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A Collaborative Approach to the Problem of Addiction


The diversity of expertise required to address the addiction problem makes it impossible for any individual scientist or clinician to be fluent in the full range of knowledge development. Yet advances in one area can profoundly affect progress in others. For example, the development of new pharmacological insights can suggest new therapeutic interventions. Advances in the understanding of risk factors can inform new biological studies. Advances in the understanding of psychiatric co-morbidity can lead to new and more effective treatment paradigms.

The Confederation of Northwest Addiction Research Centers was formed at the University of Washington to foster a collaborative approach to research and training in addiction. It's overarching goals are to facilitate communication between disciplines, enhance collaborative studies, and provide synergy in training the next generation of researchers and treatment providers. We expect that novel insights, new treatment paradigms and better-informed training will inevitably result.

What is the benefit of a collaborative approach to addressing addiction?
What can be achieved in collaboration that can't be achieved alone?

  • Impact for research
  • Teaching and training
  • Treatment and care

The Confederation is composed of experts in different disciplines (psychology, nursing, pharmacology, social work, and psychiatry), each focused on specific aspects of a very large and complex problem. Addiction needs to be approached by understanding: 1) the pharmacological effects of the drugs on the brain and biological differences between the functioning of addicted and non-addicted brains (so that we can devise more effective interventions); 2) the risk factors affecting the probability of addiction by understanding the influences of community structure, family dynamics and genetic factors that increase risk (so that we can target interventions most effectively); 3) the association between addiction risk and confounding psychiatric factors (such as depression, attention deficit hyperactivity disorder, and certain forms of mental illness that can complicate treatment); 4) the neurodevelopmental damage drug abuse has on unborn children that imposes a tremendous burden on the afflicted individuals, their families and society; 5) the ancillary effects of drug abuse including HIV and hepatitis infections caused by shared needles; 6) the effectiveness of different prevention and treatment strategies and harm reduction strategies by clinical trials in order to maximize beneficial outcomes.

Why is this important? Why now? Why should people care?
What are the current societal costs of addiction?

  • Who does addiction affect? Who is vulnerable?
  • Are there new trends in addiction?
  • What's wrong with current approaches to treatment?
  • Have we made any headway in addressing addiction?
  • Are improved treatments, prevention, or cure within reach?

The costs of addiction are staggering. Including damage to family member's lives, family health, school and work performance, and absenteeism along with the costs of the direct damage to the health of the affected person, makes the personal and societal costs enormous. Adding the legal, medical and policing costs of drug trafficking, driving accidents and incarceration, and the costs go up additional orders of magnitude. Confederation member Andrew Saxon, MD and his colleague Dennis McCarty (2005) sum up the costs this way:

The most recent national analysis estimated that overall societal costs related to alcohol use reached $148 billion and US$98 billion for drug use (1992 data; Harwood et al., 1999). Costs related to alcohol use were relatively constant over the prior 20 years. Drug use costs, however, showed a pattern of escalation (Harwood et al., 1999). Costs of crime are particularly noticeable for drug use—a cocaine-dependent individual generates between $3126 and $33,609 annually in costs related to criminal activity (Flynn et al , 1999). A large community study of chronic drug users, injection drug users, and non-drug users determined that the drug users each annually incurred about $1000 in excess health services utilization compared with non-drug users (French et al., 2000). In regard to heroin addiction alone, the estimated cost to society in 1996 reached $21.9 billion, including 11.5 billion in lost productivity, $5.2 billion for crime, and US$5 billion for medical care (Mark et al., 2001).

The financial impact is huge, but the impact on the afflicted persons and the people that care for them is the most tragic part of the story. The goal of this work is to give people effective tools to prevent these problems from occurring in the first place and intervene to change their lives if they become involved with harmful use of tobacco, alcohol or other drugs. Programs that work with elementary school students preventing substance use problems put young people on a positive trajectory with long-term outcomes in young adulthood (Hawkins et al., 1999, 2005; Brown et al., 2005). Getting people into recovery and effectively treating their drug dependence would have huge impact on their lives, those of their loved ones, and all the associated members of society affected by the addiction.

