August 26, 2021 • 57 mins
Dr. Nora Volkow has headed the U.S. National Institute on Drug Abuse (NIDA), which funds a majority of the world’s research in the area, since the early years of George W. Bush’s administration. I was pleasantly surprised when she agreed to join me for an episode of PSYCHOACTIVE since I’ve been highly critical of the agency’s priorities and its failure to fund important domains of research for what appear to be political reasons.
I pressed Dr. Volkow on a host of questions I’d long wanted to ask her: Why does NIDA devote relatively little funding to the sorts of ethnographic research that might provide important insights into the overdose epidemic? Or to researching the health effects and consequences of mass arrests and incarceration for drug law violations? Or to studying the medical benefits of marijuana and psychedelics? Or to better understanding “controlled drug use,” i.e., the ways in which people use all sorts of drugs without their drug use becoming problematic? Or to examining the potential of supervised injection facilities, heroin-assisted drug treatment and other innovative harm reduction interventions that have proven successful abroad?
I also wanted to know how she’s managed the political challenges of working under four different administrations as well as those presented by members of Congress who favor highly punitive approaches to illicit drug use. We discussed her frustrations with current laws that constrain what NIDA can do and how she tries to maintain the integrity of an agency that claims the scientific high ground while operating in a highly politicized context.
I’m fairly sure that Dr. Volkow had never before been pressed on these issues in a public interview. I found her responses frustrating but was grateful for her willingness to have this conversation.
Listen to this episode and let me know what you think. Our number is 1-833-779-2460. Our email is psychoactive@protozoa.com. Or tweet at me, @ethannadelmann.
Learn more about your ad-choices at https://www.iheartpodcastnetwork.com
See omnystudio.com/listener for privacy information.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hi, I'm Ethan Nadelman, and this is Psychoactive, a production
of I Heart Radio and Protozoa Pictures. Psychoactive is the
show where we talk about all things drugs. But any
views expressed here do not represent those of I Heeart Media,
Protozoa Pictures, or their executives and employees. Indeed, as an
(00:23):
inveterate contrarian, I can tell you they may not even
represent my own and nothing contained in this show should
be used as medical advice or encouragement to use any
type of drug. Hello, Psychoactive listeners. Uh, Today's guest is
(00:46):
a really interesting one for me. It's Dr Nora Vocal,
who has been the head of the National Institute on
Drug Abuse in the US government since two thousand and three.
That's under four different and presidential administrations, so it's been
a remarkably long run overseeing the lead agency which provides
(01:08):
the majority of funding for drug research, not just in
the US, but really the majority all around the world.
Those of you who know me, you'll know I've been
highly critical of NIDA, Nationals Drug Abuse and Dr Volka
over the years, in part because I think they've so
overemphasized trying to establish that addiction is a brain disease,
(01:31):
and and putting a lot of research into the neuroscience
and brain imaging and all of that. And I personally
think that they should be spending dramatically more money on
things like ethnographic studies and setting things like the ways
in which people control their drug use and more research
on the benefits of drugs. Now, you should also be
aware that a few years ago Nyder receives some dedicated
(01:53):
funding from Congress, specifically UM to address issues involving the
drug overdose. At the demo, and those of you have
been listening carefully know that just a few episodes ago,
in episode five, we had Professor Dan Chacheroni talking about
what's going on with the overdose epidemic? Why did almost
a hundred thousand people die last year? Uh? And so
(02:14):
I started off the interview really by pressing uh Dr
Volcale on that question, UM, And I will admit I
was frustrated by some of her answer. She kept saying,
we need more research on this, more research on that,
you know, and of course Night has been spending more
money and anybody in the world on doing research. But
I'll tell you I was pleasantly surprised that she agreed
(02:37):
to be a guest on Psychoactive. Nora grew up in
Mexico City, has a fascinating family history that will get
into early in the episode. She was an outstanding medical student,
became a psychiatrist, held all sorts of influential positions, became
a real leader in the US and around the world
trying to understand addiction by looking at the brain through
(02:58):
neural imaging and brain scans, and has had really quite
a remarkable run. So, without further ado, here's my conversation
with Nora vocal Nora, thank you so much for joining
me today on Psychoactive. That's for having me and listen.
My job here, right, I mean here, I've led until
(03:21):
recently the leading drug policy reform institute, which was intensely
critical of many government policies and oftentimes of Naida's work
and priorities. But it's my job both to be the
gracious host and also to press you on a lot
of questions which have been on my mind that I'm
sure in the minds of others. But let me just
start off on a little bit of a personal thing,
which is you have this remarkably interesting background familiar background,
(03:44):
you know, growing up in Mexico, but growing up in
the house in which your great grandfather, the Russian revolutionary
Leon Trotsky, was murdered by Stalin's agents. And yet there's
another part of your family history involving I think your
grandfather of ears, which I understand it first sensitized you
and made you start thinking about the issues of drugs
(04:06):
and addiction and what you might do to address it.
And I wonder if you could just tell us a
little more about that. Yes, and and indeed, my my
story comes from two different countries. I my father came
from Russia and his grandfather was escaping from Stalin and
ultimately the only place that gave asylum to his family
(04:28):
was was Mexico, Whereas my mother was born in Spain
and there was the Civil War, and again Mexico was
a place that gave political asylum to all of those
refugees that were escaping Franco. So I always like to
say that I was born of the two Wars, or
the last century Russian Revolution and the Civil War, and
(04:49):
so that's that's how I came to be born in Mexico.
What you were saying as in terms of what led
me to think about addiction. And indeed, Um, the father
of my other unbeknownst to me as as a child,
I had never met him because he was in Spain
and I was in Mexico, had a history of alcoholism,
(05:09):
and when I was approximately probably six years of age,
he committed suicide because he couldn't control the strong urge
to to drink and had relapsed. So I did not
find this until later, when I was already in medical school.
But in the meantime, my favorite tone call of all times,
(05:30):
my mother's older brother, also had a problem with alcohol,
and to me, it was very contrasting to see the
component about what an extraordinary individual he was, how generous,
how smart, how charismatic on the one hand, and yet
when he was drinking, his personality changed so much. And
(05:54):
I was also intrinked about the family dynamics because nobody
wanted to speak about it was like this antic secret.
It gave me that insight that, I mean, people are
not bad because they have a problem of addiction. They
just have a problem that it's more powerful that they
can't control, and it's not that they are doing this voluntarily.
(06:17):
So as I went to medical school, I was also
uphold at the way that our doctors were treating addiction.
They were ignoring it, actually refusing sometimes to give treatment
to someone that have a history of addiction because they
thought that they were doing this to themselves and whatever
happened to them, they deserved it. And I saw this
(06:38):
even as I went after my residency training in psychiatry,
where we would admit patients that have depression with an
alcohol use disorder, and I would inquire to the attendance,
how do we address the alcohol use disorder and do
not worry about it, treat the depression and once the
(06:59):
person leaves the host bital, then they will deal with
their alcohol use disorder. And later on, as I became
an attendant, directly forbidden to admit patients with an addiction
into the inpatient unit of the hospital because they were
patients that misbehaved under quote. So to me, all of
these experiences were actually activating Miami Dallas, which are the
(07:23):
centers of emotions of the brain, because it seemed completely
counter factual with what we knew then on the pharmacology
and the neuroscience of the brain, and we knew that
we could make animals actually get compulsive in administering a
drug to the expense that they would stop eating or drinking,
and they actually j pordize their life. And so they
(07:44):
are very in wire wire biological circuits that make us
vulnerable to these drugs and in some people to that
complete loss of control. So that's ultimately what led me
to try to provide knowledge that could illuminate further her
calpus understand what happens in the brain of people that
(08:06):
lose control, with the idea that hopefully science will serve
to change policies and reduce the stigma, and basically changed
the notion of criminalizing people to that of treating and
helping people and preventing them from relapsing. Yeah, so I'm
trying to think, um, if I look at what natives
(08:29):
priorities have been, and I think it was true under
to some extent your predecessor listeners as well, But for you,
really it feels like the major thrust of the agency
really has been on the brain research, right and then
your imaging in that the biggest share of the resources
have gotten there, And what I have always felt has
been a sort of inadequate attention to funding the sort
(08:51):
of ethnographic work the deep analysis into drug using communities
and drug cultures into truly understanding what's going on there,
especially we're dealing with the overdose issue and the opioid issue.
I mean, I know you find some stuff in that area,
but it seems like it's relatively modest, very modest compared
to the work that's being done. And they were imaging
(09:12):
in the brain stuff, and I mean, what's the rationale
for that? Is that you believe that the brain work
is going to lead to the big breakthrough. I mean,
here we're focusing on the opioid epidemic, right, which is
now what we're approaching a hundred thousand people dying overdose
and all sorts of other ills associated with this. Why
is such a focus on that well, I mean, obviously
we are very much interested on basic neuroscience to help
(09:34):
us understand how it affects the brain. But we invest
much more money on research that relates to those very
important components that you discuss the issue of how socio
economical factors, cultural factors influence the vulnerability of resilience for
drug taking, and so our dollar amounts spent in research
(09:56):
that relates, for example, to prevention services in implementation epidemiology,
in fact, is greater than what we've spent in basic neuroscience.
We have this need in humans of polarizing things into
this or that, and ultimately that reality is that our
social systems are product of our brains interacting with one another,
(10:18):
and our brains are a product of our circumstances. So
the challenge in science is how do we integrate these fields.
For example, a very important story we have been doing
since twenty sixteen is a developmental study of children as
a transition into adulthood. And yez, we're studying their brains,
but yez, we're doing a very in depth phenotypic characterization
(10:42):
of their social environment. And as a result of these
longitude in our study, large longitude in our story, researchers
have been able to document some extremely powerful relationships between
these adverse social environments and how the brain develops. And
also important in sites on how very early owned children
(11:03):
as mistreating if they come from certain racial backgrounds. And
we are about to start a similar study in initiating
early in infancy to follow it up, and it will
give us some much better understanding about how our environment
influences the brain. Well, but now when I'm really getting
at those. I remember back in the seventies and eighties
(11:23):
there was this incredible richness of ethnographic studies going on,
and and famous ethnographers Michael Agar and others, and a
whole cohort who are really doing in depth studies. And
now I look at the questions that emerged around say,
fentonyl on the opioids, the question about how our consumers
responding when people know that fentanyels out on the street,
that they run forward to run away for it. What
(11:44):
sorts of precautions are they taking us to be their
own use to what exentered? The people who's selling these drugs,
the lowest level retail sellers, to what extent do they
know what's in their drugs? Are they exercising any sort
of harm reduction measures us to be their own consumers?
Right to what ex center? These drugs all being mixed,
Why is ventinyl landing up and the stimulants apply with
cocaine and methamphetamine. And there's these hosts of questions, and
(12:06):
it seems to me that essentially nobody has the answers.
And when I talked to, you know, the sociologist, the
ethnographers the others who are getting funded. They're saying, Ethan,
You're right, those are really important questions. But the truth
of is it, there's only a handful of us really
getting this abundance of funding to do this stuff. Isn't
a part of the job of NAIDA to be digging
(12:26):
deeply into what's actually going on in these active markets
right now, finding these things out, and trying to dig
into what sorts of interventions you can do with active
drug users and even low level sellers in order to
reduce the harms that are resulting from ventanyl and these
other opioids being on the street. Absolutely, we have a
responsibility to bring a light that can help address these
(12:50):
very challenging times. And what I can tell you I mean,
and this is in terms I mean. One of the
main drivers about why we have synthetic opio is now
widespread through the United States is because the profits for
the dealers and those that are generating these drugs are
much greater than they are for something like heroin or
many of the other drugs that require cultivation. So one
(13:13):
of the reasons why you see so many drugs being
laced with fentannel is that the dealers are going to
be making much more money. And we do have ethnographic
reports that actually go and speak with people on the
streets and for example in Baltimore, John heroin users maybe
in some instances seeking out fentannel, but the older ones
(13:34):
are actually afraid of it, but they cannot afford to
buy pure heroin because it's more expensive. Also many instances
it is very difficult to get pure heroin even if
you have the money to pay for it. So it
is a reality that unfortunately, the enormous amount of money
that can be made by selling fentannel is driving the market.
