the world, making it very, very accessible, noninvasive, and providing us a pretty powerful tool for research that in certain instances has started to be applied for clinical purposes.
Rob Lott:Well, a big contribution of that work has been to demonstrate that drug addiction is a brain disorder, if I'm understanding the sort of trajectory correctly, a brain disorder as opposed to say a weakness of character or a moral failing. And now that's sort of the general consensus is that this is a brain disorder, a chronic condition. And I'm wondering about sort of what you witnessed in the sort of moving of the needle or sort of the transition of that general consensus away from these sort of outdated theories. They generally require evidence, which you and your colleagues have provided, but there's also an element of persuasion and consensus building across stakeholder groups. And I'm curious if you've thought about sort of how you reconcile those very two different kinds of scientific communication.
Nora Volkow:Absolutely. And I think about it constantly because of those these two lines of communication reflect perceptions that actually, to a certain extent, do have certain aspects, do connote certain aspects of the conditions that we're looking at. It's not that there is the whole truth, and this is correct and this is incorrect. The reality being behind what we did with neuroimaging, what it allowed us to do was to document very specific changes in understand the change in behavior. That was clear cut.
Nora Volkow:And from that perspective, it gave us the narrative and the argument, like when you do an imaging of the heart, you can document where the defect is in the heart that can lead you to the diagnosis of a myocardial infarction, infarction, importantly, can lead you to where you're going to do your therapeutic intervention. But being able to document this, for example, in addiction, the prefrontal cortex being dysregulated with the chronic use of drugs, it became clear that one crucial component that required therapeutic attention was the inability for the individual that's addicted to exert self regulation and control their impulses. And that provides you, again, a target for therapeutic intervention. And it also, by documenting where the deficits are, it puts us into the narrative of a disease disorder as opposed to moral failing, right? But if you look at it in a more holistic way, you also have to ask yourself the question, what is it in our brains that allow us to have a moral awareness and to be able to carry it through?
Nora Volkow:So we give it as granted as if these things are going to happen no matter what. But all of these processes, emotional and cognitive, that we give for granted are part of the function of the human brain. And if you damage certain areas of the brain, you lose the capacity to actually properly understand, for example, ethical or moral concepts, or if you don't have the neurocircuitry that allows you to actually feel empathy for or embrace a particular cultural domain, you are going to be alien to it and much less likely to be sensitive to its precepts. So it is again, we speak about a disorder, but it does not negate the possibility that underlying the changes in the brain that you are actually having in a person that's addicted, you are undermining the capacity to actually carry on behaviors that are more akin to a cultural norm of morality or ethics. Recognizing that is crucial.
Nora Volkow:And also, it forces me, because one of it is one of the concepts that has generated the most controversy because people get very, very upset by the notion that by describing addiction as a disease, you are removing the responsibility of society towards that condition, and you are blaming, that is what they claim, that individual. Because they say, Well, you know, there are societal environments that are much more conducive to drug taking that make people more vulnerable to becoming addicted. And so it's society, it's the environment. But my argument is that's not any different from obesity and diabetes. The environment and society are driving this actually vulnerability of people.
Nora Volkow:But we have, I don't know, humans have this tendency of wanting to simplify things into either this or that, where without recognizing that a disorder can have genetic components that make you vulnerable to the environmental situation that you find on. Because even if you have all of the genetic vulnerability for addiction, let's say 100% genetic vulnerability, which of course doesn't exist, but theoretically, using it as a narrative, if there are no drugs, you'll never become addicted. So this just tells you, Al Alimit, that whole concept. So in my view, I like to listen to the arguments because it behooves us to try to integrate it into our understanding of disease process, and importantly, to understand how the human brain works, right? So it is an aspect that people get very, very upset about, and they say, How could this mother of three take drugs and completely disregard their children?
Nora Volkow:She doesn't care for them. It's not that she doesn't care for them, it's that the drugs have disrupted her relative saliency and her urgency for doing certain things versus others. If you are able to get that person into treatment and recovery, you will see that they basically go back and embrace that motherhood. And they have, I mean, and in fact, working with mothers who are addicted, who have children, and it's in a way gives you the advantage because they are very invested on these children. And so you can use that as a reinforcer to help them motivate them into change.
Rob Lott:Wow, okay. Well, let's talk a little bit about the work of the National Institute on Drug Abuse. Many of the articles in the theme issue that we're highlighting at Health Affairs this month are focused on treatments like buprenorphine and methadone, as well as rescue protocols like naloxone. And I'd love to hear a little bit about NIDA's role in developing these drugs and also, I guess, what its role is in tracking how these treatments are used and ways to improve interventions using these treatments.
Nora Volkow:Yeah, and the development of treatments for substance use disorder addiction has been one of the research priorities for NIDA. Another research priority is prevention interventions. So, but those overall are now basically were recognized that a third element is that of research towards recovery. For treatment, we have basically the best treatments for substance use disorders for the treatment of opioid use disorder. We have treatments for alcohol and tobacco cessation, but their effect sizes are much lower than those that we get with the medications that we currently have.
