The Politics of Drug Abuse Research Funding

Nov 04 2009 Published by under Call yer CongressCritter, Drug Abuse Science

Our good blogfriend, Scibling and scientist-artist BioE! has a post up discussing the intersection of drug abuse health care, drug abuse science, research funding and the political process. I recommend you start with:

Double standards, politics, and drug treatment research

But there's a huge double standard in the media, and in society in general, when it comes to drug abuse treatment...Maybe it's because these other addicts are meth addicts, or potheads, or heroin addicts - probably not people you relate to or approve of. That makes it pretty easy for the media to take cheap shots at crack, etc. addicts, and question whether we should waste money trying to help them...But here's an even easier target than pot smokers: drug-using Thai transgendered prostitutes!

That last is not a joke.

I've touched on these issues a bit myself in a couple of posts.
Ex-Drug Czar
BioE! is quite right though when she says:

I know a lot of you are scientists, biologists, doctors, teachers, etc. I hope that you believe drug abuse treatment is important - even for people that aren't much like you. So I'd like to ask that if this kind of thing is as frustrating to you as it is to me, say something about it. That's why I'm writing this post, even though I fully expect to get a lot of angry comments. . . because I haven't seen many science blog posts out there on this - even though it touches on peer review, parity, and so many other issues important to the scientific/medical community...I don't see how the heck we are going to get better drug abuse treatments unless we let doctors and scientists actually study drug abuse and test treatments out in the real world. Personally, I happen to think research works - not perfectly, but it works. What do you think?

I don't know if you remember the Coalition to Protect Research or not but they've sent out an alert about what appears to be a growing strategy to bash drug-abuse science. They've issued the following talking points. I'm going to look through them and see what I might need to address in future blog posts. I'm sure my Readers will likewise have an opinion or two on the topic. [Disc: As you know, it is near certain that I have in the past held, currently hold, and/or am actively seeking to hold funding from NIDA and/or NIAAA to support my research on topics of substance abuse. I am by no means a neutral party and I encourage you, as always, to consider my remarks in this light.]