(13:56):
And so I mean in terms of scientific questions is
how do we counteract that negative effects and the strong
aggressive distribution of fentanyl and its contamination of the other drugs.
That's unfortunately, at an essence part of the normal challenges
that we have. But we need to understand also that
(14:16):
diversity of the markets and too to meet one of
the key important issues for addressing, for example, the obvious
crisis is to have more timely data, just like like
we had with COVID, Right, you see immediately you know
when you're starting to have the new variance. We don't
have that for fentanil. So if I get data, it's
at least six months later of over those mortality across
(14:40):
different areas of the country, and by then many people
have died. And the technology is out there that would
enable us to detect early on when we see in
a community the emergence of these very little drugs. I
know my own I just to say, my own sense
is that if you were the funding army of hnographers
going out there doing snowball research, paying drug users to
(15:02):
connect with other drug researchers, finding out what they're doing
around these new drugs emerging, what sorts of precautions are doing,
and even funding studies that try to enlist drug sellers,
whether they're currently incarcerated or whether they're still operating the
community to find out. Look, drug sellers don't want dead customers.
It's bad for business, right, or even trying to find
out what I mean, I don't know if you know
(15:23):
the answer. Why is it that cocaine and methamphetamine are
being cut now with fentanyl? I mean, are they trying
to make some form of new speedball or is it
just out of ignorance on the part of retail sellers.
Are the customers actually want that. I mean, what do
we know about that right now? What we know is
that many of the debts associated with stimulants our own
(15:45):
beknowns to the person that they were getting actually a
stimulant that was contaminated with fantaniel in some instances. Yes,
as you know that speed bowling was the way that
people used to want to get tired. Um, you don't
have just one reason why people maybe combining, but I
need a very important contribution is people not knowing that
(16:06):
they are getting fantonil, being stimulant users having no tolerance
for opious and therefore that drug combination is particularly little.
And yes, I mean I think that one of the
issues that you need to consider in terms of how
we have to make decisions. Absolutely, we need to understand
the problem in better ways, in more efficient ways, but
we also need to develop tools that will allow us
(16:28):
to address it. So it's not just that we are
actually have the resources just to do epidemiology and ethnography research.
We need to help develop medications. We need to develop
models that will ensure that individuals that need care will
be given care. We need to actually develop models for
(16:48):
prevention of relapses, for prevention into drug taking. It's not
just one thing that we can allocate all of our resources.
It is crucial that we understand the age share of
the problem. And it's also crucial in that respect that
with partner with other agencies so that we maximize the
resources and we can achieve more. And they're speaking about
(17:10):
something that is very very intriguing, and it's an area
that has been not thought much at and and so
I'm curious that you asked me about it, which is
the notion about the dealers. How do that dealers end
up dealing with these very dangerous strokes And that is
is something that we don't have research into that area.
(17:31):
It would be a great thing to solicit proposal for
because quite frankly, whether or not the lowest level retail
suppliers um actually know what's in their drugs and what
precautions they take and what's going on in that dynamic
would be fantastically valuable giving the amount of accidental overdose
that's happening right now. We'll be talking more after we
(17:52):
hear this add You know, I saw recently that you
wrote a piece in which you said you supported drug decriminalization,
and I know you've never been a fan of the
War on drugs. But here you've been operating in a
(18:13):
political context in which punitive prohibitionist policies, mass arrests, you know,
the heavily racial biases that go with all of that
has been pervasive. Now, one of the other criticisms has been,
you know, they're always looking for what's wrong with drugs,
but what about what's wrong with drug policies. I'm gonna
taking example. I'll see you write an article about all
(18:35):
the harmful consequences of marijuana, right, and we can agree
that one has to identify the harmful consum marijuana. But
there's nothing coming out of nightA that I'm aware of
that's looking at the harmful consequences of marijuana arrest or
marijuana related loss of employment, or even from a health context.
When you put somebody in jail for marijuana or arrest them,
restript them of the job, that has consequences for their
(18:56):
broader life. It also can be traumatic and cause things
that might impacked their brains in ways like that. So
what has been the resistance to this? Isn't that important?
I mean? And if not, you whop you know? And
it's crucial And I basically from day one. I've been
against criminalization of people that because they have a problem
with substantious disorders. I've been very, very vocal. We found
(19:19):
that research to show how negative the consequences are of
imprisonment into the brain. It actually increases the risk of
drop taking and it basically also increases right now even
more than before when it was known that risk for
overdosing and dying. A very important project that we have
been doing now for year years and now we've actually
(19:41):
expanded because we got extra resources, is with a criminal
justice setting exactly to provide alternative models that will ensure
that people, if for whatever reason first of all end
up in jail on prison, that they get treatment and
that they get support, and also to determine how one
can intervene to avoid that incarceration. We have funded research
(20:04):
showing that, as you mentioned, when you have a relative
of father and mother that ends up in jail or prison,
the risk of the child to have a substance to
use this order is much greater, and that is known
and no one is questioning it. So we've been trying
to disseminate this information. And when I am I have
to actually speak in Congress or the Senate. I bring
(20:25):
up this issue because I feel very very strongly, and
in fact, one of the reasons why I took this
position was because I say we can develop the science
in such a way as that that policy changes. I've
also been openly active criticizing the policy of incarcerating for
crack versus cocaine, which made absolutely no sense, and there's
(20:45):
record on those things. The issue comes about, I mean
that there are structural systems in such a way that
promotes certain behaviors, and science as not enough to change
those policies. So my question that I always say is
what is it that science cannot cover to change policies
(21:05):
that would get rid of these structural characteristics that are
leading to these inequalities. And we are very much interested,
for example, in policies. We found several researchers to identify
policies across the states as on how they are legalizing marijuana,
because as you look through the states, for example, you
see that the adverse effects of marijuana use are much
(21:29):
worse in some states, whereas other states that have legalized
actually have better outcomes. So understanding what policies basically protect
from negative effects and may actually lead to better outcomes,
it's crucial and we're funding it. So yes, the answer
is yes. Yeah. There's one issue I think, going back
a number of years ago, where if I pat myself
(21:50):
on the back, I think I was more right than
you were, which is people were saying, if you're gonna
legalize marijuana, you're gonna see this explosion in adolescent usaid
mari juana and problematic use. And I think you were
part of that group saying that. And what hit me
at the time, you know this is back six seven
years ago, was that adolescents have for fifty years always
had the best access to marijuana. Right, even as mari
(22:11):
wanna use among adolescents has gone up and down the
ust fifty years, the surveys that ask about access consistently
show eighty percent of high school seniors saying they have
easy access. So my sense was that marijuana use among
adolescents was not going to change much as a result,
for the simple reason that access was already so abundant,
but that where you were going to see the jump
was going to be among people our age and a
(22:33):
little older and a little younger people using it because
they preferred it to alcohol or pharmaceuticals. And in point
of fact, it looks like there's been a tripling or
quadrupling of marijuana use among people you know, our age
or older um, whereas the adolescents have stayed relatively constant.
And my job, I wouldn't be surprised if he jumps
in the future. Part of the other research I think
suggests that use of drugs oftentimes goes up and down
(22:56):
independent of what the policy is. There's a whole range
of other variables out there. And I guess when my
question now comes to you is when you write a
piece about the harms of marijuana, why not write a
piece about the benefits? What about a piece about the
controlled juice? What about one piece that looks at it all.
You know, many people were so frustrated that NITA did
(23:17):
not support the medical marijuana research. It took forever and
ever and ever. Or you look at the fact that
the vast majority people use marijuana don't really have a problem.
It is clearly problematic and even addictive for some, and
we have to be aware of that. But why not
have a more holistic, comprehensive approach to Let's just take
the drug marijuana as one example, yeah, no, and I
think that one of the reasons why is because the
(23:40):
data on the benefit from marijuana is very limited, and
it is very limited because there is limited research. And
so one of the things that I have been involved
now for more than a decade, and I must say
that I have been unsuccessful, is to stry to change
the policies that make it so very difficult for researchers
to have marijuana. So marijuana is a scalle one draw.
(24:02):
So if you, as a researcher want to do work
with marijuana, you have to get a d A license
and get approval from the FDA, and that takes at
least one year, and then if you change your protocol,
you have to go through the process again. So it's
extraordinary comberson and as a result of that, researchers don't
want to get into the field. That's one second. We
(24:23):
are also mandated, actually this is not my choice. We
are mandated to provide the marijuana for research purposes, and
so we contract these to a farm in Mississippi that
produces the marijuana. But this system is actually not ideal
because when you are testing a marijuana, say, for example,
(24:43):
you're interested on its potential value, for PTSD or for cancer,
for whatever you want, you are going to be working
with a particular plant, and it's unlikely that we have
such a plant, so it has hinder research. And I
think it was last week that finally that government has
identified to other producers that can provide marijuana, and if
(25:07):
that happens, of course that will facilitate the research into
the medical use of cannabis. I also want to comment
that neither those fund research on medical marijuana, but we
limited to potential beneficial effect for treatment of addiction, for
treatment of pain, and for treatment improving outcomes from the
(25:29):
individuals that may have HIV. So we limited to risk
conditions because otherwise all of our money would go into
research on medical properties of marijuana for US skimmers, for
carter aspolarisis for inflammation. We are hoping that the other
institutes will take those projects that pertains to the diseases
that they are working on. And you were right. I
(25:50):
was expecting that use of my juana mo cadolescens would
go up, and overall it hasn't. But what we are
starting to see, which is again important to keep an
eye on, is that regular use of marijuana appears to
be going up among other lessons, and that's that's of
course of concern. Yeah, nor you know, I so much
share your concern that with legalization that marijuana almost becoming
(26:12):
overly normalized in the way that people begin to sort
of lose its specialness and use it in ways that
are problematic. So we share some overlap there. But you
know you mentioned the Schedule one thing. You know, there
were lawsuits some years ago to try to get the
d A to reschedule marijuana from Schedule one to Schedule two,
and another lawsuit reguarding m d m A, And in
both cases the d AS administrative law judge ruled that
(26:33):
in fact, based on the evidence, it should be rescheduled.
But under U S Law, the head of the d
e A has a legal power to dismiss the recommendation
by his administrative law judge and just keep it where
it is now. I'm curious, I mean, do you think
it's appropriate for a police agency like d e A
to be control of that. Shouldn't it instead be national
in stuite of health for me to be even better
(26:53):
and independent body like Institute of Medicine at the National
Academies of Science. Well, I mean, I think that, in
my view, is not what I think. I mean, it's
the way that this system is organized. What I can
tell you is a very specifically explicitly describe this as
a problem in the meetings that I have at the
United Nations to state that the scandaling has made it
(27:15):
hard to do research, which is impedding again, investigations that
relate to the potential medical utility of cannabinoids that are
in marijuana. So I represent the science, and there are
other people that make the rules about regulations and and
that's what the missions of the agencies are. So yeah,
(27:35):
now I hear you, But you know, I was thinking
about this. There is only one other person I can
think of who has headed a drug related agency in
the federal government for longer than you. Right, You're the
longest at NIDA, You're the longest d e A, the
only one I can think of. It. It's not putting
you in I don't want to put you in bad company.