Nora Volkow:And NIDA was instrumental in the development of these medications directly and indirectly. Indirectly with methadone, because we provided the research and the science that enabled the consolidation of methadone as a treatment, and help us understand how it worked, to directly, to actually do all of the work that was necessary to bring buprenorphine into the clinic, as well as very directly to with Naltrexone, Vivitrol, to bring it eventually into the clinic in partnership with pharmaceutical industry, which of course is the one that's responsible to actually get the product and distribute it. Naloxone too, similarly, we have indirect and direct involvement in the development of naloxone, which is the most effective intervention we have for reversal of overdoses. And this comes through the indirect all of the knowledge and research done to understand how it works as an opioid receptor antagonist to the direct involvement on developing formulations of naloxone that would make it widely accessible and very, very effective for anyone, the general public, to be able to administer, even if they don't have a medical or clinical degree. And that has saved so many lives.
Nora Volkow:It's probably, in terms of the overdose crisis, one of the most consequential interventions that we've done, making naloxone user friendly and widely accessible.
Rob Lott:Great. Well, I want to hear a little more about some of the decisions you make about the various research you fund. But first, let's take a quick break. And we're back. I'm talking with Doctor.
Rob Lott:Nora Volkov, Director of the National Institute on Drug Abuse. Doctor. Volkov, you just talked a little bit about the institute's role in funding treatments like buprenorphine, and I'm curious if you can say a little bit about sort of how those treatments relate to the concept of recovery and also sort of how we think about abstinence. Is that really the only appropriate goal when it comes to treating addiction? And therefore, how do we think about that concept when we're studying drug use?
Rob Lott:Are there other goals we might consider beyond abstinence when studying drug use?
Nora Volkow:And my perspective on this and from the perspective of how we're pushing research is to consider the treatment of substance use disorder as a cascade model. First, you basically screen and make diagnosis, then you treat, and then you move towards recovery. Now, the issue is what does recovery really mean? And that definition has changed significantly. And is recovery, as you say, the only option out?
Nora Volkow:And we've come to understand that when you're very, very rigid and saying abstinence is the only way to achieve recovery, you're actually threatening the life of many people that don't even try to get recovery because they say, I want to I do not want to be abstinent. So what is important in the concept of recovery that it is a decrease in drug use in ways that are not harmful, number one. Number two, that there is an improvement in the health of the individual. And number three, that there is improvement in the well-being and the social involvement of the person. That what becomes crucial for recovery.
Nora Volkow:And whether that means abstinence or not, we don't have an inflexible attitude towards it. Because if someone can achieve well-being and can become an active member of their society and basically control the risk and dangers of taking drugs, and they can still use drugs in a responsible way, then that may be where they go at. I mean, obviously, theoretically, we would want recovery to achieve lack of drug use, but we are aware that in instances where it's not the option of the person, we should be respectful.
Rob Lott:How does NIDA view the role of health disparities in substance use disorder treatment? What do we know about how and where those disparities surface and the best way to study them? And I guess against that backdrop, I'd love to hear how the institute factors those elements into its funding decisions.
Nora Volkow:Yeah. Health disparities in substance use disorders emerge in the whole trajectory. It emerges from the trajectory on your vulnerability for using drugs, your vulnerability to escalate into addiction, your vulnerability to receive or not treatment, or to end up incarceration, and your vulnerability to achieve recovery, and your vulnerability to die from an overdose. Health disparities are seen throughout all of them. So, the perspective of research, we are interested on developing models of care that can help bridge those differences that exist in health outcomes.
Nora Volkow:And for example, I think that the mortality that you observe from overdoses is significantly higher among people who are homeless. So therefore, we know that, and the research, therefore, is what type of intervention can be done to provide alternatives for these individuals who are homeless so that you can protect them from overdosing. So, it is a fundamental aspect of the substance use disorder throughout the whole cascade of care that we were just describing.
Rob Lott:Got it. Okay. Well, I'd love it if you could look forward with us for a minute and say a little bit about maybe the biggest gaps that remain in our current understanding of addiction, science, and medicine. What is it going to take to close those gaps?
Nora Volkow:I'm laughing because there are many, many, many gaps. Yeah. And they go, I mean, there are obviously from the perspective of understanding scientifically what are key elements at which there is a transition from one phase to the other that makes you vulnerable so that we can intervene? How do we identify them at an individual level, not at a population level, which is where we are from? But I want to more focus on the issue of issues that are more tangible in terms of their proximity, which is how can we change the healthcare system care so that they embrace more wholeheartedly the obligation that we have as clinicians to screen, treat, and provide with the linkages to for recovery that are necessary for someone to succeed.