Talking Points
Substance use and abuse is costly to Americans, tearing at the fabric of our society and taking a huge financial toll on our resources. Beyond the unacceptably high rates of morbidity and mortality, substance use and abuse is often implicated in family disintegration, loss of employment, failure in school, domestic violence, child abuse, and other crimes. Placing dollar figures on the problem, smoking, alcohol and illegal drug use exact an exorbitant economic cost on our Nation, estimated at over $600 billion annually.
Over the past three decades, NIDA-supported research has revolutionized our understanding of addiction as a chronic, relapsing brain disease - knowledge that is helping to correctly situate addiction as a serious public health issue that demands strategic solutions. By supporting research that reveals how drugs affect the brain and behavior and how multiple factors influence drug abuse and its consequences, NIDA is advancing effective strategies to prevent people from ever using drugs and to treat them when they cannot stop.
Just in the past five years, research supported by NIAAA has reframed the understanding of alcohol dependence demonstrating that: 1) it is a developmental disorder that often has its roots in childhood and adolescence; 2) the highest prevalence of alcohol dependence in the U.S. general population occurs in 18-24 year olds; and 3) a large percentage of individuals with alcohol dependence are functional, and some are even leaders in society, and therefore go largely unnoticed by the healthcare system. These findings underscore NIAAA's opportunity to fund research that will facilitate better prediction of individuals at risk for future dependence by understanding the complex interplay between genetic, environmental, and developmental factors and to preempt future problems by focusing research on prevention efforts on children and adolescents as well as screening and guidance to people of all ages about how drinking patterns, especially binge drinking, relate to risks for adverse health outcomes.
The recent boost in funding from the American Recovery and Reinvestment Act (ARRA) will speed the pace of research, provide jobs, and advance the science needed to address this devastating disease. Research spanning genetic and other risk factors to neighborhood specific prevention approaches to novel medications to treat addiction to translating effective strategies to community settings, ARRA funding will help move us toward a future when substance abuse is viewed and treated in a manner similar to other medical conditions, easing the tremendous suffering that addiction brings to individuals, communities, and our society as a whole.
· Drug abuse and addiction are a major burden to society.
· Of all illicit drugs represented in rehab centers around the country, marijuana is most common, representing 17 percent of the people in rehab.
· More than 18 million people ages 18 and older suffer from alcohol abuse or dependence and only 7 percent of them receive any form of treatment.
· Estimates of the total overall costs of substance abuse in the United States -- including health- and crime-related costs as well as losses in productivity -- exceed half a trillion dollars annually.
· This includes approximately $181 billion for illicit drugs, $168 billion for tobacco, and $185 billion for alcohol.
· Staggering as these numbers are, there are series public health--and safety--implications, which include family disintegration, loss of employment, failure in school, domestic violence, child abuse, and other crimes.
· Addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking and use despite harmful consequences to the individual who is addicted and to those around them.
· Addiction is a disease that affects both brain and behavior. Research has identified many of the biological and environmental factors and is beginning to search for the genetic variations that contribute to the development and progression of the disease. Scientists use this knowledge to develop effective prevention and treatment approaches that reduce the toll drug abuse takes on individuals, families, and communities.
· Increased understanding of the basics of addiction will empower people to make informed choices in their own lives, adopt science-based policies and programs that reduce drug abuse and addiction in their communities, and support scientific research that improves the Nation's well-being.
· According to the Centers for Disease Control and Prevention, alcohol is the third leading cause of preventable death in the U.S. Even more importantly from a public health perspective, alcohol misuse negatively affects the quality of life for millions of Americans. The World Health Organization ranks alcohol as one of the top ten causes of Disability Adjusted Life Years (DALYs) in the United States.
· A complex disorder, risk for alcohol dependence is a consequence of the interplay of multiple genes, multiple environmental factors, and the interaction of these genes and environmental factors.
· The consequences of alcohol misuse can affect both drinkers and those around them at all stages of life, from damage due to alcohol exposure of the developing embryo, to injuries, to tissue and organ damage resulting from chronic, heavy alcohol use.
· Alcohol health services research, a multidisciplinary field of applied research, seeks to improve the effectiveness, efficiency and equity of services designed to reduce the public health burden of alcohol use disorders across the lifespan. It does this by examining how social factors, financing systems, service environments, organizational structures and processes, health technologies, and personal beliefs and behaviors affect access to and utilization of healthcare, the quality and cost of healthcare, and in the end our health and well-being. Ultimately the goal is to identify ways to organize, manage, finance, and deliver high-quality care consistent with developmental needs of patients and their families.

Yep, lots of fodder for discussion here. Lots. I'm hoping to find some discussion starters that will be of interest to you, Dear Reader, in the coming months.

15 responses so far

  • becca says:

    A#1) I have the utmost respect for drug-using Thai transgender prostitutes
    B#2) I still think that, with proper sociological consideration and interpersonal kindness, 'drug-using Thai transgender prostitutes' could be the punchline for a really hilarious joke.
    2) Not to be too nasty in my snark, but don't the things that 'reframe the understanding of alcohol dependence' vary from 'unsurprising' (item 2) to 'yeah, duh, guys. You needed research for that?' (items 1 and 3). Did we really only figure those things out in the last five years???
    3)The Talking Points sound to me like the B&S section of a grant. A good grant, mind you. But still. They take a level of willing-suspension-of-skepticism-for-the-basis-of-your-assumptions. I mean, arguing in one breath about how hard it can be to identify alcoholics and then about how dire the problem of alcoholism is? What happens to the 93% of people who never get treatment? In what senses are functional drug users a problem, and to what degree does this stem directly from the illegal nature of the drugs? Would it perhaps be more to the point to develop medications that are not bad for people long term that still provide the cognitive/emotional effects that cause people to enjoy drugs?
    I think drug research is both interesting and important. But I'm not at all convinced there's a collective agreement on what the overall aims of such research should be (this is not in any way an argument against it- I'd say the same about public education, for example).