You're goill be Harry Anslinger, right, the guy around the
thorough Vieau of narcotics for like thirty two years or
(27:57):
something like that. But you are in a position of
tremendous influence by virtue of your tenure, and I have
to ask you this question, and as frankly as you
can answer it, I'd be curious. You came in under
President Bush in two thousand and three when the drugs
are John Walters was a fanatical anti drug guy. I
saw some of your testimony in front of that congressman
(28:19):
Mark Suitor, I mean, real drug ward nutcases, and I
admired the fact that you were telling him what the
evidence was on needle exchange. And then you go under
Obama and things open up, especially in the second term,
and then you're dealing with Trump and the first head
of Health and Human Services, your boss, I guess twice removed,
who like doesn't know his asked from his elbow about
method on and now under Biden, where things are opening
(28:41):
up somewhat. Can you say anything, frankly about what it's
like to deal with that political context, especially at the
federal level. Well, I've always spoken up, and I've said
it very specifically. We are an agency of science and
we need to be allowed to do science. Let the
evidence speak. The moment that our actions become politicized, we
(29:05):
lose any credibility. Obviously in some instances it maybe you
just have to be a little bit more diplomatic on
the way that you present these things. But I do
believe that that is our job, that's our responsibility. We
need to bring the science that can help guide decisions,
because if we don't do it, then we shouldn't be
(29:26):
in these positions. Well, okay, so let me repeat to
you something I've been saying since the nineties, and and
you know, please don't take offense at it, but it
was kind of my broader perspective on this thing. And
I don't think it's as true today as it was then,
but I still think there's truth to it. I would
say they're trying to do innovative drug abuse research in
the United States is a little like trying to do
(29:47):
innovative social science research in the old Soviet Union. That
curious researchers quickly learned that there are certain questions the
authorities don't want to have asked and certain answers they
don't want to have given. And then if you persis
often asking the wrong questions, you're giving the wrong answers. Well,
you're less likely to have your grants fundedge, you're less
likely to be asked to serve on grant review committees,
(30:08):
you're more likely to have your publications or things sent
to hostile reviewers. And what happens then is that many researches,
especially in the hard scientists, basically developed, you know, political blinders,
and that over time those political blinders become intellectual blinders
where they even forget to really ask some of the
most interesting questions that might happen. And so then I
(30:30):
asked people in the U S what does it feel like,
and they'll say, well, you know, Ethan, I'd say, we
were constantly advised by night A grant officers until maybe
around Obama's second term not to use the phrase harm
reduction and our grand proposals. Um we are even now
don't use the words control drug use and a grand proposal,
or it's just gonna say forget it. If I ask,
(30:52):
why isn't night OF funding research on the prescribing of
pharmaceutical heroin the way the Europeans are, or safe injection sites,
or a whole range of other things. And there don't
seem to be any good scientific reasons for not funding
that stuff. It seems to be about a political context
in which funding for this stuff is politically disapproved, and
(31:12):
that even if the people in your agency or yourself
approve of it, there's a realization that members of Congress,
you know, could get furious for funding things like this.
So what's your frankisty answer to all of that? My
Branco law answer to this is absolutely there were certain
terms that when you have it in the grand we
would be questioned about why we were founding science and
sort and such a subject matter. So my perspective was,
(31:36):
as you cannot go into an argument like that openly
when the arguments are so irrational, So you just change
that terminology is used, so you don't use carm reduction,
use other terms. I mean, again, we need to have
flexibility in our brains to accomplish what is it that
we want to accomplish. We want science that can bring
up actions that can improve It's not just because it
(31:58):
is academically interesting. So if I can keep on funding
things without having them come in and and removing asking
us to cut the funding by changing the terminology, what
do I lose? I mean, it is again, what battles
do you want to do? Right? I mean? And I
certainly I do navigate that they are tremendous prejudices as
(32:20):
still and tremendous stigmatization against addiction and its treatments. And
so my job is how within this environment and we
continue doing the work to minimize actually negative effects. Now
you're bringing something because of course I think about these things.
I mean sort of actually in terms of the Europeans
(32:41):
have been using high doses of morphine to treat people
that actually are not responding to other treatments of heroin
and those we've looked into that and one of the
reasons why it was not it did not make sense
for us at that time definitively on the basis of
the analysis to bring that as a treatment that could
be tested in the at that states. It was much
(33:02):
more consuming in resources to set up those injection sides.
And also the other problem with it is that patients
were developing arrhythmias with these guy doses of heroin, so
they were not so benign. And as it relates to
m safe injection sides, I mean, we've been not directly
funding the research on the safe injection sides, but we've
(33:23):
been funding the researchers that are doing that work to
understand downstream how these support systems as a community can
help people, for example, engage in treatment, how they can
prevent them from getting infected from HIV, and how they
can prevent them from overdosing and time. But let me
(33:44):
just ask you, I mean, just take example, the Heroin
maintenance thing, you know, back actually before your time, in
the late nineties, I pulled together a group of researchers
from the US and Canada and the Europeans who are
all interested in getting trials going on in North America.
We called it NAOMI, the North American OPI Medica Asian Initiative.
And what happened was that the Canadian leg took off
and they actually did it, and they now have it
(34:05):
in many cities in Canada, and you now see it
in many countries in Europe, and it is proving overwhelming successful.
It's not perfect, as you said, there are some problems resulting,
but it's reduced crime, reduced over those, reduced problems of addiction,
all this sort of stuff. But in the US, what
happened was the researchers said, Ethan, we're never going to
be able to get the funding. And even more recently,
the last meeting I had organized before I left Drug
(34:26):
Policy Lines four years ago it was a meeting to
bring together a younger generation of researchers, and people are saying, well,
why can't we at least give it a shot here,
or even if we don't use heroin pharmaceutical heroin, why
not use hydromorphone. You know, delouded, right, a drug that's
given out in American hospitals two hundreds of thousands of people.
We know from control double blind studies that long term
heroin attics can't tell the difference between delouded hydromorphone and heroin.
(34:50):
And then the public value benefit, which I mean part
of what happened in Europe was they started doing these
things and it helped transform people's understanding of heroin and
addiction that you meanize it. Rather than people being these
junkies chasing this dirty drug, people began to realize that
the drug itself was not as dangerous and it was
more the fact that it was illegal. So it seemed
(35:10):
that some allocation of nita's resource is something like this
would be usually advantageous. And I know when I talked
to mayors and police choose around the country, they said, hey,
as a research study, sure we won't object to it.
Why not make that a priority, especially given the issues
with sentinel now and so many people dying. Well, you
know what has made a gigantic difference, and the data
(35:31):
is out there, I mean, because this helps a very
restricted number of people. But what has made a magnificent
difference in terms of over those mortalities and outcomes is
what France has done with bupren orphins. So, if we
have alternative medications that actually are safer and that can
be deployed, and we're not doing that because the insurance
companies are not willing to reimburse, my focus is going
(35:54):
to be on how can I affect practices that are
likely to have a larger impact. And again, and it's
the issue of when you don't have all of the
resources of the world, you have to strategize which are
the ones that are going to have the largest impact.
And if you just look at the data in the
United States, the majority of people that are on treatment
for opiot disorder are on buoprinorphin. And so right now,
(36:17):
for example, one of our priorities is to actually expand
our basically knowledge base on clinical trials for the use
of booprenorphin on people that are being exposed to fantonil,
for which there is no clear call evidence about how
to properly treat them, what doses to use, why not
(36:37):
use extended formulations, how to initiate them in boopernorphin, and
also the sustainability of these practices in terms of costs.
So I see it as you know, there's not enough
money to be poured into the treatment of people with
substance use disorder, so trying to come up with models
that will ensure that the treatment will be provided it's
(36:59):
also key component. Let's take a break here and go
to an ad. When I was calling around, one person
who sang your praises, said that you've been very supportive
of expanding the access to method on rupernurphine behind bars, right,
(37:21):
You've been a big advocate that. I remember ten fifteen
years ago Drug Policy Alliance, we'll be organizing side sessions
at the annual meetings of American Correctional Association, and it
was just incredibly difficult to get correctional officials to come
along with this. And when I asked my friend what
was most significant about that, he said, you know, what
we found was that people they appreciate the opportunities you
(37:42):
just figure out what worked for them. For some, bruperophine
work better than method on. For others, method on work
better for some, nel trek Zone was the preferred one,
you know, for our listeners. The first two of those
drugs are basically sort of agonists, and there's like giving uh, say,
a nicotine patch to a cigarette addict, and al trek
Zone is an antagonist, which you know blocks the dealing
of these drugs. But it seems like just when we're
(38:02):
dealing with depression, we tried different antidepressants. When we're trying
dealing with pain management, we ideally are trying different opio
s see will work better. It does seem that when
it comes to dealing with heroin adjection and other illicit
drug opioid adjection, we should be making as many options
available as possible. I mean, I mean you basically agree
with that D percent agree And I use the same
(38:23):
analogiens as how many antidepressants we have, how many antibiotics
we have, and we are the only condition for we
said we have three. That's enough. In many ways, and
I perhaps shouldn't use this word. We've been very constrained
in many ways by the need to actually document that
the medications and the treatment are producing abstinence. And we've
(38:44):
been knowing that certain treatments, while not producing abstinence, will
improve the quality of life of people and protect them.
And so we've been trying to have a dialogue and
we've had a dialogue with the FDA. This is the
outcomes that they required to change those outcome so that
we can allow for treatments that, while not producing abstinence,
are going to be beneficial for the patients. They are
(39:07):
willing for us to consider this if we can provide
them evidence that this is meaningful. So we're funding researchers
to show this. And so now there is data that
we indicates, for example, that whooprint orphin or metal or
other medications, even if they don't produce abstinence, they reduce
the negative outcomes with HIV, They improve retention into anti
(39:27):
retroviral therapy, they decrease the likelihood of being incarcerated. So
these are meaningful consequences to that person. So we are
again negotiating towards also discussing possible medications that we may
have tested in the past that we're found nonefications because
the outcomes was impossible to reach complete abstinence a very,
(39:49):
very difficult work to achieve, and I think it is
different from what we demand for antidepressants or for an analgestic.
You don't demand that the pain become completely you didn
and a fifteen percent reduction, I mean, so we are
this has made the development of medications much harder. Uh so,
I mean you essentially see the dealing with this sort
(40:10):
of twelve step absinence only ideology has a real challenge
for you that it really gets in the way of
effective drug treatment and changing policies. Is that fair to say? Well,
what I mean, I'm not so categorical in my thinkings.
I mean, my perspective is recognizing that there is a
diversity of people and for some individuals that of Step
(40:30):
programs maybe um life saving, but for many others they
are not. And so in my perspective, I value that
all Step programs because I do recognize that they offer
support for people and have been able to help people recover.
So why would I be critical of that? What I
am critical of is their categorical rejection by many of them,
(40:53):
of the use of medications for treatment of substance use disorders.
I was actually speaking with a volunteer patient with an
opiate use disorder who is on boubernorphine and who was
very much in conflict because he wanted very much to
be part of the twelve step program, but he didn't
want to lie to them that he actually was taking
(41:14):
Boobern norphin and he didn't want to stop taking Boobern
rphin because he recognized that it helped him enormously. Why
I put individuals that are already with tremendous challenges in
a conflict to have to decide one versus the other?
What else it tell us that both of them can improve.
We do it for cancer, we do it for HIV,
we do it for everything. Why do we need to
(41:35):
have one or the other? So do you remind me?
I remember coming across a twelve step program being run
out of Bellevue Hospital years ago, which was a twelve
step program for people and that slimated it who felt
discriminated against the normal twelve step programs, like the methodology,
like the community there, but felt Tay can do it.
But now let me switch back to this thing. You know,
part of the promise, supposedly, I think of the focus
(41:56):
on the brain and the way you've put the resources
between the brain and addiction. Was hoped that new medications
would come out for dealing with addiction. But if we
look at the basics, right, methanon, ruper norphine, nil tracks on,
and niloxon for dealing with overdose. All four of those
drugs were patented between fifty and seventy or more years ago,
and really nothing new, really of significance has come along.
(42:19):
I mean, part of what was interesting about the heroin
hydromorphone stuff in Europe and some other innovations there was
at least it was another thing that worked for people
for whom method on a grouper rhine was not working.
