September 9, 2025 • 30 mins
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Health Affairs' Rob Lott interviews Nora Volkow, director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health, to discuss addiction as a brain disorder, treatments for opioid use disorder, and what’s next in addiction research.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Rob Lott (00:00):
Hello, and welcome to A Health Podicy. I'm your host,
(00:04):
Rob Lott. Friends, it's anothervery special episode of A Health
Podicy, the kind of episode wedo about once a month with a
step away from our typical focuson the authors of the latest
(00:24):
papers published in HealthAffairs. And instead, we reach
out to some of the luminaries inour field to hear their story
and get their take on the healthpolicy landscape today. This
month at Health Affairs, ourwork is all about the opioid
crisis.
In September, we published aspecial theme issue looking at
(00:48):
the latest research and evidenceshaping the public policy
response to this urgent nationaland global health challenge. And
so for our special guests, we'veturned to none other than
Doctor. Nora Volkov, Director ofthe National Institute on Drug
Abuse at the National Institutesof Health. We typically refer to
(01:11):
this institute as NIDA, and it'sthe world's largest funder of
scientific research on thehealth aspects of drug use and
addiction. Doctor.
Volkov is a researchpsychiatrist whose work has
documented how changes in thedopamine system affect the brain
regions involved with reward andself control in addiction. She
(01:36):
has also made importantcontributions to our
understanding of neurobiology asit relates to fields like
obesity, ADHD, and aging. AndI'm thrilled to have her here
today. Doctor. Nora Volkov,thank you so much for joining
the podcast.
Nora Volkow (01:53):
Well, very much for having me. It's a pleasure.
Rob Lott (01:57):
Well, let's just jump right in. In a moment, I want to
ask you about your work leadingNaida, but first I'd love to
hear briefly about your ownresearch. I know you've
pioneered the use of brainimaging to investigate how
substance use affects brainfunctions, and I was hoping
maybe you could say a little bitabout how that field has changed
(02:21):
over the years. What did it looklike when you entered it? And
what does it look like today?
Nora Volkow (02:26):
Yeah, it has changed dramatically and it has
transformed it. And I actually,I have always been extremely
interested on understanding howis it that a drug can modify the
function of our brain to theextent that we no longer follow
the behaviors that are morelikely to lead us to succeed,
but instead become literallyslaves of drugs. And to me,
(02:50):
that's fundamental because it'sthe notion of losing your free
will to do something. And as aresearcher, my perspective was
to study the changes in thebrain could give us an insight
about how we made decisions andpriority and our capacity to do
them. And that's how I gotimmediately saw the power of
(03:14):
imaging technologies.
And when I was a medicalstudent, imaging was just
emerging, and we could only lookin terms of the brain with
structural changes. And towardsthe end of my medical school,
beginning of my residency, westarted to have imaging that
allow us to look at function,and that blew my brain. Because
(03:37):
I realized that it would bepossible when you look at the
brain and you try to understandhow it leads to behavior is like
looking at a car and trying tounderstand how it's going to
perform. If it's not moving, ifyou're not driving it, you'll
never know. And by looking atfunction and seeing how the
brain responds to different typeof stimuli, it was obvious that
(04:00):
this would be a transformativetool, and it has been.
So, therefore, I jumped rightaway into using it for
understanding changes in thebrain, brain activity of people
that have psychiatric diseasesthat had never been understood,
and including addiction. And soI went into actually favoring
(04:22):
the study of addiction becauseit allows us to focus and target
very specifically the wholemechanisms by which we exert
self regulation and makedecisions of what is most
important. So that's how mycareer went on into research.
How has the field changed sincethen? Well, the tools that we
(04:43):
have were limited initially, asI mentioned, just to structural
imaging like CAT scan, and thenwe developed technologies that
allow you to look not just atbrain function, but also
biochemistry.
Positron emission tomography wasthe technology that allows us to
do that, and it's still the mainimportant technology for brain
(05:06):
neurochemistry. But in themeantime, MRI started to emerge
as an extremely promisingtechnology. And with as it was
launched, our researchersstarted to realize that what the
signals that we were deriving ofthe brain, whether it was doing
a task or resting, thinking ofnothing in specific, which we
(05:30):
were obtaining, like when youlook at the television set and
there's all of this noise, it'sexactly the way that you would
look at these images, and therewere all of these points
planking back and forth, andthey were dismissed as noise.
But researchers at Wisconsinfigured out that this was not
noise, that it had certainfrequencies that could be
(05:50):
predicted and that theseoscillatory frequencies were
corresponding together, weresimilar in certain areas of the
brain and very different fromothers. And they put two and two
together, and they view thepotential of using these signals
as a mean of understanding howdifferent regions of the brain
(06:11):
work together to perform a task,a process.
And then everything changed.Because fMRI, which is
functional magnetic resonanceimaging, which is basically the
utilization of these earlyawareness that these signals
that actually reflectoscillatory activity that
(06:32):
connotes information about brainorganization, has enabled us to
look at a much higher temporaland spatial resolution of what
happens in the human brain thanwhat we had had with
technologies like positivetransmission tomography, or PET
scan. So that's how it has. Soit went from being very limited
(06:54):
to a few technologies and a veryfew sites in The United States
and in the world that could doit, to now having MRI available
for fMRI studies across many,many places in The United States
and in the world, making itvery, very accessible,
noninvasive, and providing us apretty powerful tool for
(07:15):
research that in certaininstances has started to be
applied for clinical purposes.