  • The Decider says:

    How long will people with a genetic predisposition to substance dependence have to continue to suffer from the righteousness of politicos. If the rethuglicans were to care only about money, they might care to note, as Our Humble Narrator alludes to above, that research on drug abuse genetics and biochemistry together with exploration of treatment options can reduce health care costs and lost labor to the tune of tens of billions of dollars. Hell, we could fund another multi-year attack and occupancy of another country if we cold effectively manage the tens of millions of people in the United States with substance dependence issues.
    As for those of you who will come back and say that substance abusers have a choice in their addiction and why can't they stop, tell me about why you can't stop stuffing your jabbering piehole with TripleStackMcLipids and forcing my health care premiums to skyrocket so I can take care of your obesity, hypertension, and diabetes.
    We all have our poisons and we all have our genetics. So how about a little fucking compassion and humanity?

  • leigh says:

    becca, i disagree with your contrasting between how hard it is to identify them in public venues vs how dire the problem is. the way i see it, they don't really contradict each other.
    consider that people who have trouble with drugs can (either on their own or via an enabler type) really hold their shit together on the job and appear to be a perfectly productive person. their colleagues and friends might have no clue. if people are good at anything, it's concealing our problems and things we might not want others to know about in public.
    yet, there is a tremendous societal impact associated with drug abuse, even if it's going on in private. for instance, people whose lives are directly affected/who directly depend on someone who is having trouble with drugs are quite demonstrably caught in the rippling societal effects of drug abuse.
    and on functional drug use... this does not always last indefinitely. and we don't know, what makes someone progress into nonfunctional drug use vs maintaining drug use that can be managed along with the demands of daily life?
    (that is not to say that a functional drug user has no societal impact as described above, either.)
    *disclaimer also: my past and/or present work may or may not be supported by one or more of the abovementioned funding agencies.

  • SurgPA says:

    becca wrote: "I mean, arguing in one breath about how hard it can be to identify alcoholics and then about how dire the problem of alcoholism is? What happens to the 93% of people who never get treatment? In what senses are functional drug users a problem?"
    Well, one of them just ended up in my ICU after driving his car into a tree with a BAL>200: left kidney laceration (*probably* can manage non-operatively), pelvic fracture, nearly scalped himself (earning a blood transfusion due to loss), now intubated and will require about a 5 day hospitalization before going to rehab for the pelvic fracture.... Or there's the high-functioning 55 year-old who went into delerium-tremons last week on post-op day #2 from an elective surgery, requiring his own trip to the ICU, intensivist monitoring, extended hospitalization etc...
    It's anectdotal, so all the usual caveats apply, but talk to anyone who's worked in health care for a while, and they'll tell you that the functional-and-undiagnosed alcoholic who develops acute medical complications as a direct result of their use is not rare and not even uncommon. While you might have expected the former example (a bona fide Hell's Angels biker) to have substance abuse problems, the latter was a well-educated white collar professional; I'm sure I've seen many like him who had alcohol dependence that I had no reason to suspect. I can't confirm the numbers quoted above, but the direct medical cost alone is certainly enormous. Functional drug users still suffer intermittent consequences of their use, and the cumulative burden on the health care system is just one way they are a problem.

  • Pete Guither says:

    Boy it's really hard to read those talking points when they start off so badly.
    The first paragraph twice mindlessly conflates use and abuse — not an auspicious start. And then there's that delightful $600 billion figure — a great way to get people excited about the problem, but not very useful in real life. After all, it includes the costs of prohibition as if they were the costs of drug abuse. And the the vast majority of that figure is the elusive "lost productivity" figure, which is a very controversial formula with little relation to reality.
    Finally, there's the note about the large numbers of marijuana abusers in treatment, ignoring the fact that most of them are there because of criminal justice referral (and that they may not be actually, you know, addicted).