But is there anything on the horizon, whether with opioids
or whether in dealing with the stimulants. I think you
you're out there saying the best thing we have is
contingency management, a behavioral approach rather pharmacological approach. Is there
(42:41):
anything promising on the horizon, the short horizon for adding
some other drug to this mix? Yeah, there is. And
I don't think that we should minimize celtic interventions because
one of the things that the neuroscience has enabled us
to do is to understand how these behavioral interventions are
affecting neurocircuits influenced by drugs, and so you can tailor
(43:02):
then the intervention in such a way that it will
maximize its efficacy. And in terms also the understanding of
the neurow secretry that is engaged in addiction has offered
an opportunity to start to work with a neural modulation technologies.
For example, I think it was last year that the
FDA approved the use of transparential magnetic stimulation for the
(43:24):
treatment of nicotine addiction. We are also taking advantage of
the peripheral system which impacts on the brain and in
in cortical regions and it modifies our sensations, and that
in turn has resulted on approval of a peripheral stimulation
device for the treatment of opiate withdrawal. I mean, the
problem of developing medications, as you know is it takes
(43:46):
something like twelve years from the idea until it comes out,
and the process it requires an enormous amount of money.
So what we do as an agency is try to
engage industry, whether it's big or small industry, to buy
into that product and develop it. Because it's like two
point five billion dollars to take that treatment into that clinic,
which of course will completely kill our budget for two years.
(44:10):
Well let me ask you, so another category of drugs,
the psychedelics psychologs research was pretty amply funded in the
fifties and sixties by the federal government, and then with
all the counterculture stuff and Timothy Leary, it was basically
obliterated in the US and much of the world. And
now it's beginning to come back. And I know, you know,
my friend Rick Doblin, who heads the Multi Distmary Associate
Psychologic Studies, has raised tens of billions of dollars of
(44:33):
philanthropic funds, but still there's been no government funding there
at all. And now you have this issue of four
profit players coming in, as you're saying, is sometimes needed
for drug development. But I wonder we'll be seeing something
coming out of NAIDA. I mean, I just saw that
in late May. You know, your boss Francis Collins, the
head and a Student Health, said to Congress really interesting
stuff going on with psilocybin. And National Cancer Institute just
(44:54):
hosted something on psychedelics and end of life care, right,
and I think National Student Mental Health another one of
your sister agencies has been holding webinar seminars about the psychedelics.
So what about National Student Rug Abuse? I mean, I
think I saw there was a couple of things maybe
about ketamine in addiction, But can we expect to see
you beginning to fund stuff on psulocybin and treatment of
addection or even or pain or things like that. Is
(45:17):
that on the horizon for the short term. I mean,
it was an eye opener to uncover that ketamine it's
actually has turned out to be an extremely useful intervention
for treatment resistant depression, and it is a result of
research that led to these really important advancement on the
way that we treat people with depressive disorders. So yes,
(45:39):
and there we have been funding research that it's ongoing,
and keptamin for opiate treatment and also keptamine for pain
also has potential for PCP. If you look at that data,
actually the evidence is strongest form showing potential benefits for depression,
and the strongest data on depression, I would say it's
on individuals that suffer from cancer terminal illnesses and they
(46:03):
have pretty dramatically positive results that persists that at eight months.
That is the area where there is probably the most
ongoing treatment. There is a story, there's a couple of
stories that have shown some benefit in a nicotine addiction,
but they were not blinded, so it's very difficult to
actually know the potential signal. So we are open they
(46:25):
have to come up with that proposal that will be
deemed meritorious and we rely on review committees to evaluate
the likelihood of success. And the data for addictions is
in terms of the evidence, it is much more limited.
But but no, I mean, let me just press you
because I mean, obviously with psilocybin there's research being privately
(46:47):
funded that is showing great promise. We know with ayahuasca,
lots of interesting things are emerging in terms of people
processing not just trauma but also times addiction. And you know,
there are people talking about the promise of psychedelics in
the treatment of depression and things like this. They could
revolutionize the pharmacological you know, treatment in some of these areas.
I mean, I'll tell you it wasn't long ago that
(47:08):
a prominent researcher who I think you know well, um,
who had done research on other drugs, you know, cocaine, nicotine,
it was getting interest in psychedelics and he was hopeful
of getting a national student drug abuse funding for research
on psilocybin, and what he ended up doing was telling
the organizers of a conference on psychedelics to disinvite me
because if he showed up at a conference where Ethan
(47:29):
Naedelman was talking, that would show that psychedelics is all
political and therefore he won't get funding. Now I think
he still hasn't gotten funding. But given the enthusiasm coming
out and all of the intriguing research out there, why
not go more strongly into this area? Now? I mean,
is there a fear of the political fallout or what? No,
I don't think that there is a person a fear
(47:50):
of the political fallout. I think that we are seeing.
I mean m d m AS is an addictive draw.
Psilocybing is not an addictive draw. And yet I mean
it's being utilized in a way that it's safe for
the treatment of people with depressions. So the notion of
when you get proposals, you are competing with other grants
in terms of likelihood of success in the proposal that
(48:13):
you have and likelihood of implementation, so they are the
review process is important and you cannot just come in
and with an idea without showing as you know, for
the grant, most of the ground mechanisms requires that you
do provide a background that supports the likelihood that you
will be successful. And the reason why why this is
done is again limitation of resources. So you have to
(48:35):
take risks, but you want to take risks that are
more likely to be successful. So Northlesia with the n
d M A, right, I mean n DMA seemed Night
have spent a lot of money trying to establish the
neurotoxicity of m d M A, and I remember there
was this sort of embarrassing thing that happened. Not it
was after you, I think, before you came in. Right,
We're Night given a big grant to researcher at Hopkins,
(48:57):
George Ricardi, who came out with this big study and
Science saying that all these monkeys that died from m
d M A and then it turned out lo and
behold he had given them large doses of amphetamine and
people were highly suspicious of the results even before I
got published in Science. And the day that article came out,
your predecessor Alan Lester said, got you Using m d
M A is like playing Russian roulette, which was an
(49:19):
incredibly irresponsible thing for a former head of NADA and
head of the American Academy Arts to Science say, now
you have the f d A, right, it's about to
proceeds in phase three trials with doing m d m
A for treating PTSD. Right, they've established the safety margins.
Right are you concerned? I mean, given all the that's
happened last fifteen twenty years and with m d m
A going through all these incredibly expensive long trials and
(49:43):
now the possible expansion of m DMA to treat PTSD,
do you have any concerns about that? Or you enthusiastic
about this development? I basically I support science that can
help bring new treatments. I actually was one of the
ones that was very skeptical when the paper came up
in science because we have been looking into the effects
of drugs in the brain and and and and also
(50:03):
the Europeans have a long history of actually studying the
effects of ecstasy and no one has reported anything like that.
And overall, the issue with with ecstasy has has had
more to do and I guess everybody what is concerning
the potential of john people using it in situations where
they are very crowded and that can result in HYPERTERMI
(50:24):
or there have been some debts associated with it. If again,
and it's this the history. I mean, we've learned, we
need to learn from what what the evidence is showing up.
If we can use gatamine for the treatment of severe
depression in a way that is safe, this is an
example of really that we can do. We can use
drugs that we thought were dangerous and using in ways
(50:47):
that are therapeutic. In fact, we use fentanyl extensively for
surgical procedures and it's a very valuable drug. So we
cannot demonize fentanyl because they elicit drug is being market
it in the streets. Because fantaniel also has a very
valuable application in medicine and can be life savings. And
the same thing with prescription opius. And this is something
(51:10):
that I've also been very vocal about. And so again
we polarize everything. It's either good or bad and I
and you know, my brain is why can't we not
have this and that these two things are correct. We
are over prescribing, but at the same time we are
restricting it to people that needed. They are not exclusive.
You know, one thing that worries me, right you know,
(51:31):
I oftentimes describe the War on drugs is being justified
in terms of being one great big child protection act.
And when you would say that politicians, why can't we
legalize marijuana for medical purposes? And they go what about
the kids? Or I remember what about needle exchange? And
the former governor of New Jersey, of Christie Whitman others
would say what about the kids, and always go what
about the kids? What about the kids? What about the kids?
And when we hear that now is on the issue
of nicotine and vaping, right, I mean, here you have
(51:54):
a kind of breakthrough technological innovation that has the potential
that's dramatically less staydangerous. The cigarettes and heat not burned
vaping devices are dramatically less dangerous than cigarettes. You're not safe,
but dramatically less dangerous. And then we see the rapid
uptake of jeweling among kids a few years ago. And
now it seems just like this massive miseducation campaign of
(52:15):
which the U. S. Government, including the Center Disease Control,
has been an ample part. I mean, you have now
a majority of Americans believing that the cigarettes are as
are more dangerous than combustible cigarettes. You have a majority
of Americans and even certain fields of medicine believing that
nicotine is what causes cancer. Rather than nicotine being the
hook that addicts people to cigarettes. You have people believing
(52:35):
that that whole the Valley syndrome where people were landing
up in the hospital was about nicotine e' cigarettes, whereas
we know now and in fact, there was a good
reason to believe in the beginning it was about illegally
produced tainted THHC cartridges. So the question I'm asking is
what is the responsibility what is your obligation as the
head of NAIDA to make sure that these massive public
misperceptions get corrected. This is going to be my last
(52:59):
answer because I do have to run to another meeting,
but it there's I mean, I cannot know not respond
to this extremely important question because it's another example about
how we swing back and forward and and the reality
is that jazz vaping of nicotine can result in people
that are naive to become addicted very rapidly and can
actually lead to toxicity because in the cartridges you can
actually concentrate high doses of nicotine that you would never
(53:21):
be able to smoke with combustible on the other hand,
as you say, electronic cigarettes offer an alternative delivery for
nicotine on people that cannot stop smoking, and in the
process at the European data has shown that actually they
are benefits. So one of the things that we have
been very interested on doing is funding research that will
document benefits of the use of the electronic cigarettes on
(53:45):
for nicotine's cessation or for alternatives for treatment. So there
is true on both of those things. I mean, although
I am impressed by the evidence coming from Ken warrener
many other people pointing out that from a public health perspective,
the net benefits for smokers and switching so exceeds any
potential risk to young people from vaping, and that the
(54:05):
evidence of kids starting to vaping moving into cigarettes unless
they were already engaging with two bustibles beforehand, is so
low that you have an overwhelming case for responsible public
health policy that I wish say, yes, it's so simple.
I think that I believe I'm saying it's a balancing
I see the other side of of the coin, and
(54:26):
I actually because I know that data on both sides,
but but that I think if we are actually ultimately
trying to understand I mean a very specific question that,
believe it or not, there's very little work. How does
nicotine exposure during brain development influence that trajectories? I mean,
what are its effects? And as you know, one of
(54:47):
the things that nicotine is associated with, once you've been
taking it and you stop, you have greater likelihood of
depressive symptoms of anxiety. So I have a fascination for
nicotine is another extremely interesting comp own board. It can
be very addictive. Okay, my last, my very last question
here here you've been supporting decriminalization, supporting a public health approach,
(55:08):
opposing the drug war. Can you envision in your life
post night to Um joining up with drug policy reform
organizations to push for policies that are more grounded in
public health and human rights and harm reduction and opposing
the punitive prohibitionist policies if they are effective. Yes, great, Okay,
I don't just like to think about problems. I'd like
to solve them. I agree, we're in the same milk
(55:29):
that way. Listen, Nora, thank you ever so much for
taking the time to do this. I really appreciate it
is a very highly engaging conversation and I wish you
the best of luck. Under this current administration. Thanks very much, guys,
a la vista. Psychoactive is a production of I Heart
Radio and Protozoa Pictures. It's hosted by me Ethan Edelman.
It's produced by Katcha Kumkova and Ben Kibrick. The executive
(55:53):
producers are Dylan Golden, Ari Handel, Elizabeth Geesus and Darren
Aronovski for Protozoa Pictures, Al Williams and Matt Frederick for
I Heart Radio and me Ethan Nadelman. Our music is
by Ari Blusian and a special thanks to a vit Brio, SF,
Bianca Grimshaw and Robert Beatty. If you'd like to share
your own stories, comments or ideas, please leave us a
(56:16):
message at eight three three seven seven nine sixty. That's
one eight three three psycho zero. You can also email
us as Psychoactive at protozoa dot com or find me
on Twitter at Ethan Nadelman. And if you couldn't keep
track of all this, find the information in the show notes.