Rob Lott (07:21):
Well, a big contribution of that work has
been to demonstrate that drugaddiction is a brain disorder,
if I'm understanding the sort oftrajectory correctly, a brain
disorder as opposed to say aweakness of character or a moral
failing. And now that's sort ofthe general consensus is that
(07:46):
this is a brain disorder, achronic condition. And I'm
wondering about sort of what youwitnessed in the sort of moving
of the needle or sort of thetransition of that general
consensus away from these sortof outdated theories. They
generally require evidence,which you and your colleagues
have provided, but there's alsoan element of persuasion and
(08:09):
consensus building acrossstakeholder groups. And I'm
curious if you've thought aboutsort of how you reconcile those
very two different kinds ofscientific communication.
Nora Volkow (08:22):
Absolutely. And I think about it constantly
because of those these two linesof communication reflect
perceptions that actually, to acertain extent, do have certain
aspects, do connote certainaspects of the conditions that
we're looking at. It's not thatthere is the whole truth, and
(08:43):
this is correct and this isincorrect. The reality being
behind what we did withneuroimaging, what it allowed us
to do was to document veryspecific changes in understand
the change in behavior. That wasclear cut.
And from that perspective, itgave us the narrative and the
(09:04):
argument, like when you do animaging of the heart, you can
document where the defect is inthe heart that can lead you to
the diagnosis of a myocardialinfarction, infarction,
importantly, can lead you towhere you're going to do your
therapeutic intervention. Butbeing able to document this, for
example, in addiction, theprefrontal cortex being
(09:24):
dysregulated with the chronicuse of drugs, it became clear
that one crucial component thatrequired therapeutic attention
was the inability for theindividual that's addicted to
exert self regulation andcontrol their impulses. And that
provides you, again, a targetfor therapeutic intervention.
(09:46):
And it also, by documentingwhere the deficits are, it puts
us into the narrative of adisease disorder as opposed to
moral failing, right? But if youlook at it in a more holistic
way, you also have to askyourself the question, what is
it in our brains that allow usto have a moral awareness and to
(10:11):
be able to carry it through?
So we give it as granted as ifthese things are going to happen
no matter what. But all of theseprocesses, emotional and
cognitive, that we give forgranted are part of the function
of the human brain. And if youdamage certain areas of the
brain, you lose the capacity toactually properly understand,
(10:34):
for example, ethical or moralconcepts, or if you don't have
the neurocircuitry that allowsyou to actually feel empathy for
or embrace a particular culturaldomain, you are going to be
alien to it and much less likelyto be sensitive to its precepts.
(10:57):
So it is again, we speak about adisorder, but it does not negate
the possibility that underlyingthe changes in the brain that
you are actually having in aperson that's addicted, you are
undermining the capacity toactually carry on behaviors that
are more akin to a cultural normof morality or ethics.
(11:19):
Recognizing that is crucial.
And also, it forces me, becauseone of it is one of the concepts
that has generated the mostcontroversy because people get
very, very upset by the notionthat by describing addiction as
a disease, you are removing theresponsibility of society
(11:39):
towards that condition, and youare blaming, that is what they
claim, that individual. Becausethey say, Well, you know, there
are societal environments thatare much more conducive to drug
taking that make people morevulnerable to becoming addicted.
And so it's society, it's theenvironment. But my argument is
(12:01):
that's not any different fromobesity and diabetes. The
environment and society aredriving this actually
vulnerability of people.
But we have, I don't know,humans have this tendency of
wanting to simplify things intoeither this or that, where
without recognizing that adisorder can have genetic
(12:23):
components that make youvulnerable to the environmental
situation that you find on.Because even if you have all of
the genetic vulnerability foraddiction, let's say 100%
genetic vulnerability, which ofcourse doesn't exist, but
theoretically, using it as anarrative, if there are no
drugs, you'll never becomeaddicted. So this just tells
(12:44):
you, Al Alimit, that wholeconcept. So in my view, I like
to listen to the argumentsbecause it behooves us to try to
integrate it into ourunderstanding of disease
process, and importantly, tounderstand how the human brain
works, right? So it is an aspectthat people get very, very upset
(13:07):
about, and they say, How couldthis mother of three take drugs
and completely disregard theirchildren?
She doesn't care for them. It'snot that she doesn't care for
them, it's that the drugs havedisrupted her relative saliency
and her urgency for doingcertain things versus others. If
(13:30):
you are able to get that personinto treatment and recovery, you
will see that they basically goback and embrace that
motherhood. And they have, Imean, and in fact, working with
mothers who are addicted, whohave children, and it's in a way
gives you the advantage becausethey are very invested on these
(13:53):
children. And so you can usethat as a reinforcer to help
them motivate them into change.
Rob Lott (14:00):
Wow, okay. Well, let's talk a little bit about the work
of the National Institute onDrug Abuse. Many of the articles
in the theme issue that we'rehighlighting at Health Affairs
this month are focused ontreatments like buprenorphine
and methadone, as well as rescueprotocols like naloxone. And I'd
(14:22):
love to hear a little bit aboutNIDA's role in developing these
drugs and also, I guess, whatits role is in tracking how
these treatments are used andways to improve interventions
using these treatments.
Nora Volkow (14:37):
Yeah, and the development of treatments for
substance use disorder addictionhas been one of the research
priorities for NIDA. Anotherresearch priority is prevention
interventions. So, but thoseoverall are now basically were
recognized that a third elementis that of research towards
(14:58):
recovery. For treatment, we havebasically the best treatments
for substance use disorders forthe treatment of opioid use
disorder. We have treatments foralcohol and tobacco cessation,
but their effect sizes are muchlower than those that we get
with the medications that wecurrently have.