  • It would be nice if we didn't put a price tag on research this important, but the reality is that the world of science (like the world of business) is governed by the almighty dollar. If there's money in addiction recovery, then you can best believe that where the advancements will be. But until we get to that point, the whole field is going to have to kick and scream for every dollar.

  • SurgPA says:

    Pete, What percentage of the cost is due to "lost productivity"? You said the vast majority - is that 70%? 80%? I haven't seen any specific breakdowns along those lines. Obviously it accounts for some portion, but I'd be suprised if it was the vast majority. Actually, I'd suspect the numbers are skewed toward the expensive end by tobacco. The prevalence of use is high (although probably not as high as alcohol), the cessation rates are low, and most users eventually develop lung damage (I'm thinking COPD, leaving cancer out of the picture)that leads to significant direct medical costs. Again, lacking specific numbers, it's hard for me to claim this as the majority of the cost...

  • affected says:

    All I can say is that regardless of whether or not you like the talking points, this is really important research that needs to be done. In learning about how the brain misfunctions in addition, we also learn something about normal function too. I am also curious to learn more about the developmental/early life stage factors and how they contribute to disease, both from a professional standpoint (interested in devo toxicology), and a personal one (partner's family struggles with alcohol- they fall under the "functional" category for the most part, and am concerned for my own son's future!).

  • k8 says:

    Becca, the other 93% who don't get treatment end up in jails, mental institutions and the morgue. Some sooner than others. And it is not always because someone doesn't want to recover. There is a fundamental lack of knowledge about the "disease," there is no one treatment model that corners the market on recovery - in fact the success rates of current treatment models are utterly dismal. Health insurance fails to cover treatment models they don't "recognize," (whether they work or not) and they certainly don't provide resources for the long-term treatment of this so-called chronic disease.
    Add that to the stigma the addict or alcoholic faces from the majority of the population who feel their addiction entirely self-inflicted and a moral failing, and it's no wonder only 7% of those who need treatment actually receive it. Until addiction is recognized as the explosive public health problem that it actually is, none of that will change.
    Whether anyone agrees with the "choice" an alcoholic or addict made to injest that first drink or drug, addiction remains a clear public health issue that demands new research.
    And of course I'm biased, because I'm a recovering alcoholic who watched her fiance die a slow and painful death. Me - an educated woman with a master's degree in counseling psychology and him - also educated who was a Social Worker. We weren't your cracked out pot heads on the street. And it is only a twist of fate that it's not you.

  • becca says:

    leigh- I guess what I'm saying is, the difference between someone who is high-functioning and a user, and high-functioning and an abuser, can be very fuzzy indeed.
    "we don't know, what makes someone progress into nonfunctional drug use vs maintaining drug use that can be managed along with the demands of daily life?"
    Very true, and a fascinating research problem. But I think even this is not an issue that can be best understood with a binary model (transition from Functional to Nonfunctional).
    k8- I'm sorry to hear about your fiance.
    I've got to point out what's wrong with your statement though, not to be mean, but you'll see what I'm getting at in a minute...
    *Wouldn't most of the people in psychiatric institutions be counted under those 'getting treatment'?
    *93% of 18 is 16.7 million people. The best estimate I got for alcohol related deaths was ~85,000/year. The total number of incarcerated individuals in this country is ~2.5 million. Even if all of the people in jail were dependent on or abusers of alcohol, I still don't see how you can get to 16.7 million people.
    *So the bulk of those that are dependent on or abuse alcohol are not in the Dire Consequences category of jail and death. *The 18-and over population of the US is ~230 million; 18 million is therefore about 8%. This strikes me as pretty common.
    Basically, my idea of a 'high functioning individual who is dependent on or abuses alcohol' isn't just someone who avoids jail, death, and psychiatric institutions. It isn't just someone who holds down a job. It isn't just someone who doesn't abuse people in their life, or make exceptionally bad financial decisions due to alcohol. When we focus on those things, I think we ignore a continuum of alcohol use-dependence-abuse.
    What about frat boys that don't drink themselves to death, but who go for weeks where they drink 5 or more drinks every night? Or grad students that come home and have a couple of six packs in a few hours to free up their brains to work on a grant? How about professors who think it's wonderful to take their rotation student out for cocktails? Or professionals who suggest giving newborns whiskey to stop the crying? And how about all gray cases of incredibly sweet drunks who only know how to express any feelings when wasted?
    Heck, what about comrade physioprof and MFJ?
    These are the alcohol users I know. These are the alcohol users I worry about. Are they alcoholics? Nope. I'm not even sure any of them would be counted in that 18 million. Are those uses of alcohol reflections of the most healthy and balanced aspects of those individual's psyches? Not really.
    Basically, I'm arguing against drawing stark distinctions between "normal" and "abnormal" uses of drugs. Both for the sake of compassion for those that use them and for the sake of practical solutions (it's human nature to want to feel good; some ways of pursuing that are more socially acceptable than others, some ways are healthier than others, but those two features do not completely correlate with each other).