(56:41):
Listen in next time for my conversation with Tim Ferris,
the investor and productivity guru who has been funding research
on psychedelics and it also has a fair number of
experiences to share himself. Here's a bunch of college kids
eating handfuls of mushrooms, no measurement involved to see what
would happen. Nonetheless, I knew, just after these experiences, which
(57:01):
I did once a year for a number of years,
that there was an antidepressant after glow optimism that lasted
for several months. Subscribe to Psychoactive now see it, don't
miss it.
Hi, I'm Ethan Nadelman, and this is Psychoactive, a production
of I Heart Radio and Protozoa Pictures. Psychoactive is the
show where we talk about all things drugs. But any
views expressed here do not represent those of I Heeart Media,
Protozoa Pictures, or their executives and employees. Indeed, as an
(00:23):
inveterate contrarian, I can tell you they may not even
represent my own and nothing contained in this show should
be used as medical advice or encouragement to use any
type of drug. Hello, Psychoactive listeners. Uh, Today's guest is
(00:46):
a really interesting one for me. It's Dr Nora Vocal,
who has been the head of the National Institute on
Drug Abuse in the US government since two thousand and three.
That's under four different and presidential administrations, so it's been
a remarkably long run overseeing the lead agency which provides
(01:08):
the majority of funding for drug research, not just in
the US, but really the majority all around the world.
Those of you who know me, you'll know I've been
highly critical of NIDA, Nationals Drug Abuse and Dr Volka
over the years, in part because I think they've so
overemphasized trying to establish that addiction is a brain disease,
(01:31):
and and putting a lot of research into the neuroscience
and brain imaging and all of that. And I personally
think that they should be spending dramatically more money on
things like ethnographic studies and setting things like the ways
in which people control their drug use and more research
on the benefits of drugs. Now, you should also be
aware that a few years ago Nyder receives some dedicated
(01:53):
funding from Congress, specifically UM to address issues involving the
drug overdose. At the demo, and those of you have
been listening carefully know that just a few episodes ago,
in episode five, we had Professor Dan Chacheroni talking about
what's going on with the overdose epidemic? Why did almost
a hundred thousand people die last year? Uh? And so
(02:14):
I started off the interview really by pressing uh Dr
Volcale on that question, UM, And I will admit I
was frustrated by some of her answer. She kept saying,
we need more research on this, more research on that,
you know, and of course Night has been spending more
money and anybody in the world on doing research. But
I'll tell you I was pleasantly surprised that she agreed
(02:37):
to be a guest on Psychoactive. Nora grew up in
Mexico City, has a fascinating family history that will get
into early in the episode. She was an outstanding medical student,
became a psychiatrist, held all sorts of influential positions, became
a real leader in the US and around the world
trying to understand addiction by looking at the brain through
(02:58):
neural imaging and brain scans, and has had really quite
a remarkable run. So, without further ado, here's my conversation
with Nora vocal Nora, thank you so much for joining
me today on Psychoactive. That's for having me and listen.
My job here, right, I mean here, I've led until
(03:21):
recently the leading drug policy reform institute, which was intensely
critical of many government policies and oftentimes of Naida's work
and priorities. But it's my job both to be the
gracious host and also to press you on a lot
of questions which have been on my mind that I'm
sure in the minds of others. But let me just
start off on a little bit of a personal thing,
which is you have this remarkably interesting background familiar background,
(03:44):
you know, growing up in Mexico, but growing up in
the house in which your great grandfather, the Russian revolutionary
Leon Trotsky, was murdered by Stalin's agents. And yet there's
another part of your family history involving I think your
grandfather of ears, which I understand it first sensitized you
and made you start thinking about the issues of drugs
(04:06):
and addiction and what you might do to address it.
And I wonder if you could just tell us a
little more about that. Yes, and and indeed, my my
story comes from two different countries. I my father came
from Russia and his grandfather was escaping from Stalin and
ultimately the only place that gave asylum to his family
(04:28):
was was Mexico, Whereas my mother was born in Spain
and there was the Civil War, and again Mexico was
a place that gave political asylum to all of those
refugees that were escaping Franco. So I always like to
say that I was born of the two Wars, or
the last century Russian Revolution and the Civil War, and
(04:49):
so that's that's how I came to be born in Mexico.
What you were saying as in terms of what led
me to think about addiction. And indeed, Um, the father
of my other unbeknownst to me as as a child,
I had never met him because he was in Spain
and I was in Mexico, had a history of alcoholism,
(05:09):
and when I was approximately probably six years of age,
he committed suicide because he couldn't control the strong urge
to to drink and had relapsed. So I did not
find this until later, when I was already in medical school.
But in the meantime, my favorite tone call of all times,
(05:30):
my mother's older brother, also had a problem with alcohol,
and to me, it was very contrasting to see the
component about what an extraordinary individual he was, how generous,
how smart, how charismatic on the one hand, and yet
when he was drinking, his personality changed so much. And
(05:54):
I was also intrinked about the family dynamics because nobody
wanted to speak about it was like this antic secret.
It gave me that insight that, I mean, people are
not bad because they have a problem of addiction. They
just have a problem that it's more powerful that they
can't control, and it's not that they are doing this voluntarily.
(06:17):
So as I went to medical school, I was also
uphold at the way that our doctors were treating addiction.
They were ignoring it, actually refusing sometimes to give treatment
to someone that have a history of addiction because they
thought that they were doing this to themselves and whatever
happened to them, they deserved it. And I saw this
(06:38):
even as I went after my residency training in psychiatry,
where we would admit patients that have depression with an
alcohol use disorder, and I would inquire to the attendance,
how do we address the alcohol use disorder and do
not worry about it, treat the depression and once the
(06:59):
person leaves the host bital, then they will deal with
their alcohol use disorder. And later on, as I became
an attendant, directly forbidden to admit patients with an addiction
into the inpatient unit of the hospital because they were
patients that misbehaved under quote. So to me, all of
these experiences were actually activating Miami Dallas, which are the
(07:23):
centers of emotions of the brain, because it seemed completely
counter factual with what we knew then on the pharmacology
and the neuroscience of the brain, and we knew that
we could make animals actually get compulsive in administering a
drug to the expense that they would stop eating or drinking,
and they actually j pordize their life. And so they
(07:44):
are very in wire wire biological circuits that make us
vulnerable to these drugs and in some people to that
complete loss of control. So that's ultimately what led me
to try to provide knowledge that could illuminate further her
calpus understand what happens in the brain of people that
(08:06):
lose control, with the idea that hopefully science will serve
to change policies and reduce the stigma, and basically changed
the notion of criminalizing people to that of treating and
helping people and preventing them from relapsing. Yeah, so I'm
trying to think, um, if I look at what natives
(08:29):
priorities have been, and I think it was true under
to some extent your predecessor listeners as well, But for you,
really it feels like the major thrust of the agency
really has been on the brain research, right and then
your imaging in that the biggest share of the resources
have gotten there, And what I have always felt has
been a sort of inadequate attention to funding the sort
(08:51):
of ethnographic work the deep analysis into drug using communities
and drug cultures into truly understanding what's going on there,
especially we're dealing with the overdose issue and the opioid issue.
I mean, I know you find some stuff in that area,
but it seems like it's relatively modest, very modest compared
to the work that's being done. And they were imaging
(09:12):
in the brain stuff, and I mean, what's the rationale
for that? Is that you believe that the brain work
is going to lead to the big breakthrough. I mean,
here we're focusing on the opioid epidemic, right, which is
now what we're approaching a hundred thousand people dying overdose
and all sorts of other ills associated with this. Why
is such a focus on that well, I mean, obviously
we are very much interested on basic neuroscience to help
(09:34):
us understand how it affects the brain. But we invest
much more money on research that relates to those very
important components that you discuss the issue of how socio
economical factors, cultural factors influence the vulnerability of resilience for
drug taking, and so our dollar amounts spent in research
(09:56):
that relates, for example, to prevention services in implementation epidemiology,
in fact, is greater than what we've spent in basic neuroscience.
We have this need in humans of polarizing things into
this or that, and ultimately that reality is that our
social systems are product of our brains interacting with one another,
(10:18):
and our brains are a product of our circumstances. So
the challenge in science is how do we integrate these fields.
For example, a very important story we have been doing
since twenty sixteen is a developmental study of children as
a transition into adulthood. And yez, we're studying their brains,
but yez, we're doing a very in depth phenotypic characterization
(10:42):
of their social environment. And as a result of these
longitude in our study, large longitude in our story, researchers
have been able to document some extremely powerful relationships between
these adverse social environments and how the brain develops. And
also important in sites on how very early owned children
(11:03):
as mistreating if they come from certain racial backgrounds. And
we are about to start a similar study in initiating
early in infancy to follow it up, and it will
give us some much better understanding about how our environment
influences the brain. Well, but now when I'm really getting
at those. I remember back in the seventies and eighties
(11:23):
there was this incredible richness of ethnographic studies going on,
and and famous ethnographers Michael Agar and others, and a
whole cohort who are really doing in depth studies. And
now I look at the questions that emerged around say,
fentonyl on the opioids, the question about how our consumers
responding when people know that fentanyels out on the street,
that they run forward to run away for it. What
(11:44):
sorts of precautions are they taking us to be their
own use to what exentered? The people who's selling these drugs,
the lowest level retail sellers, to what extent do they
know what's in their drugs? Are they exercising any sort
of harm reduction measures us to be their own consumers?
Right to what ex center? These drugs all being mixed,
Why is ventinyl landing up and the stimulants apply with
cocaine and methamphetamine. And there's these hosts of questions, and
(12:06):
it seems to me that essentially nobody has the answers.
And when I talked to, you know, the sociologist, the
ethnographers the others who are getting funded. They're saying, Ethan,
You're right, those are really important questions. But the truth
of is it, there's only a handful of us really
getting this abundance of funding to do this stuff. Isn't
a part of the job of NAIDA to be digging
(12:26):
deeply into what's actually going on in these active markets
right now, finding these things out, and trying to dig
into what sorts of interventions you can do with active
drug users and even low level sellers in order to
reduce the harms that are resulting from ventanyl and these
other opioids being on the street. Absolutely, we have a
responsibility to bring a light that can help address these
(12:50):
very challenging times. And what I can tell you I mean,
and this is in terms I mean. One of the
main drivers about why we have synthetic opio is now
widespread through the United States is because the profits for
the dealers and those that are generating these drugs are
much greater than they are for something like heroin or
many of the other drugs that require cultivation. So one
(13:13):
of the reasons why you see so many drugs being
laced with fentannel is that the dealers are going to
be making much more money. And we do have ethnographic
reports that actually go and speak with people on the
streets and for example in Baltimore, John heroin users maybe
in some instances seeking out fentannel, but the older ones
(13:34):
are actually afraid of it, but they cannot afford to
buy pure heroin because it's more expensive. Also many instances
it is very difficult to get pure heroin even if
you have the money to pay for it. So it
is a reality that unfortunately, the enormous amount of money
that can be made by selling fentannel is driving the market.
(13:56):
And so I mean in terms of scientific questions is
how do we counteract that negative effects and the strong
aggressive distribution of fentanyl and its contamination of the other drugs.
That's unfortunately, at an essence part of the normal challenges
that we have. But we need to understand also that
(14:16):
diversity of the markets and too to meet one of
the key important issues for addressing, for example, the obvious
crisis is to have more timely data, just like like
we had with COVID, Right, you see immediately you know
when you're starting to have the new variance. We don't
have that for fentanil. So if I get data, it's
at least six months later of over those mortality across
(14:40):
different areas of the country, and by then many people
have died. And the technology is out there that would
enable us to detect early on when we see in
a community the emergence of these very little drugs. I
know my own I just to say, my own sense
is that if you were the funding army of hnographers
going out there doing snowball research, paying drug users to
(15:02):
connect with other drug researchers, finding out what they're doing
around these new drugs emerging, what sorts of precautions are doing,
and even funding studies that try to enlist drug sellers,
whether they're currently incarcerated or whether they're still operating the
community to find out. Look, drug sellers don't want dead customers.