And NIDA was instrumental in thedevelopment of these medications
(15:22):
directly and indirectly.Indirectly with methadone,
because we provided the researchand the science that enabled the
consolidation of methadone as atreatment, and help us
understand how it worked, todirectly, to actually do all of
the work that was necessary tobring buprenorphine into the
clinic, as well as very directlyto with Naltrexone, Vivitrol, to
(15:45):
bring it eventually into theclinic in partnership with
pharmaceutical industry, whichof course is the one that's
responsible to actually get theproduct and distribute it.
Naloxone too, similarly, we haveindirect and direct involvement
in the development of naloxone,which is the most effective
(16:05):
intervention we have forreversal of overdoses. And this
comes through the indirect allof the knowledge and research
done to understand how it worksas an opioid receptor antagonist
to the direct involvement ondeveloping formulations of
naloxone that would make itwidely accessible and very, very
(16:25):
effective for anyone, thegeneral public, to be able to
administer, even if they don'thave a medical or clinical
degree. And that has saved somany lives.
It's probably, in terms of theoverdose crisis, one of the most
consequential interventions thatwe've done, making naloxone user
(16:46):
friendly and widely accessible.
Rob Lott (16:49):
Great. Well, I want to hear a little more about some of
the decisions you make about thevarious research you fund. But
first, let's take a quick break.And we're back. I'm talking with
(17:55):
Doctor.
Nora Volkov, Director of theNational Institute on Drug
Abuse. Doctor. Volkov, you justtalked a little bit about the
institute's role in fundingtreatments like buprenorphine,
and I'm curious if you can say alittle bit about sort of how
those treatments relate to theconcept of recovery and also
(18:18):
sort of how we think aboutabstinence. Is that really the
only appropriate goal when itcomes to treating addiction? And
therefore, how do we think aboutthat concept when we're studying
drug use?
Are there other goals we mightconsider beyond abstinence when
studying drug use?
Nora Volkow (18:41):
And my perspective on this and from the perspective
of how we're pushing research isto consider the treatment of
substance use disorder as acascade model. First, you
basically screen and makediagnosis, then you treat, and
then you move towards recovery.Now, the issue is what does
(19:02):
recovery really mean? And thatdefinition has changed
significantly. And is recovery,as you say, the only option out?
And we've come to understandthat when you're very, very
rigid and saying abstinence isthe only way to achieve
recovery, you're actuallythreatening the life of many
people that don't even try toget recovery because they say, I
(19:24):
want to I do not want to beabstinent. So what is important
in the concept of recovery thatit is a decrease in drug use in
ways that are not harmful,number one. Number two, that
there is an improvement in thehealth of the individual. And
number three, that there isimprovement in the well-being
(19:44):
and the social involvement ofthe person. That what becomes
crucial for recovery.
And whether that meansabstinence or not, we don't have
an inflexible attitude towardsit. Because if someone can
achieve well-being and canbecome an active member of their
society and basically controlthe risk and dangers of taking
(20:09):
drugs, and they can still usedrugs in a responsible way, then
that may be where they go at. Imean, obviously, theoretically,
we would want recovery toachieve lack of drug use, but we
are aware that in instanceswhere it's not the option of the
person, we should be respectful.
Rob Lott (20:31):
How does NIDA view the role of health disparities in
substance use disordertreatment? What do we know about
how and where those disparitiessurface and the best way to
study them? And I guess againstthat backdrop, I'd love to hear
how the institute factors thoseelements into its funding
(20:51):
decisions.
Nora Volkow (20:53):
Yeah. Health disparities in substance use
disorders emerge in the wholetrajectory. It emerges from the
trajectory on your vulnerabilityfor using drugs, your
vulnerability to escalate intoaddiction, your vulnerability to
receive or not treatment, or toend up incarceration, and your
vulnerability to achieverecovery, and your vulnerability
(21:14):
to die from an overdose. Healthdisparities are seen throughout
all of them. So, the perspectiveof research, we are interested
on developing models of carethat can help bridge those
differences that exist in healthoutcomes.
And for example, I think thatthe mortality that you observe
(21:35):
from overdoses is significantlyhigher among people who are
homeless. So therefore, we knowthat, and the research,
therefore, is what type ofintervention can be done to
provide alternatives for theseindividuals who are homeless so
that you can protect them fromoverdosing. So, it is a
fundamental aspect of thesubstance use disorder
(21:58):
throughout the whole cascade ofcare that we were just
describing.
Rob Lott (22:02):
Got it. Okay. Well, I'd love it if you could look
forward with us for a minute andsay a little bit about maybe the
biggest gaps that remain in ourcurrent understanding of
addiction, science, andmedicine. What is it going to
take to close those gaps?
Nora Volkow (22:21):
I'm laughing because there are many, many,
many gaps. Yeah. And they go, Imean, there are obviously from
the perspective of understandingscientifically what are key
elements at which there is atransition from one phase to the
other that makes you vulnerableso that we can intervene? How do
we identify them at anindividual level, not at a
(22:42):
population level, which is wherewe are from? But I want to more
focus on the issue of issuesthat are more tangible in terms
of their proximity, which is howcan we change the healthcare
system care so that they embracemore wholeheartedly the
obligation that we have asclinicians to screen, treat, and
(23:04):
provide with the linkages to forrecovery that are necessary for
someone to succeed.
