Nora Volkow, MD, Discusses the Current State of the Opioid Epidemic and Explains How NIDA Is Actively Shifting Strategies

In this video, Nora Volkow, MD, director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health, discusses recent updates on the opioid epidemic, and highlights how NIDA is working to shift their focus to actively address the changing landscape of the epidemic. 

Video Transcript

I'm Nora Volkow and I direct the National Institute on Drug Use. We are actually the main institute that is responsible for driving the science that leads us to understand the effects of drugs in the brain, in our body, and also to help us understand, what do drugs do in our brain that leads to addiction?

We use this knowledge to derive then interventions to prevent substance use and addiction, but also interventions to treat those that are suffering from addiction and to help them recover.

We are currently faced with one of the most challenging crisis that we have ever observed in the United States from drugs that was started more than two decades ago with the opioid prescription pills that led people to become addicted.

And then shifted and changed into an increase in parallel with increased entry of heroin into the country. And as of 2016, we have seen a new direction of the opioid epidemic that is derived from the introduction of synthetic opioid fentanyl, very potent, that was used initially to just contaminate heroin because it was more profitable, more powerful drug.

And now we're seeing it used to lace stimulant drugs like cocaine and methamphetamine that is resulting on people that consume these drugs of being at risk for overdosing and dying. So this has expanded the number of people that are now vulnerable to overdoses from opioids.

Because whereas in the past it was predominantly targeting people that were taking opioids, now we're seeing people overdosing who are not using opiates, don't believe they are using opiates, but they consume a stimulant drug, cocaine or methamphetamine, that has fentanyl.

And even more recently, and accelerated by the COVID pandemic, we're seeing another group of people that are now vulnerable, which are those that will consume here and there illicit prescriptions that they get from the black market.

There's been an eightfold increase in the number of illicit prescription medicines that actually contain fentanyl. And so you, for example, may want to take a prescription pill because you cannot sleep. You buy it in the black market, in the web, and it's contaminated and you overdose.

Or say, for example, young people that use prescription drugs in parties and they mix them with alcohol. They purchase one of those pills that's contaminated with fentanyl and they die. So we have seen the shifting from people initially were given prescription pills for pain that had opioids, become addicted to them, or these pills are diverted and other become addicted to them.

And then entry of heroin, leading people that could not get prescription opiates to start taking heroin or people initiating taking heroin directly, to one where we're seeing much more expanded people that consume cocaine being vulnerable, people that consume methamphetamine being vulnerable.

And now people that actually may be occasional users that are being vulnerable for fentanyl. That needs demands that will shift our strategies so that we can ensure that we have interventions that can help prevent the overdose fatalities in these groups that were not touched in the past.

I think that also as a society, and this also is one of our priorities, we need to step back and say, what is making Americans vulnerable to taking drugs? Because we're seeing a rise in overdose deaths in adolescents that we have never ever seen before.

And this is important because if we do not address the issue of prevention drug use very early, adolescents who are the ones that are starting to experiment, we will always be catching up new drug for the other.

So it started with prescription pills. Prescription pills have stabilized and have started to go down, the legal ones, prescription opioids. But now we have other drugs surging. And COVID did not help, because COVID was a very stressful time for all of us and one of the consequences was social isolation.

People don't really realize how important social interactions are for wellbeing. And to the extent that addiction actually leads you to isolate yourself, that actually is one of the factors that promotes the risky behaviors.

And here comes COVID and already someone that has that tendency to withdraw because of the addiction no longer has the social support system that exists in communities that closed down. And that also exacerbated the escalation of drug use, led people who were recovering to relapse, and push people that were not taking drugs into drug taking.

And another factor that is also one that has made the situation even worse is with the COVID pandemic, we've seen an increase in the homeless population in the United States. The homeless population is one that is very vulnerable for drugs.

We've seen a significant rise, probably one of the highest rates of overdoses among homeless people. So all of those factors coming together at the same time that you see the healthcare system overwhelmed with having to take care of patients that had COVID no longer being able to provide support and treatment for people with substance use disorder. So it was like a perfect storm.