It's bad for business, right, or even trying to find
out what I mean, I don't know if you know
(15:23):
the answer. Why is it that cocaine and methamphetamine are
being cut now with fentanyl? I mean, are they trying
to make some form of new speedball or is it
just out of ignorance on the part of retail sellers.
Are the customers actually want that. I mean, what do
we know about that right now? What we know is
that many of the debts associated with stimulants our own
(15:45):
beknowns to the person that they were getting actually a
stimulant that was contaminated with fantaniel in some instances. Yes,
as you know that speed bowling was the way that
people used to want to get tired. Um, you don't
have just one reason why people maybe combining, but I
need a very important contribution is people not knowing that
(16:06):
they are getting fantonil, being stimulant users having no tolerance
for opious and therefore that drug combination is particularly little.
And yes, I mean I think that one of the
issues that you need to consider in terms of how
we have to make decisions. Absolutely, we need to understand
the problem in better ways, in more efficient ways, but
we also need to develop tools that will allow us
(16:28):
to address it. So it's not just that we are
actually have the resources just to do epidemiology and ethnography research.
We need to help develop medications. We need to develop
models that will ensure that individuals that need care will
be given care. We need to actually develop models for
(16:48):
prevention of relapses, for prevention into drug taking. It's not
just one thing that we can allocate all of our resources.
It is crucial that we understand the age share of
the problem. And it's also crucial in that respect that
with partner with other agencies so that we maximize the
resources and we can achieve more. And they're speaking about
(17:10):
something that is very very intriguing, and it's an area
that has been not thought much at and and so
I'm curious that you asked me about it, which is
the notion about the dealers. How do that dealers end
up dealing with these very dangerous strokes And that is
is something that we don't have research into that area.
(17:31):
It would be a great thing to solicit proposal for
because quite frankly, whether or not the lowest level retail
suppliers um actually know what's in their drugs and what
precautions they take and what's going on in that dynamic
would be fantastically valuable giving the amount of accidental overdose
that's happening right now. We'll be talking more after we
(17:52):
hear this add You know, I saw recently that you
wrote a piece in which you said you supported drug decriminalization,
and I know you've never been a fan of the
War on drugs. But here you've been operating in a
(18:13):
political context in which punitive prohibitionist policies, mass arrests, you know,
the heavily racial biases that go with all of that
has been pervasive. Now, one of the other criticisms has been,
you know, they're always looking for what's wrong with drugs,
but what about what's wrong with drug policies. I'm gonna
taking example. I'll see you write an article about all
(18:35):
the harmful consequences of marijuana, right, and we can agree
that one has to identify the harmful consum marijuana. But
there's nothing coming out of nightA that I'm aware of
that's looking at the harmful consequences of marijuana arrest or
marijuana related loss of employment, or even from a health context.
When you put somebody in jail for marijuana or arrest them,
restript them of the job, that has consequences for their
(18:56):
broader life. It also can be traumatic and cause things
that might impacked their brains in ways like that. So
what has been the resistance to this? Isn't that important?
I mean? And if not, you whop you know? And
it's crucial And I basically from day one. I've been
against criminalization of people that because they have a problem
with substantious disorders. I've been very, very vocal. We found
(19:19):
that research to show how negative the consequences are of
imprisonment into the brain. It actually increases the risk of
drop taking and it basically also increases right now even
more than before when it was known that risk for
overdosing and dying. A very important project that we have
been doing now for year years and now we've actually
(19:41):
expanded because we got extra resources, is with a criminal
justice setting exactly to provide alternative models that will ensure
that people, if for whatever reason first of all end
up in jail on prison, that they get treatment and
that they get support, and also to determine how one
can intervene to avoid that incarceration. We have funded research
(20:04):
showing that, as you mentioned, when you have a relative
of father and mother that ends up in jail or prison,
the risk of the child to have a substance to
use this order is much greater, and that is known
and no one is questioning it. So we've been trying
to disseminate this information. And when I am I have
to actually speak in Congress or the Senate. I bring
(20:25):
up this issue because I feel very very strongly, and
in fact, one of the reasons why I took this
position was because I say we can develop the science
in such a way as that that policy changes. I've
also been openly active criticizing the policy of incarcerating for
crack versus cocaine, which made absolutely no sense, and there's
(20:45):
record on those things. The issue comes about, I mean
that there are structural systems in such a way that
promotes certain behaviors, and science as not enough to change
those policies. So my question that I always say is
what is it that science cannot cover to change policies
(21:05):
that would get rid of these structural characteristics that are
leading to these inequalities. And we are very much interested,
for example, in policies. We found several researchers to identify
policies across the states as on how they are legalizing marijuana,
because as you look through the states, for example, you
see that the adverse effects of marijuana use are much
(21:29):
worse in some states, whereas other states that have legalized
actually have better outcomes. So understanding what policies basically protect
from negative effects and may actually lead to better outcomes,
it's crucial and we're funding it. So yes, the answer
is yes. Yeah. There's one issue I think, going back
a number of years ago, where if I pat myself
(21:50):
on the back, I think I was more right than
you were, which is people were saying, if you're gonna
legalize marijuana, you're gonna see this explosion in adolescent usaid
mari juana and problematic use. And I think you were
part of that group saying that. And what hit me
at the time, you know this is back six seven
years ago, was that adolescents have for fifty years always
had the best access to marijuana. Right, even as mari
(22:11):
wanna use among adolescents has gone up and down the
ust fifty years, the surveys that ask about access consistently
show eighty percent of high school seniors saying they have
easy access. So my sense was that marijuana use among
adolescents was not going to change much as a result,
for the simple reason that access was already so abundant,
but that where you were going to see the jump
was going to be among people our age and a
(22:33):
little older and a little younger people using it because
they preferred it to alcohol or pharmaceuticals. And in point
of fact, it looks like there's been a tripling or
quadrupling of marijuana use among people you know, our age
or older um, whereas the adolescents have stayed relatively constant.
And my job, I wouldn't be surprised if he jumps
in the future. Part of the other research I think
suggests that use of drugs oftentimes goes up and down
(22:56):
independent of what the policy is. There's a whole range
of other variables out there. And I guess when my
question now comes to you is when you write a
piece about the harms of marijuana, why not write a
piece about the benefits? What about a piece about the
controlled juice? What about one piece that looks at it all.
You know, many people were so frustrated that NITA did
(23:17):
not support the medical marijuana research. It took forever and
ever and ever. Or you look at the fact that
the vast majority people use marijuana don't really have a problem.
It is clearly problematic and even addictive for some, and
we have to be aware of that. But why not
have a more holistic, comprehensive approach to Let's just take
the drug marijuana as one example, yeah, no, and I
think that one of the reasons why is because the
(23:40):
data on the benefit from marijuana is very limited, and
it is very limited because there is limited research. And
so one of the things that I have been involved
now for more than a decade, and I must say
that I have been unsuccessful, is to stry to change
the policies that make it so very difficult for researchers
to have marijuana. So marijuana is a scalle one draw.
(24:02):
So if you, as a researcher want to do work
with marijuana, you have to get a d A license
and get approval from the FDA, and that takes at
least one year, and then if you change your protocol,
you have to go through the process again. So it's
extraordinary comberson and as a result of that, researchers don't
want to get into the field. That's one second. We
(24:23):
are also mandated, actually this is not my choice. We
are mandated to provide the marijuana for research purposes, and
so we contract these to a farm in Mississippi that
produces the marijuana. But this system is actually not ideal
because when you are testing a marijuana, say, for example,
(24:43):
you're interested on its potential value, for PTSD or for cancer,
for whatever you want, you are going to be working
with a particular plant, and it's unlikely that we have
such a plant, so it has hinder research. And I
think it was last week that finally that government has
identified to other producers that can provide marijuana, and if
(25:07):
that happens, of course that will facilitate the research into
the medical use of cannabis. I also want to comment
that neither those fund research on medical marijuana, but we
limited to potential beneficial effect for treatment of addiction, for
treatment of pain, and for treatment improving outcomes from the
(25:29):
individuals that may have HIV. So we limited to risk
conditions because otherwise all of our money would go into
research on medical properties of marijuana for US skimmers, for
carter aspolarisis for inflammation. We are hoping that the other
institutes will take those projects that pertains to the diseases
that they are working on. And you were right. I
(25:50):
was expecting that use of my juana mo cadolescens would
go up, and overall it hasn't. But what we are
starting to see, which is again important to keep an
eye on, is that regular use of marijuana appears to
be going up among other lessons, and that's that's of
course of concern. Yeah, nor you know, I so much
share your concern that with legalization that marijuana almost becoming
(26:12):
overly normalized in the way that people begin to sort
of lose its specialness and use it in ways that
are problematic. So we share some overlap there. But you
know you mentioned the Schedule one thing. You know, there
were lawsuits some years ago to try to get the
d A to reschedule marijuana from Schedule one to Schedule two,
and another lawsuit reguarding m d m A, And in
both cases the d AS administrative law judge ruled that
(26:33):
in fact, based on the evidence, it should be rescheduled.
But under U S Law, the head of the d
e A has a legal power to dismiss the recommendation
by his administrative law judge and just keep it where
it is now. I'm curious, I mean, do you think
it's appropriate for a police agency like d e A
to be control of that. Shouldn't it instead be national
in stuite of health for me to be even better
(26:53):
and independent body like Institute of Medicine at the National
Academies of Science. Well, I mean, I think that, in
my view, is not what I think. I mean, it's
the way that this system is organized. What I can
tell you is a very specifically explicitly describe this as
a problem in the meetings that I have at the
United Nations to state that the scandaling has made it
(27:15):
hard to do research, which is impedding again, investigations that
relate to the potential medical utility of cannabinoids that are
in marijuana. So I represent the science, and there are
other people that make the rules about regulations and and
that's what the missions of the agencies are. So yeah,
(27:35):
now I hear you, But you know, I was thinking
about this. There is only one other person I can
think of who has headed a drug related agency in
the federal government for longer than you. Right, You're the
longest at NIDA, You're the longest d e A, the
only one I can think of. It. It's not putting
you in I don't want to put you in bad company.
You're goill be Harry Anslinger, right, the guy around the
thorough Vieau of narcotics for like thirty two years or
(27:57):
something like that. But you are in a position of
tremendous influence by virtue of your tenure, and I have
to ask you this question, and as frankly as you
can answer it, I'd be curious. You came in under
President Bush in two thousand and three when the drugs
are John Walters was a fanatical anti drug guy. I
saw some of your testimony in front of that congressman
(28:19):
Mark Suitor, I mean, real drug ward nutcases, and I
admired the fact that you were telling him what the
evidence was on needle exchange. And then you go under
Obama and things open up, especially in the second term,
and then you're dealing with Trump and the first head
of Health and Human Services, your boss, I guess twice removed,
who like doesn't know his asked from his elbow about
method on and now under Biden, where things are opening
(28:41):
up somewhat. Can you say anything, frankly about what it's
like to deal with that political context, especially at the
federal level. Well, I've always spoken up, and I've said
it very specifically. We are an agency of science and
we need to be allowed to do science. Let the
evidence speak. The moment that our actions become politicized, we
(29:05):
lose any credibility. Obviously in some instances it maybe you
just have to be a little bit more diplomatic on
the way that you present these things. But I do
believe that that is our job, that's our responsibility. We
need to bring the science that can help guide decisions,
because if we don't do it, then we shouldn't be
(29:26):
in these positions. Well, okay, so let me repeat to
you something I've been saying since the nineties, and and
you know, please don't take offense at it, but it
was kind of my broader perspective on this thing. And
I don't think it's as true today as it was then,
but I still think there's truth to it. I would
say they're trying to do innovative drug abuse research in
the United States is a little like trying to do
(29:47):
innovative social science research in the old Soviet Union. That
curious researchers quickly learned that there are certain questions the
authorities don't want to have asked and certain answers they
don't want to have given. And then if you persis
often asking the wrong questions, you're giving the wrong answers. Well,
you're less likely to have your grants fundedge, you're less
likely to be asked to serve on grant review committees,
(30:08):
you're more likely to have your publications or things sent
to hostile reviewers. And what happens then is that many researches,
especially in the hard scientists, basically developed, you know, political blinders,
and that over time those political blinders become intellectual blinders
where they even forget to really ask some of the
most interesting questions that might happen. And so then I
(30:30):
asked people in the U S what does it feel like,
and they'll say, well, you know, Ethan, I'd say, we
were constantly advised by night A grant officers until maybe
around Obama's second term not to use the phrase harm
reduction and our grand proposals. Um we are even now
don't use the words control drug use and a grand proposal,
or it's just gonna say forget it. If I ask,
(30:52):
why isn't night OF funding research on the prescribing of
pharmaceutical heroin the way the Europeans are, or safe injection sites,
or a whole range of other things. And there don't
seem to be any good scientific reasons for not funding
that stuff. It seems to be about a political context
in which funding for this stuff is politically disapproved, and
(31:12):
that even if the people in your agency or yourself
approve of it, there's a realization that members of Congress,
you know, could get furious for funding things like this.