We have advanced in that field,but there's still a majority of
healthcare systems where thereis no treatment for substance
use disorder, there's noexpertise, and where it is
actually discriminated, anddespite all of the knowledge
(23:27):
that has emerged. So to me, thisis a priority. Why is it that
clinicians don't want toactually, for example,
clinicians, even if they havethe specialty of psychiatry,
don't want to treat substanceuse disorders? Why is that?
Because they are not reimbursedat the same level as if they
were treating other conditions.
(23:47):
So, what are roadblocks that areimpeding the actual treatment of
substance use disorder iscrucial. I mean, just to let you
do you know that one of the mainsources for paying for substance
use disorder, even though itshould be covered by Medicaid
and Medicare, like any othermedical condition, is pay. I
(24:08):
mean, out of pocket pay becauseclinicians don't accept
insurance. Insurance isinsufficient. So there are also
other series of roadblocks.
So to me, this is a gigantic gapthat is contributing to the
health disparities on the onehand, but it's also perpetuating
the overdose crisis that whileit's getting better, is still
(24:32):
very, very consequential andvery costly, by the way.
Rob Lott (24:36):
Can you say a little more about those costs? Is that
just the cost of untreatedaddiction? What other costs do
you see?
Nora Volkow (24:45):
Oh, yeah, untreated addiction has downstream effects
because you are not a productivemember of the society and you
create complete stress in yourfamily and your support system.
So, it is actually very, verydevastating, not to say the
economic consequences ofoverdoses, but if you look at
the consequences of addiction tohealth, let's take one of them
(25:08):
that is very fresh in my brain,infectious diseases. So
injection drug use contributesto HIV, to hepatitis C, to
endocarditis. And endocarditisis a condition for which the
average cost for hospitalizationare around $250,000. If
untreated, the chances of dyingare one hundred percent.
(25:31):
And people that enter with aninfectious an endocarditis from
injection drug use many timesleave against medical advice
because they are not properlytreated for their withdrawal
symptoms or the management oftheir pain condition is
inadequate. So, they signthemselves against medical
advice without treatment. Andthen frequently they come back
(25:55):
and many of them have recurrentepisodes. So, this is an example
of the cost associated with it.So, the medical costs, the cost
to society in terms of lack ofproductivity are also gigantic.
And consider also the costs thatare linked with controlling
drugs and policing them and theviolence that goes with it. And
(26:18):
I don't even have good numbersabout the cost to society of the
illicit drug market and tryingto regulate and control it.
Those don't even enter in thecalculations, but yet they are
very, very important. And Iwould say that an even more
fundamental level, if you wantto degrade the basic structure
(26:38):
of a society, you bring drugsin. Now, how do you actually
quantify the impact of that to asociety?
I mean, you just make peoplejust sort of indifferent to what
goes on and drive them towardsdoing drugs instead of engaging
(26:58):
in other activities. That ispretty devastating. And so this
is where I would say the costsare enormous.
Rob Lott (27:07):
I imagine there's an opportunity cost as well that
you're sort of hinting atsomeone that's has to spend time
getting treatment or gettingcare for an infection, as you
say, is not able to spend timeworking in their job or caring
for their family as well.
Nora Volkow (27:25):
Absolutely. And even if you don't have a medical
condition associated with druguse, which are very, very
prevalent, but even if youdon't, and if you are addicted,
you are not going to performproperly because the main drive
is to be sure that you get thedrug, to be sure that you don't
get into deprivation from thatdrug. And it is extraordinarily
(27:47):
powerful. It's like you arebeing driven when you don't have
food to seek it out in order foryou to survive. So, it's when
you don't have food accessibleand available, that becomes a
top priority.
You cannot think on otherthings. So, this is another
major reason why the impact ofin the productivity of people
(28:09):
that are addicted is much lower.
Rob Lott (28:12):
Well, it's almost time for us to wrap up. And I wonder
if we could close briefly bythinking about perhaps a young
researcher contemplating maybeentering the field of addiction
science or maybe a youngphysician thinking about what
specialty to go into and maybethinking about addiction
(28:33):
medicine. What would you say tothem today about whether or not
to go down that route and whatthey should maybe consider as
they make their decision?
Nora Volkow (28:44):
Well, I think it's fascinating, one of the most
interesting areas of science togo into a disease that affects
the human brain. And it's alsoone that is at the
transformative stage in thatwe're developing completely new
tools and very, very promisinginterventions for modifying that
vulnerability or that diseaseprocess. So, I would say it has
(29:10):
been a very, very neglectedcondition. But now that is
changing, and it's changing fortwo reasons. One of them,
because we've become aware ofthat devastation of not paying
attention to substance usedisorder in healthcare, but
second, for the enormousadvances that have come up in
our understanding of how thehuman brain works, the
(29:30):
technologies that allow us toevaluate it, and the tools that
allow us to actually interveneto strengthen specific circuits
or to weaken others, and tocombine these technologies with
the opportunity of newmedications and therapeutics.
So, it's really an extraordinarytime to come into the field of
(29:50):
addiction as a clinician or as aneuroscientist or as a social
scientist as it is to actuallycome into the field in general
of psychiatric disorders.
Rob Lott (30:01):
Well, a really optimistic perspective for our
listeners and for potentialfuture researchers and
clinicians. Doctor. Nora Volko,thank you so much for taking the
time to chat with us today. Ireally enjoyed it.
Nora Volkow (30:16):
Thanks very much. I also enjoy it.
Rob Lott (30:18):
To our listeners, thanks for tuning in. If you
enjoyed this episode, of course,share it with a friend, leave a
review, and, of course, tune innext week. Take care, everyone.