And when we look at it, in situations of stress like this one, they obviously can be very tragic, but we need to also step back again and look, what is it that we learned? Because in situations of stress, certain vulnerabilities of a society become evident on the one hand, but also it promotes innovation by people that need to solve the problem.

So what we've learned is that strategies that people develop in communities in order to deal with the challenges that they have actually can now be transferred and translated into other settings and have valuable positive outcomes. And as you know, with the COVID pandemic, there were laws that were changed.

So for the methadone clinics, you could take home methadone. We've been evaluating, we've been funding researchers to look into it because we want to understand how that affects outcomes. The data shows that the outcomes have been positive and there's no evidence basically of people overdosing on methadone.

So it's a safe practice, apparently, that seems to improve the outcomes. Similarly, expanding access to buprenorphine has been shown to buffer to a certain extent that difficulty that people had on accessing healthcare systems. So that one also. And we hope that it becomes permanent.

The easiness of being able to prescribe buprenorphine across states through telehealth to a phone call has made buprenorphine accessible to people in rural communities that don't have otherwise access to a healthcare center nearby, or that they fear or are frightened by the healthcare system because they have been mistreated.

So there are many good things that came around the creativity of people to address the problems. And so that has been, again, research that we're interested on consolidating and crystallizing. And finally, telehealth.

I mean, telehealth has been pushed and accelerated by the COVID pandemic, but it also has increased accessibility of support for people with addiction. Not only, for example, you can get access to your medications, you can get access to group therapy, you can get access to someone that can act as your coach.

You can get access to mental health support since comorbid medical conditions. Psychiatric conditions are very high, as well as some of the medical conditions. And that is an opportunity to maximize. So what data do we need?

What evidence is necessary in order for the insurances to embrace the use of new tools and obviously reimburse for them? And that is where we are now. Similarly, what type of research we need to change policies.

Because policies can be, for example, the one on methadone on OTPs of your treatment programs only has been very curtailing. So how do we create knowledge that can help push the policies? So we are right now prioritizing research that aims at implementation of evidence-based practices.

How do you implement? How do we assess the value of those so that we can use that knowledge to change policy? And also, we're prioritizing prevention research. Again, like in any medical condition, I mean, the most important thing, the most consequential is prevent that disorder.

And yet with addiction, we're never given that preeminence that it deserves. There are many evidence-based prevention interventions that have been shown to work, but they are not prioritized. So no one is supporting them.

So we are aiming to maximize studies that can evaluate the outcomes when you intervene with these evidence-based prevention interventions, and then use that similarly to get incentives to support their implementation.

And so this is in just broad strokes. We're working with healthcare systems. We have a very strong connection with the justice department. Because unfortunately, we still criminalize many people that take drugs and we put them in prisons or jails and forget about them.

We don't provide them that treatment or support for them to be successful when they leave that prison or the jail. Telehealth has helped because now with telehealth, the jail system has opened up to providing treatment for individuals with substance use disorder at a much higher rate than in the past.

So we're working with them on that to develop optimal models and also models that link them. Once they get released from jails or prison, you don't want them to relapse. So you need to generate models of transfer that will support them.

And so we have the healthcare, we have the justice involvement. We have communities. We work with private companies, small and big, to develop and to accelerate innovative technologies and innovative medications to provide for treatments. So these are some of the areas.

And ultimately to have knowledge, and I've sort of learned this very clearly with the COVID pandemic, that aims to very much address change policies. Because if you can create policies that requires that, for example, screen every teenager for a substance use disorder so you can intervene or a mental health illness, those are factors that are going to be at risk for addiction. You can have an uptick.

And also policies that ensure that you're going to provide your services equitable. Because what we've done, and this is something that, as I say, in a situation of stress, you see the weaknesses and the flaws of our society.

The structural racism became very evident and to the extent that America is opening up their eyes to the price we pay, all of us Americans, for having these really antiquated, unjustifiable rules that are freeing some individuals as lower grade citizens than others and not providing them the support has basically very negative consequences.

So we are policies that ensure that doesn't happen. And another one, how do you generate knowledge that will lead to those policies changing?