So what's your frankisty answer to all of that? My
Branco law answer to this is absolutely there were certain
terms that when you have it in the grand we
would be questioned about why we were founding science and
sort and such a subject matter. So my perspective was,
(31:36):
as you cannot go into an argument like that openly
when the arguments are so irrational, So you just change
that terminology is used, so you don't use carm reduction,
use other terms. I mean, again, we need to have
flexibility in our brains to accomplish what is it that
we want to accomplish. We want science that can bring
up actions that can improve It's not just because it
(31:58):
is academically interesting. So if I can keep on funding
things without having them come in and and removing asking
us to cut the funding by changing the terminology, what
do I lose? I mean, it is again, what battles
do you want to do? Right? I mean? And I
certainly I do navigate that they are tremendous prejudices as
(32:20):
still and tremendous stigmatization against addiction and its treatments. And
so my job is how within this environment and we
continue doing the work to minimize actually negative effects. Now
you're bringing something because of course I think about these things.
I mean sort of actually in terms of the Europeans
(32:41):
have been using high doses of morphine to treat people
that actually are not responding to other treatments of heroin
and those we've looked into that and one of the
reasons why it was not it did not make sense
for us at that time definitively on the basis of
the analysis to bring that as a treatment that could
be tested in the at that states. It was much
(33:02):
more consuming in resources to set up those injection sides.
And also the other problem with it is that patients
were developing arrhythmias with these guy doses of heroin, so
they were not so benign. And as it relates to
m safe injection sides, I mean, we've been not directly
funding the research on the safe injection sides, but we've
(33:23):
been funding the researchers that are doing that work to
understand downstream how these support systems as a community can
help people, for example, engage in treatment, how they can
prevent them from getting infected from HIV, and how they
can prevent them from overdosing and time. But let me
(33:44):
just ask you, I mean, just take example, the Heroin
maintenance thing, you know, back actually before your time, in
the late nineties, I pulled together a group of researchers
from the US and Canada and the Europeans who are
all interested in getting trials going on in North America.
We called it NAOMI, the North American OPI Medica Asian Initiative.
And what happened was that the Canadian leg took off
and they actually did it, and they now have it
(34:05):
in many cities in Canada, and you now see it
in many countries in Europe, and it is proving overwhelming successful.
It's not perfect, as you said, there are some problems resulting,
but it's reduced crime, reduced over those, reduced problems of addiction,
all this sort of stuff. But in the US, what
happened was the researchers said, Ethan, we're never going to
be able to get the funding. And even more recently,
the last meeting I had organized before I left Drug
(34:26):
Policy Lines four years ago it was a meeting to
bring together a younger generation of researchers, and people are saying, well,
why can't we at least give it a shot here,
or even if we don't use heroin pharmaceutical heroin, why
not use hydromorphone. You know, delouded, right, a drug that's
given out in American hospitals two hundreds of thousands of people.
We know from control double blind studies that long term
heroin attics can't tell the difference between delouded hydromorphone and heroin.
(34:50):
And then the public value benefit, which I mean part
of what happened in Europe was they started doing these
things and it helped transform people's understanding of heroin and
addiction that you meanize it. Rather than people being these
junkies chasing this dirty drug, people began to realize that
the drug itself was not as dangerous and it was
more the fact that it was illegal. So it seemed
(35:10):
that some allocation of nita's resource is something like this
would be usually advantageous. And I know when I talked
to mayors and police choose around the country, they said, hey,
as a research study, sure we won't object to it.
Why not make that a priority, especially given the issues
with sentinel now and so many people dying. Well, you
know what has made a gigantic difference, and the data
(35:31):
is out there, I mean, because this helps a very
restricted number of people. But what has made a magnificent
difference in terms of over those mortalities and outcomes is
what France has done with bupren orphins. So, if we
have alternative medications that actually are safer and that can
be deployed, and we're not doing that because the insurance
companies are not willing to reimburse, my focus is going
(35:54):
to be on how can I affect practices that are
likely to have a larger impact. And again, and it's
the issue of when you don't have all of the
resources of the world, you have to strategize which are
the ones that are going to have the largest impact.
And if you just look at the data in the
United States, the majority of people that are on treatment
for opiot disorder are on buoprinorphin. And so right now,
(36:17):
for example, one of our priorities is to actually expand
our basically knowledge base on clinical trials for the use
of booprenorphin on people that are being exposed to fantonil,
for which there is no clear call evidence about how
to properly treat them, what doses to use, why not
(36:37):
use extended formulations, how to initiate them in boopernorphin, and
also the sustainability of these practices in terms of costs.
So I see it as you know, there's not enough
money to be poured into the treatment of people with
substance use disorder, so trying to come up with models
that will ensure that the treatment will be provided it's
(36:59):
also key component. Let's take a break here and go
to an ad. When I was calling around, one person
who sang your praises, said that you've been very supportive
of expanding the access to method on rupernurphine behind bars, right,
(37:21):
You've been a big advocate that. I remember ten fifteen
years ago Drug Policy Alliance, we'll be organizing side sessions
at the annual meetings of American Correctional Association, and it
was just incredibly difficult to get correctional officials to come
along with this. And when I asked my friend what
was most significant about that, he said, you know, what
we found was that people they appreciate the opportunities you
(37:42):
just figure out what worked for them. For some, bruperophine
work better than method on. For others, method on work
better for some, nel trek Zone was the preferred one,
you know, for our listeners. The first two of those
drugs are basically sort of agonists, and there's like giving uh, say,
a nicotine patch to a cigarette addict, and al trek
Zone is an antagonist, which you know blocks the dealing
of these drugs. But it seems like just when we're
(38:02):
dealing with depression, we tried different antidepressants. When we're trying
dealing with pain management, we ideally are trying different opio
s see will work better. It does seem that when
it comes to dealing with heroin adjection and other illicit
drug opioid adjection, we should be making as many options
available as possible. I mean, I mean you basically agree
with that D percent agree And I use the same
(38:23):
analogiens as how many antidepressants we have, how many antibiotics
we have, and we are the only condition for we
said we have three. That's enough. In many ways, and
I perhaps shouldn't use this word. We've been very constrained
in many ways by the need to actually document that
the medications and the treatment are producing abstinence. And we've
(38:44):
been knowing that certain treatments, while not producing abstinence, will
improve the quality of life of people and protect them.
And so we've been trying to have a dialogue and
we've had a dialogue with the FDA. This is the
outcomes that they required to change those outcome so that
we can allow for treatments that, while not producing abstinence,
are going to be beneficial for the patients. They are
(39:07):
willing for us to consider this if we can provide
them evidence that this is meaningful. So we're funding researchers
to show this. And so now there is data that
we indicates, for example, that whooprint orphin or metal or
other medications, even if they don't produce abstinence, they reduce
the negative outcomes with HIV, They improve retention into anti
(39:27):
retroviral therapy, they decrease the likelihood of being incarcerated. So
these are meaningful consequences to that person. So we are
again negotiating towards also discussing possible medications that we may
have tested in the past that we're found nonefications because
the outcomes was impossible to reach complete abstinence a very,
(39:49):
very difficult work to achieve, and I think it is
different from what we demand for antidepressants or for an analgestic.
You don't demand that the pain become completely you didn
and a fifteen percent reduction, I mean, so we are
this has made the development of medications much harder. Uh so,
I mean you essentially see the dealing with this sort
(40:10):
of twelve step absinence only ideology has a real challenge
for you that it really gets in the way of
effective drug treatment and changing policies. Is that fair to say? Well,
what I mean, I'm not so categorical in my thinkings.
I mean, my perspective is recognizing that there is a
diversity of people and for some individuals that of Step
(40:30):
programs maybe um life saving, but for many others they
are not. And so in my perspective, I value that
all Step programs because I do recognize that they offer
support for people and have been able to help people recover.
So why would I be critical of that? What I
am critical of is their categorical rejection by many of them,
(40:53):
of the use of medications for treatment of substance use disorders.
I was actually speaking with a volunteer patient with an
opiate use disorder who is on boubernorphine and who was
very much in conflict because he wanted very much to
be part of the twelve step program, but he didn't
want to lie to them that he actually was taking
(41:14):
Boobern norphin and he didn't want to stop taking Boobern
rphin because he recognized that it helped him enormously. Why
I put individuals that are already with tremendous challenges in
a conflict to have to decide one versus the other?
What else it tell us that both of them can improve.
We do it for cancer, we do it for HIV,
we do it for everything. Why do we need to
(41:35):
have one or the other? So do you remind me?
I remember coming across a twelve step program being run
out of Bellevue Hospital years ago, which was a twelve
step program for people and that slimated it who felt
discriminated against the normal twelve step programs, like the methodology,
like the community there, but felt Tay can do it.
But now let me switch back to this thing. You know,
part of the promise, supposedly, I think of the focus
(41:56):
on the brain and the way you've put the resources
between the brain and addiction. Was hoped that new medications
would come out for dealing with addiction. But if we
look at the basics, right, methanon, ruper norphine, nil tracks on,
and niloxon for dealing with overdose. All four of those
drugs were patented between fifty and seventy or more years ago,
and really nothing new, really of significance has come along.
(42:19):
I mean, part of what was interesting about the heroin
hydromorphone stuff in Europe and some other innovations there was
at least it was another thing that worked for people
for whom method on a grouper rhine was not working.
But is there anything on the horizon, whether with opioids
or whether in dealing with the stimulants. I think you
you're out there saying the best thing we have is
contingency management, a behavioral approach rather pharmacological approach. Is there
(42:41):
anything promising on the horizon, the short horizon for adding
some other drug to this mix? Yeah, there is. And
I don't think that we should minimize celtic interventions because
one of the things that the neuroscience has enabled us
to do is to understand how these behavioral interventions are
affecting neurocircuits influenced by drugs, and so you can tailor
(43:02):
then the intervention in such a way that it will
maximize its efficacy. And in terms also the understanding of
the neurow secretry that is engaged in addiction has offered
an opportunity to start to work with a neural modulation technologies.
For example, I think it was last year that the
FDA approved the use of transparential magnetic stimulation for the
(43:24):
treatment of nicotine addiction. We are also taking advantage of
the peripheral system which impacts on the brain and in
in cortical regions and it modifies our sensations, and that
in turn has resulted on approval of a peripheral stimulation
device for the treatment of opiate withdrawal. I mean, the
problem of developing medications, as you know is it takes
(43:46):
something like twelve years from the idea until it comes out,
and the process it requires an enormous amount of money.