Thanks for listening. If youenjoyed today's episode, I hope
you'll tell a friend about ahealth policy.
Hello, and welcome to A Health Podicy. I'm your host,
(00:04):
Rob Lott. Friends, it's anothervery special episode of A Health
Podicy, the kind of episode wedo about once a month with a
step away from our typical focuson the authors of the latest
(00:24):
papers published in HealthAffairs. And instead, we reach
out to some of the luminaries inour field to hear their story
and get their take on the healthpolicy landscape today. This
month at Health Affairs, ourwork is all about the opioid
crisis.
In September, we published aspecial theme issue looking at
(00:48):
the latest research and evidenceshaping the public policy
response to this urgent nationaland global health challenge. And
so for our special guests, we'veturned to none other than
Doctor. Nora Volkov, Director ofthe National Institute on Drug
Abuse at the National Institutesof Health. We typically refer to
(01:11):
this institute as NIDA, and it'sthe world's largest funder of
scientific research on thehealth aspects of drug use and
addiction. Doctor.
Volkov is a researchpsychiatrist whose work has
documented how changes in thedopamine system affect the brain
regions involved with reward andself control in addiction. She
(01:36):
has also made importantcontributions to our
understanding of neurobiology asit relates to fields like
obesity, ADHD, and aging. AndI'm thrilled to have her here
today. Doctor. Nora Volkov,thank you so much for joining
the podcast.
Nora Volkow (01:53):
Well, very much for having me. It's a pleasure.
Rob Lott (01:57):
Well, let's just jump right in. In a moment, I want to
ask you about your work leadingNaida, but first I'd love to
hear briefly about your ownresearch. I know you've
pioneered the use of brainimaging to investigate how
substance use affects brainfunctions, and I was hoping
maybe you could say a little bitabout how that field has changed
(02:21):
over the years. What did it looklike when you entered it? And
what does it look like today?
Nora Volkow (02:26):
Yeah, it has changed dramatically and it has
transformed it. And I actually,I have always been extremely
interested on understanding howis it that a drug can modify the
function of our brain to theextent that we no longer follow
the behaviors that are morelikely to lead us to succeed,
but instead become literallyslaves of drugs. And to me,
(02:50):
that's fundamental because it'sthe notion of losing your free
will to do something. And as aresearcher, my perspective was
to study the changes in thebrain could give us an insight
about how we made decisions andpriority and our capacity to do
them. And that's how I gotimmediately saw the power of
(03:14):
imaging technologies.
And when I was a medicalstudent, imaging was just
emerging, and we could only lookin terms of the brain with
structural changes. And towardsthe end of my medical school,
beginning of my residency, westarted to have imaging that
allow us to look at function,and that blew my brain. Because
(03:37):
I realized that it would bepossible when you look at the
brain and you try to understandhow it leads to behavior is like
looking at a car and trying tounderstand how it's going to
perform. If it's not moving, ifyou're not driving it, you'll
never know. And by looking atfunction and seeing how the
brain responds to different typeof stimuli, it was obvious that
(04:00):
this would be a transformativetool, and it has been.
So, therefore, I jumped rightaway into using it for
understanding changes in thebrain, brain activity of people
that have psychiatric diseasesthat had never been understood,
and including addiction. And soI went into actually favoring
(04:22):
the study of addiction becauseit allows us to focus and target
very specifically the wholemechanisms by which we exert
self regulation and makedecisions of what is most
important. So that's how mycareer went on into research.
How has the field changed sincethen? Well, the tools that we
(04:43):
have were limited initially, asI mentioned, just to structural
imaging like CAT scan, and thenwe developed technologies that
allow you to look not just atbrain function, but also
biochemistry.
Positron emission tomography wasthe technology that allows us to
do that, and it's still the mainimportant technology for brain
(05:06):
neurochemistry. But in themeantime, MRI started to emerge
as an extremely promisingtechnology. And with as it was
launched, our researchersstarted to realize that what the
signals that we were deriving ofthe brain, whether it was doing
a task or resting, thinking ofnothing in specific, which we
(05:30):
were obtaining, like when youlook at the television set and
there's all of this noise, it'sexactly the way that you would
look at these images, and therewere all of these points
planking back and forth, andthey were dismissed as noise.
But researchers at Wisconsinfigured out that this was not
noise, that it had certainfrequencies that could be
(05:50):
predicted and that theseoscillatory frequencies were
corresponding together, weresimilar in certain areas of the
brain and very different fromothers. And they put two and two
together, and they view thepotential of using these signals
as a mean of understanding howdifferent regions of the brain
(06:11):
work together to perform a task,a process.
And then everything changed.Because fMRI, which is
functional magnetic resonanceimaging, which is basically the
utilization of these earlyawareness that these signals
that actually reflectoscillatory activity that
(06:32):
connotes information about brainorganization, has enabled us to
look at a much higher temporaland spatial resolution of what
happens in the human brain thanwhat we had had with
technologies like positivetransmission tomography, or PET
scan. So that's how it has. Soit went from being very limited
(06:54):
to a few technologies and a veryfew sites in The United States
and in the world that could doit, to now having MRI available
for fMRI studies across many,many places in The United States
and in the world, making itvery, very accessible,
noninvasive, and providing us apretty powerful tool for
(07:15):
research that in certaininstances has started to be
applied for clinical purposes.