Nora Volkow:We have advanced in that field, but there's still a majority of healthcare systems where there is no treatment for substance use disorder, there's no expertise, and where it is actually discriminated, and despite all of the knowledge that has emerged. So to me, this is a priority. Why is it that clinicians don't want to actually, for example, clinicians, even if they have the specialty of psychiatry, don't want to treat substance use disorders? Why is that? Because they are not reimbursed at the same level as if they were treating other conditions.
Nora Volkow:So, what are roadblocks that are impeding the actual treatment of substance use disorder is crucial. I mean, just to let you do you know that one of the main sources for paying for substance use disorder, even though it should be covered by Medicaid and Medicare, like any other medical condition, is pay. I mean, out of pocket pay because clinicians don't accept insurance. Insurance is insufficient. So there are also other series of roadblocks.
Nora Volkow:So to me, this is a gigantic gap that is contributing to the health disparities on the one hand, but it's also perpetuating the overdose crisis that while it's getting better, is still very, very consequential and very costly, by the way.
Rob Lott:Can you say a little more about those costs? Is that just the cost of untreated addiction? What other costs do you see?
Nora Volkow:Oh, yeah, untreated addiction has downstream effects because you are not a productive member of the society and you create complete stress in your family and your support system. So, it is actually very, very devastating, not to say the economic consequences of overdoses, but if you look at the consequences of addiction to health, let's take one of them that is very fresh in my brain, infectious diseases. So injection drug use contributes to HIV, to hepatitis C, to endocarditis. And endocarditis is a condition for which the average cost for hospitalization are around $250,000. If untreated, the chances of dying are one hundred percent.
Nora Volkow:And people that enter with an infectious an endocarditis from injection drug use many times leave against medical advice because they are not properly treated for their withdrawal symptoms or the management of their pain condition is inadequate. So, they sign themselves against medical advice without treatment. And then frequently they come back and many of them have recurrent episodes. So, this is an example of the cost associated with it. So, the medical costs, the cost to society in terms of lack of productivity are also gigantic.
Nora Volkow:And consider also the costs that are linked with controlling drugs and policing them and the violence that goes with it. And I don't even have good numbers about the cost to society of the illicit drug market and trying to regulate and control it. Those don't even enter in the calculations, but yet they are very, very important. And I would say that an even more fundamental level, if you want to degrade the basic structure of a society, you bring drugs in. Now, how do you actually quantify the impact of that to a society?
Nora Volkow:I mean, you just make people just sort of indifferent to what goes on and drive them towards doing drugs instead of engaging in other activities. That is pretty devastating. And so this is where I would say the costs are enormous.
Rob Lott:I imagine there's an opportunity cost as well that you're sort of hinting at someone that's has to spend time getting treatment or getting care for an infection, as you say, is not able to spend time working in their job or caring for their family as well.
Nora Volkow:Absolutely. And even if you don't have a medical condition associated with drug use, which are very, very prevalent, but even if you don't, and if you are addicted, you are not going to perform properly because the main drive is to be sure that you get the drug, to be sure that you don't get into deprivation from that drug. And it is extraordinarily powerful. It's like you are being driven when you don't have food to seek it out in order for you to survive. So, it's when you don't have food accessible and available, that becomes a top priority.
Nora Volkow:You cannot think on other things. So, this is another major reason why the impact of in the productivity of people that are addicted is much lower.
Rob Lott:Well, it's almost time for us to wrap up. And I wonder if we could close briefly by thinking about perhaps a young researcher contemplating maybe entering the field of addiction science or maybe a young physician thinking about what specialty to go into and maybe thinking about addiction medicine. What would you say to them today about whether or not to go down that route and what they should maybe consider as they make their decision?
Nora Volkow:Well, I think it's fascinating, one of the most interesting areas of science to go into a disease that affects the human brain. And it's also one that is at the transformative stage in that we're developing completely new tools and very, very promising interventions for modifying that vulnerability or that disease process. So, I would say it has been a very, very neglected condition. But now that is changing, and it's changing for two reasons. One of them, because we've become aware of that devastation of not paying attention to substance use disorder in healthcare, but second, for the enormous advances that have come up in our understanding of how the human brain works, the technologies that allow us to evaluate it, and the tools that allow us to actually intervene to strengthen specific circuits or to weaken others, and to combine these technologies with the opportunity of new medications and therapeutics.
Nora Volkow:So, it's really an extraordinary time to come into the field of addiction as a clinician or as a neuroscientist or as a social scientist as it is to actually come into the field in general of psychiatric disorders.
Rob Lott:Well, a really optimistic perspective for our listeners and for potential future researchers and clinicians. Doctor. Nora Volko, thank you so much for taking the time to chat with us today. I really enjoyed it.
Nora Volkow:Thanks very much. I also enjoy it.
Rob Lott:To our listeners, thanks for tuning in. If you enjoyed this episode, of course, share it with a friend, leave a review, and, of course, tune in next week. Take care, everyone. Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.