So what we do as an agency is try to
engage industry, whether it's big or small industry, to buy
into that product and develop it. Because it's like two
point five billion dollars to take that treatment into that clinic,
which of course will completely kill our budget for two years.
(44:10):
Well let me ask you, so another category of drugs,
the psychedelics psychologs research was pretty amply funded in the
fifties and sixties by the federal government, and then with
all the counterculture stuff and Timothy Leary, it was basically
obliterated in the US and much of the world. And
now it's beginning to come back. And I know, you know,
my friend Rick Doblin, who heads the Multi Distmary Associate
Psychologic Studies, has raised tens of billions of dollars of
(44:33):
philanthropic funds, but still there's been no government funding there
at all. And now you have this issue of four
profit players coming in, as you're saying, is sometimes needed
for drug development. But I wonder we'll be seeing something
coming out of NAIDA. I mean, I just saw that
in late May. You know, your boss Francis Collins, the
head and a Student Health, said to Congress really interesting
stuff going on with psilocybin. And National Cancer Institute just
(44:54):
hosted something on psychedelics and end of life care, right,
and I think National Student Mental Health another one of
your sister agencies has been holding webinar seminars about the psychedelics.
So what about National Student Rug Abuse? I mean, I
think I saw there was a couple of things maybe
about ketamine in addiction, But can we expect to see
you beginning to fund stuff on psulocybin and treatment of
addection or even or pain or things like that. Is
(45:17):
that on the horizon for the short term. I mean,
it was an eye opener to uncover that ketamine it's
actually has turned out to be an extremely useful intervention
for treatment resistant depression, and it is a result of
research that led to these really important advancement on the
way that we treat people with depressive disorders. So yes,
(45:39):
and there we have been funding research that it's ongoing,
and keptamin for opiate treatment and also keptamine for pain
also has potential for PCP. If you look at that data,
actually the evidence is strongest form showing potential benefits for depression,
and the strongest data on depression, I would say it's
on individuals that suffer from cancer terminal illnesses and they
(46:03):
have pretty dramatically positive results that persists that at eight months.
That is the area where there is probably the most
ongoing treatment. There is a story, there's a couple of
stories that have shown some benefit in a nicotine addiction,
but they were not blinded, so it's very difficult to
actually know the potential signal. So we are open they
(46:25):
have to come up with that proposal that will be
deemed meritorious and we rely on review committees to evaluate
the likelihood of success. And the data for addictions is
in terms of the evidence, it is much more limited.
But but no, I mean, let me just press you
because I mean, obviously with psilocybin there's research being privately
(46:47):
funded that is showing great promise. We know with ayahuasca,
lots of interesting things are emerging in terms of people
processing not just trauma but also times addiction. And you know,
there are people talking about the promise of psychedelics in
the treatment of depression and things like this. They could
revolutionize the pharmacological you know, treatment in some of these areas.
I mean, I'll tell you it wasn't long ago that
(47:08):
a prominent researcher who I think you know well, um,
who had done research on other drugs, you know, cocaine, nicotine,
it was getting interest in psychedelics and he was hopeful
of getting a national student drug abuse funding for research
on psilocybin, and what he ended up doing was telling
the organizers of a conference on psychedelics to disinvite me
because if he showed up at a conference where Ethan
(47:29):
Naedelman was talking, that would show that psychedelics is all
political and therefore he won't get funding. Now I think
he still hasn't gotten funding. But given the enthusiasm coming
out and all of the intriguing research out there, why
not go more strongly into this area? Now? I mean,
is there a fear of the political fallout or what? No,
I don't think that there is a person a fear
(47:50):
of the political fallout. I think that we are seeing.
I mean m d m AS is an addictive draw.
Psilocybing is not an addictive draw. And yet I mean
it's being utilized in a way that it's safe for
the treatment of people with depressions. So the notion of
when you get proposals, you are competing with other grants
in terms of likelihood of success in the proposal that
(48:13):
you have and likelihood of implementation, so they are the
review process is important and you cannot just come in
and with an idea without showing as you know, for
the grant, most of the ground mechanisms requires that you
do provide a background that supports the likelihood that you
will be successful. And the reason why why this is
done is again limitation of resources. So you have to
(48:35):
take risks, but you want to take risks that are
more likely to be successful. So Northlesia with the n
d M A, right, I mean n DMA seemed Night
have spent a lot of money trying to establish the
neurotoxicity of m d M A, and I remember there
was this sort of embarrassing thing that happened. Not it
was after you, I think, before you came in. Right,
We're Night given a big grant to researcher at Hopkins,
(48:57):
George Ricardi, who came out with this big study and
Science saying that all these monkeys that died from m
d M A and then it turned out lo and
behold he had given them large doses of amphetamine and
people were highly suspicious of the results even before I
got published in Science. And the day that article came out,
your predecessor Alan Lester said, got you Using m d
M A is like playing Russian roulette, which was an
(49:19):
incredibly irresponsible thing for a former head of NADA and
head of the American Academy Arts to Science say, now
you have the f d A, right, it's about to
proceeds in phase three trials with doing m d m
A for treating PTSD. Right, they've established the safety margins.
Right are you concerned? I mean, given all the that's
happened last fifteen twenty years and with m d m
A going through all these incredibly expensive long trials and
(49:43):
now the possible expansion of m DMA to treat PTSD,
do you have any concerns about that? Or you enthusiastic
about this development? I basically I support science that can
help bring new treatments. I actually was one of the
ones that was very skeptical when the paper came up
in science because we have been looking into the effects
of drugs in the brain and and and and also
(50:03):
the Europeans have a long history of actually studying the
effects of ecstasy and no one has reported anything like that.
And overall, the issue with with ecstasy has has had
more to do and I guess everybody what is concerning
the potential of john people using it in situations where
they are very crowded and that can result in HYPERTERMI
(50:24):
or there have been some debts associated with it. If again,
and it's this the history. I mean, we've learned, we
need to learn from what what the evidence is showing up.
If we can use gatamine for the treatment of severe
depression in a way that is safe, this is an
example of really that we can do. We can use
drugs that we thought were dangerous and using in ways
(50:47):
that are therapeutic. In fact, we use fentanyl extensively for
surgical procedures and it's a very valuable drug. So we
cannot demonize fentanyl because they elicit drug is being market
it in the streets. Because fantaniel also has a very
valuable application in medicine and can be life savings. And
the same thing with prescription opius. And this is something
(51:10):
that I've also been very vocal about. And so again
we polarize everything. It's either good or bad and I
and you know, my brain is why can't we not
have this and that these two things are correct. We
are over prescribing, but at the same time we are
restricting it to people that needed. They are not exclusive.
You know, one thing that worries me, right you know,
(51:31):
I oftentimes describe the War on drugs is being justified
in terms of being one great big child protection act.
And when you would say that politicians, why can't we
legalize marijuana for medical purposes? And they go what about
the kids? Or I remember what about needle exchange? And
the former governor of New Jersey, of Christie Whitman others
would say what about the kids, and always go what
about the kids? What about the kids? What about the kids?
And when we hear that now is on the issue
of nicotine and vaping, right, I mean, here you have
(51:54):
a kind of breakthrough technological innovation that has the potential
that's dramatically less staydangerous. The cigarettes and heat not burned
vaping devices are dramatically less dangerous than cigarettes. You're not safe,
but dramatically less dangerous. And then we see the rapid
uptake of jeweling among kids a few years ago. And
now it seems just like this massive miseducation campaign of
(52:15):
which the U. S. Government, including the Center Disease Control,
has been an ample part. I mean, you have now
a majority of Americans believing that the cigarettes are as
are more dangerous than combustible cigarettes. You have a majority
of Americans and even certain fields of medicine believing that
nicotine is what causes cancer. Rather than nicotine being the
hook that addicts people to cigarettes. You have people believing
(52:35):
that that whole the Valley syndrome where people were landing
up in the hospital was about nicotine e' cigarettes, whereas
we know now and in fact, there was a good
reason to believe in the beginning it was about illegally
produced tainted THHC cartridges. So the question I'm asking is
what is the responsibility what is your obligation as the
head of NAIDA to make sure that these massive public
misperceptions get corrected. This is going to be my last
(52:59):
answer because I do have to run to another meeting,
but it there's I mean, I cannot know not respond
to this extremely important question because it's another example about
how we swing back and forward and and the reality
is that jazz vaping of nicotine can result in people
that are naive to become addicted very rapidly and can
actually lead to toxicity because in the cartridges you can
actually concentrate high doses of nicotine that you would never
(53:21):
be able to smoke with combustible on the other hand,
as you say, electronic cigarettes offer an alternative delivery for
nicotine on people that cannot stop smoking, and in the
process at the European data has shown that actually they
are benefits. So one of the things that we have
been very interested on doing is funding research that will
document benefits of the use of the electronic cigarettes on
(53:45):
for nicotine's cessation or for alternatives for treatment. So there
is true on both of those things. I mean, although
I am impressed by the evidence coming from Ken warrener
many other people pointing out that from a public health perspective,
the net benefits for smokers and switching so exceeds any
potential risk to young people from vaping, and that the
(54:05):
evidence of kids starting to vaping moving into cigarettes unless
they were already engaging with two bustibles beforehand, is so
low that you have an overwhelming case for responsible public
health policy that I wish say, yes, it's so simple.
I think that I believe I'm saying it's a balancing
I see the other side of of the coin, and
(54:26):
I actually because I know that data on both sides,
but but that I think if we are actually ultimately
trying to understand I mean a very specific question that,
believe it or not, there's very little work. How does
nicotine exposure during brain development influence that trajectories? I mean,
what are its effects? And as you know, one of
(54:47):
the things that nicotine is associated with, once you've been
taking it and you stop, you have greater likelihood of
depressive symptoms of anxiety. So I have a fascination for
nicotine is another extremely interesting comp own board. It can
be very addictive. Okay, my last, my very last question
here here you've been supporting decriminalization, supporting a public health approach,
(55:08):
opposing the drug war. Can you envision in your life
post night to Um joining up with drug policy reform
organizations to push for policies that are more grounded in
public health and human rights and harm reduction and opposing
the punitive prohibitionist policies if they are effective. Yes, great, Okay,
I don't just like to think about problems. I'd like
to solve them. I agree, we're in the same milk
(55:29):
that way. Listen, Nora, thank you ever so much for
taking the time to do this. I really appreciate it
is a very highly engaging conversation and I wish you
the best of luck. Under this current administration. Thanks very much, guys,
a la vista. Psychoactive is a production of I Heart
Radio and Protozoa Pictures. It's hosted by me Ethan Edelman.
It's produced by Katcha Kumkova and Ben Kibrick. The executive
(55:53):
producers are Dylan Golden, Ari Handel, Elizabeth Geesus and Darren
Aronovski for Protozoa Pictures, Al Williams and Matt Frederick for
I Heart Radio and me Ethan Nadelman. Our music is
by Ari Blusian and a special thanks to a vit Brio, SF,
Bianca Grimshaw and Robert Beatty. If you'd like to share
your own stories, comments or ideas, please leave us a
(56:16):
message at eight three three seven seven nine sixty. That's
one eight three three psycho zero. You can also email
us as Psychoactive at protozoa dot com or find me
on Twitter at Ethan Nadelman. And if you couldn't keep
track of all this, find the information in the show notes.
(56:41):
Listen in next time for my conversation with Tim Ferris,
the investor and productivity guru who has been funding research
on psychedelics and it also has a fair number of
experiences to share himself. Here's a bunch of college kids
eating handfuls of mushrooms, no measurement involved to see what
would happen. Nonetheless, I knew, just after these experiences, which
(57:01):
I did once a year for a number of years,
that there was an antidepressant after glow optimism that lasted
for several months. Subscribe to Psychoactive now see it, don't
miss it.
Popular Podcasts
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
The Nikki Glaser Podcast
Every week comedian and infamous roaster Nikki Glaser provides a fun, fast-paced, and brutally honest look into current pop-culture and her own personal life.