Rob Lott (07:21):
Well, a big contribution of that work has
been to demonstrate that drugaddiction is a brain disorder,
if I'm understanding the sort oftrajectory correctly, a brain
disorder as opposed to say aweakness of character or a moral
failing. And now that's sort ofthe general consensus is that
(07:46):
this is a brain disorder, achronic condition. And I'm
wondering about sort of what youwitnessed in the sort of moving
of the needle or sort of thetransition of that general
consensus away from these sortof outdated theories. They
generally require evidence,which you and your colleagues
have provided, but there's alsoan element of persuasion and
(08:09):
consensus building acrossstakeholder groups. And I'm
curious if you've thought aboutsort of how you reconcile those
very two different kinds ofscientific communication.
Nora Volkow (08:22):
Absolutely. And I think about it constantly
because of those these two linesof communication reflect
perceptions that actually, to acertain extent, do have certain
aspects, do connote certainaspects of the conditions that
we're looking at. It's not thatthere is the whole truth, and
(08:43):
this is correct and this isincorrect. The reality being
behind what we did withneuroimaging, what it allowed us
to do was to document veryspecific changes in understand
the change in behavior. That wasclear cut.
And from that perspective, itgave us the narrative and the
(09:04):
argument, like when you do animaging of the heart, you can
document where the defect is inthe heart that can lead you to
the diagnosis of a myocardialinfarction, infarction,
importantly, can lead you towhere you're going to do your
therapeutic intervention. Butbeing able to document this, for
example, in addiction, theprefrontal cortex being
(09:24):
dysregulated with the chronicuse of drugs, it became clear
that one crucial component thatrequired therapeutic attention
was the inability for theindividual that's addicted to
exert self regulation andcontrol their impulses. And that
provides you, again, a targetfor therapeutic intervention.
(09:46):
And it also, by documentingwhere the deficits are, it puts
us into the narrative of adisease disorder as opposed to
moral failing, right? But if youlook at it in a more holistic
way, you also have to askyourself the question, what is
it in our brains that allow usto have a moral awareness and to
(10:11):
be able to carry it through?
So we give it as granted as ifthese things are going to happen
no matter what. But all of theseprocesses, emotional and
cognitive, that we give forgranted are part of the function
of the human brain. And if youdamage certain areas of the
brain, you lose the capacity toactually properly understand,
(10:34):
for example, ethical or moralconcepts, or if you don't have
the neurocircuitry that allowsyou to actually feel empathy for
or embrace a particular culturaldomain, you are going to be
alien to it and much less likelyto be sensitive to its precepts.
(10:57):
So it is again, we speak about adisorder, but it does not negate
the possibility that underlyingthe changes in the brain that
you are actually having in aperson that's addicted, you are
undermining the capacity toactually carry on behaviors that
are more akin to a cultural normof morality or ethics.
(11:19):
Recognizing that is crucial.
And also, it forces me, becauseone of it is one of the concepts
that has generated the mostcontroversy because people get
very, very upset by the notionthat by describing addiction as
a disease, you are removing theresponsibility of society
(11:39):
towards that condition, and youare blaming, that is what they
claim, that individual. Becausethey say, Well, you know, there
are societal environments thatare much more conducive to drug
taking that make people morevulnerable to becoming addicted.
And so it's society, it's theenvironment. But my argument is
(12:01):
that's not any different fromobesity and diabetes. The
environment and society aredriving this actually
vulnerability of people.
But we have, I don't know,humans have this tendency of
wanting to simplify things intoeither this or that, where
without recognizing that adisorder can have genetic
(12:23):
components that make youvulnerable to the environmental
situation that you find on.Because even if you have all of
the genetic vulnerability foraddiction, let's say 100%
genetic vulnerability, which ofcourse doesn't exist, but
theoretically, using it as anarrative, if there are no
drugs, you'll never becomeaddicted. So this just tells
(12:44):
you, Al Alimit, that wholeconcept. So in my view, I like
to listen to the argumentsbecause it behooves us to try to
integrate it into ourunderstanding of disease
process, and importantly, tounderstand how the human brain
works, right? So it is an aspectthat people get very, very upset
(13:07):
about, and they say, How couldthis mother of three take drugs
and completely disregard theirchildren?
She doesn't care for them. It'snot that she doesn't care for
them, it's that the drugs havedisrupted her relative saliency
and her urgency for doingcertain things versus others. If
(13:30):
you are able to get that personinto treatment and recovery, you
will see that they basically goback and embrace that
motherhood. And they have, Imean, and in fact, working with
mothers who are addicted, whohave children, and it's in a way
gives you the advantage becausethey are very invested on these
(13:53):
children. And so you can usethat as a reinforcer to help
them motivate them into change.
Rob Lott (14:00):
Wow, okay. Well, let's talk a little bit about the work
of the National Institute onDrug Abuse. Many of the articles
in the theme issue that we'rehighlighting at Health Affairs
this month are focused ontreatments like buprenorphine
and methadone, as well as rescueprotocols like naloxone. And I'd
(14:22):
love to hear a little bit aboutNIDA's role in developing these
drugs and also, I guess, whatits role is in tracking how
these treatments are used andways to improve interventions
using these treatments.
Nora Volkow (14:37):
Yeah, and the development of treatments for
substance use disorder addictionhas been one of the research
priorities for NIDA. Anotherresearch priority is prevention
interventions. So, but thoseoverall are now basically were
recognized that a third elementis that of research towards
(14:58):
recovery. For treatment, we havebasically the best treatments
for substance use disorders forthe treatment of opioid use
disorder. We have treatments foralcohol and tobacco cessation,
but their effect sizes are muchlower than those that we get
with the medications that wecurrently have.