  • Pinus says:

    I think the real problem with drug and alcohol abuse that everybody thinks they are an expert, because they know somebody who has a problem, or because they drink or smoke weed from time to time. Scientists/Researchers do this as well.

  • Klem says:

    Research is also needed on the cost/benefits of drug prohibition.
    Dispatches from the Culture Wars (03 Nov 2009):

    Sen. James Webb of Virginia is working to pass a bill that would establish a commission to look at our entire criminal justice system, top to bottom, and make recommendations for reform; Sen. Charles Grassley is trying to make sure that commission can't even consider the possibility of decriminalizing or legalizing any currently illegal substances.

    Grassley has proposed an amendment to that bill that would prohibit the commission from even considering any changes to the Controlled Substances Act.

    Grassley Seeks to Censor Drug War Solutions: Dispatches from the Culture Wars
    Grassley Defends Censorship. Kinda.: Dispatches from the Culture Wars
    Also of interest, Dutch among lowest cannabis users in Europe-report: Reuters (05 Nov 2009).

  • DrugMonkey says:

    And from your last link, Klem:
    Countries with the lowest usage rates, according to the Lisbon-based agency, were Romania, Malta, Greece and Bulgaria.
    Would those be countries with highly permissive laws as well? Or are you cherry picking again?
    Also what about this comment?
    the highest being Italy at 14.6 percent. Usage in Italy used to be among the lowest at below 10 percent a decade ago.
    because I see from this link that Italy had some relaxation of cannabis laws recently:

    She said the amount of cannabis allowed for personal use — 500mg — would be doubled. Nearly 10 per cent of Italians smoke cannabis regularly, according to a recent survey. A third of Italian teenagers between the ages of 15 and 19 say they have smoked it at least once.
    Paolo Ferrero, the Welfare Minister, who is a Communist, said he would ask Parliament to repeal the “zero tolerance” policy and re-establish the distinction between hard and soft drugs.

    This seems to suggest that decriminalization efforts increase cannabis use.
    Like I always say, quoting spot examples is a poorer way to get at the truth than is understanding all the available data and the context for each finding.
    N.b., the source report for Klem's news link is very interesting reading.

  • DrugMonkey says:

    Hmm. Looking over the European Monitoring Centre for Drugs and Drug Addiction report I've just linked very briefly, I see two mentions of Portugal. As some readers may recall, this is a favorite of legalize-eet commenters because they decriminalized and didn't see an increase in use. I noted that Portugal had a strikingly low rate of cannabis use in the first places. Such things make me question the general application of any results of, e.g., decriminalization. I wondered what explained the low base-rate prior to decriminalization.
    The two tidbits are an unusually high male:female ratio of use and a failure of the 15-24 year olds to report the highest past-12mo use rates.

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