And NIDA was instrumental in thedevelopment of these medications
(15:22):
directly and indirectly.Indirectly with methadone,
because we provided the researchand the science that enabled the
consolidation of methadone as atreatment, and help us
understand how it worked, todirectly, to actually do all of
the work that was necessary tobring buprenorphine into the
clinic, as well as very directlyto with Naltrexone, Vivitrol, to
(15:45):
bring it eventually into theclinic in partnership with
pharmaceutical industry, whichof course is the one that's
responsible to actually get theproduct and distribute it.
Naloxone too, similarly, we haveindirect and direct involvement
in the development of naloxone,which is the most effective
(16:05):
intervention we have forreversal of overdoses. And this
comes through the indirect allof the knowledge and research
done to understand how it worksas an opioid receptor antagonist
to the direct involvement ondeveloping formulations of
naloxone that would make itwidely accessible and very, very
(16:25):
effective for anyone, thegeneral public, to be able to
administer, even if they don'thave a medical or clinical
degree. And that has saved somany lives.
It's probably, in terms of theoverdose crisis, one of the most
consequential interventions thatwe've done, making naloxone user
(16:46):
friendly and widely accessible.
Rob Lott (16:49):
Great. Well, I want to hear a little more about some of
the decisions you make about thevarious research you fund. But
first, let's take a quick break.And we're back. I'm talking with
(17:55):
Doctor.
Nora Volkov, Director of theNational Institute on Drug
Abuse. Doctor. Volkov, you justtalked a little bit about the
institute's role in fundingtreatments like buprenorphine,
and I'm curious if you can say alittle bit about sort of how
those treatments relate to theconcept of recovery and also
(18:18):
sort of how we think aboutabstinence. Is that really the
only appropriate goal when itcomes to treating addiction? And
therefore, how do we think aboutthat concept when we're studying
drug use?
Are there other goals we mightconsider beyond abstinence when
studying drug use?
Nora Volkow (18:41):
And my perspective on this and from the perspective
of how we're pushing research isto consider the treatment of
substance use disorder as acascade model. First, you
basically screen and makediagnosis, then you treat, and
then you move towards recovery.Now, the issue is what does
(19:02):
recovery really mean? And thatdefinition has changed
significantly. And is recovery,as you say, the only option out?
And we've come to understandthat when you're very, very
rigid and saying abstinence isthe only way to achieve
recovery, you're actuallythreatening the life of many
people that don't even try toget recovery because they say, I
(19:24):
want to I do not want to beabstinent. So what is important
in the concept of recovery thatit is a decrease in drug use in
ways that are not harmful,number one. Number two, that
there is an improvement in thehealth of the individual. And
number three, that there isimprovement in the well-being
(19:44):
and the social involvement ofthe person. That what becomes
crucial for recovery.
And whether that meansabstinence or not, we don't have
an inflexible attitude towardsit. Because if someone can
achieve well-being and canbecome an active member of their
society and basically controlthe risk and dangers of taking
(20:09):
drugs, and they can still usedrugs in a responsible way, then
that may be where they go at. Imean, obviously, theoretically,
we would want recovery toachieve lack of drug use, but we
are aware that in instanceswhere it's not the option of the
person, we should be respectful.
Rob Lott (20:31):
How does NIDA view the role of health disparities in
substance use disordertreatment? What do we know about
how and where those disparitiessurface and the best way to
study them? And I guess againstthat backdrop, I'd love to hear
how the institute factors thoseelements into its funding
(20:51):
decisions.
Nora Volkow (20:53):
Yeah. Health disparities in substance use
disorders emerge in the wholetrajectory. It emerges from the
trajectory on your vulnerabilityfor using drugs, your
vulnerability to escalate intoaddiction, your vulnerability to
receive or not treatment, or toend up incarceration, and your
vulnerability to achieverecovery, and your vulnerability
(21:14):
to die from an overdose. Healthdisparities are seen throughout
all of them. So, the perspectiveof research, we are interested
on developing models of carethat can help bridge those
differences that exist in healthoutcomes.
And for example, I think thatthe mortality that you observe
(21:35):
from overdoses is significantlyhigher among people who are
homeless. So therefore, we knowthat, and the research,
therefore, is what type ofintervention can be done to
provide alternatives for theseindividuals who are homeless so
that you can protect them fromoverdosing. So, it is a
fundamental aspect of thesubstance use disorder
(21:58):
throughout the whole cascade ofcare that we were just
describing.
Rob Lott (22:02):
Got it. Okay. Well, I'd love it if you could look
forward with us for a minute andsay a little bit about maybe the
biggest gaps that remain in ourcurrent understanding of
addiction, science, andmedicine. What is it going to
take to close those gaps?
Nora Volkow (22:21):
I'm laughing because there are many, many,
many gaps. Yeah. And they go, Imean, there are obviously from
the perspective of understandingscientifically what are key
elements at which there is atransition from one phase to the
other that makes you vulnerableso that we can intervene? How do
we identify them at anindividual level, not at a
(22:42):
population level, which is wherewe are from? But I want to more
focus on the issue of issuesthat are more tangible in terms
of their proximity, which is howcan we change the healthcare
system care so that they embracemore wholeheartedly the
obligation that we have asclinicians to screen, treat, and
(23:04):
provide with the linkages to forrecovery that are necessary for
someone to succeed.
We have advanced in that field,but there's still a majority of
healthcare systems where thereis no treatment for substance
use disorder, there's noexpertise, and where it is
actually discriminated, anddespite all of the knowledge
(23:27):
that has emerged. So to me, thisis a priority. Why is it that
clinicians don't want toactually, for example,
clinicians, even if they havethe specialty of psychiatry,
don't want to treat substanceuse disorders? Why is that?
Because they are not reimbursedat the same level as if they
were treating other conditions.
(23:47):
So, what are roadblocks that areimpeding the actual treatment of
substance use disorder iscrucial. I mean, just to let you
do you know that one of the mainsources for paying for substance
use disorder, even though itshould be covered by Medicaid
and Medicare, like any othermedical condition, is pay. I
(24:08):
mean, out of pocket pay becauseclinicians don't accept
insurance. Insurance isinsufficient. So there are also
other series of roadblocks.
So to me, this is a gigantic gapthat is contributing to the
health disparities on the onehand, but it's also perpetuating
the overdose crisis that whileit's getting better, is still
(24:32):
very, very consequential andvery costly, by the way.
Rob Lott (24:36):
Can you say a little more about those costs? Is that
just the cost of untreatedaddiction? What other costs do
you see?
Nora Volkow (24:45):
Oh, yeah, untreated addiction has downstream effects
because you are not a productivemember of the society and you
create complete stress in yourfamily and your support system.
So, it is actually very, verydevastating, not to say the
economic consequences ofoverdoses, but if you look at
the consequences of addiction tohealth, let's take one of them
(25:08):
that is very fresh in my brain,infectious diseases. So
injection drug use contributesto HIV, to hepatitis C, to
endocarditis. And endocarditisis a condition for which the
average cost for hospitalizationare around $250,000. If
untreated, the chances of dyingare one hundred percent.
(25:31):
And people that enter with aninfectious an endocarditis from
injection drug use many timesleave against medical advice
because they are not properlytreated for their withdrawal
symptoms or the management oftheir pain condition is
inadequate. So, they signthemselves against medical
advice without treatment. Andthen frequently they come back
(25:55):
and many of them have recurrentepisodes. So, this is an example
of the cost associated with it.So, the medical costs, the cost
to society in terms of lack ofproductivity are also gigantic.
And consider also the costs thatare linked with controlling
drugs and policing them and theviolence that goes with it. And
(26:18):
I don't even have good numbersabout the cost to society of the
illicit drug market and tryingto regulate and control it.
Those don't even enter in thecalculations, but yet they are
very, very important. And Iwould say that an even more
fundamental level, if you wantto degrade the basic structure
(26:38):
of a society, you bring drugsin. Now, how do you actually
quantify the impact of that to asociety?
I mean, you just make peoplejust sort of indifferent to what
goes on and drive them towardsdoing drugs instead of engaging
(26:58):
in other activities. That ispretty devastating. And so this
is where I would say the costsare enormous.
Rob Lott (27:07):
I imagine there's an opportunity cost as well that
you're sort of hinting atsomeone that's has to spend time
getting treatment or gettingcare for an infection, as you
say, is not able to spend timeworking in their job or caring
for their family as well.
Nora Volkow (27:25):
Absolutely. And even if you don't have a medical
condition associated with druguse, which are very, very
prevalent, but even if youdon't, and if you are addicted,
you are not going to performproperly because the main drive
is to be sure that you get thedrug, to be sure that you don't
get into deprivation from thatdrug. And it is extraordinarily
(27:47):
powerful. It's like you arebeing driven when you don't have
food to seek it out in order foryou to survive. So, it's when
you don't have food accessibleand available, that becomes a
top priority.
You cannot think on otherthings. So, this is another
major reason why the impact ofin the productivity of people
(28:09):
that are addicted is much lower.
Rob Lott (28:12):
Well, it's almost time for us to wrap up. And I wonder
if we could close briefly bythinking about perhaps a young
researcher contemplating maybeentering the field of addiction
science or maybe a youngphysician thinking about what
specialty to go into and maybethinking about addiction
(28:33):
medicine. What would you say tothem today about whether or not
to go down that route and whatthey should maybe consider as
they make their decision?
Nora Volkow (28:44):
Well, I think it's fascinating, one of the most
interesting areas of science togo into a disease that affects
the human brain. And it's alsoone that is at the
transformative stage in thatwe're developing completely new
tools and very, very promisinginterventions for modifying that
vulnerability or that diseaseprocess. So, I would say it has
(29:10):
been a very, very neglectedcondition. But now that is
changing, and it's changing fortwo reasons. One of them,
because we've become aware ofthat devastation of not paying
attention to substance usedisorder in healthcare, but
second, for the enormousadvances that have come up in
our understanding of how thehuman brain works, the
(29:30):
technologies that allow us toevaluate it, and the tools that
allow us to actually interveneto strengthen specific circuits
or to weaken others, and tocombine these technologies with
the opportunity of newmedications and therapeutics.
So, it's really an extraordinarytime to come into the field of
(29:50):
addiction as a clinician or as aneuroscientist or as a social
scientist as it is to actuallycome into the field in general
of psychiatric disorders.
Rob Lott (30:01):
Well, a really optimistic perspective for our
listeners and for potentialfuture researchers and
clinicians. Doctor. Nora Volko,thank you so much for taking the
time to chat with us today. Ireally enjoyed it.
Nora Volkow (30:16):
Thanks very much. I also enjoy it.
Rob Lott (30:18):
To our listeners, thanks for tuning in. If you
enjoyed this episode, of course,share it with a friend, leave a
review, and, of course, tune innext week. Take care, everyone.
Thanks for listening. If youenjoyed today's episode, I hope
you'll tell a friend about ahealth policy.
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