Further, addiction is not limited to those in poverty and who live in the poorest neighborhoods of our urban centers . Use of tobacco and alcohol while associated with extreme poverty, is positively related to income. Urban, suburban, and rural rates of drug use are similar. There is some regional variation with the Northeast and the West having higher rates of use than other areas (Johnston et al., 2006) Addiction is distributed among all classes and occupations. It is rare to find a person who doesn't know someone personally who has been affected by addiction.

What's wrong with current approaches to treatment?

Today we know more about addiction than ever before. We know when tobacco , alcohol, and other drug use starts and how substance use progresses to addiction ( Johnston, et al, 2006 ). We know about how substance use and harmful patterns of use are distributed across development and across schools and neighborhoods in Washington State (Washington State Epidemiological Work Group). We also know about many of the predictors both of drug use initiation and its progression to addiction that includes individual, social and environmental factors (Hawkins et al, 1992, 1996). Importantly, we know many preventive and treatment interventions have been found to be effective reducing initiation and progression to addiction, as well as increasing rates of recovery from addiction and maintaining recovery (Volkow and Li, 2005; Hawkins and Catalano, 2004). Progress has been great as federal and state funds have been invested in discovering the causes of addiction as well as its prevention and treatment.

Despite this scientific progress, we are far from a cure. Rates of drug use among children, adolescents, and adults remain high (Johnston et al., 2006). Annual deaths attributed to tobacco are approximately 400k, alcohol 100k and illicit drugs 40K (McCarty and Saxon, 2005). Despite effective prevention and treatment programs demonstrating efficacy, we know less about how efficacious programs interact with the individual, the provider, and the length of time intervention is provided. Further, most individuals who are addicted receive no treatment at all (SAMHSA Office of Applied Studies, 2004). Prevention services research has demonstrated that prevention programs that are ineffective or have not been evaluated are more likely to be used in schools and communities than prevention programs that have been tested and found to be effective (Hallfors & Godette, 2002; Ringwalt et al., 2002). Thus, despite scientific progress in addiction research, much of what is known by scientists is less well known and has not been implemented in practice settings including local and state government agencies, community prevention and treatment agencies, medical and health care agencies. Finally, the public is often even less informed about these issues, and as a result are less effective advocates for effective addiction prevention, treatment and aftercare.

In part this disconnect among scientific disciplines and between science and practice is due to the isolation of many streams of scientific progress. For example, progress has often occurred within areas of study of epidemiology, etiology, prevention, treatment and aftercare. Further, within these areas of study, it has often been difficult to establish collaborative links between genetic, biological, medical and health, psychological, and social research. Twenty-first century addiction science needs to integrate gains made across several fields and engage in synergistic efforts that are cross discipline, cross stage, and most importantly translate bench science to the bedside in new prevention on and treatment approaches based on this integration and catalytic effort.

The Confederation of Northwest Addiction Research Centers was formed to coordinate and enhance research and graduate training in the area of drug and alcohol addiction at the University of Washington to engender a truly 21st century addiction science. Despite the tremendous strength in Addiction Research at the University of Washington, including almost $43 million dollars of addiction-related research funding from multiple NIH institutes (NIDA, NIAAA and NIMH) supporting research and training on drug and alcohol abuse, research spanning multiple disciplines including social work, nursing, medicine, public health, pharmacology, virology more, and research from molecular to the societal levels, a group of directors of research and training centers were concerned that there was a lack of cross-disciplinary fertilization and synergy that is required to catalyze research aimed at the reduction of human and monetary costs of addiction. It was clear that enhanced communication and scientific collaboration was needed for the field to leverage current findings as well as develop new bio-psycho-social-environmental models of addiction prevention and treatment. Further, it was clear that a need for multidisciplinary education for scientists, students, practitioners and policy makers would be required to enhance addiction science and increase the translation of science to practice.

The Confederation was formed to facilitate scientific collaborations, coordinate fund raising, coordinate education, and enhance communication within the drug abuse research and training community at the University of Washington and in the larger NW community. Members of the Confederation represent diverse disciplines including epidemiology, pharmacology, microbiology, psychiatry, psychology, sociology, social work, nursing, psychosocial and community health, more. We have been meeting for almost a year, and have discovered the potential synergy of our collaboration. However, additional funds could help catalyze the synergy that has already begun. Fully understanding each others language and paradigms and the potential for cross disciplinary synergy in developing and testing more comprehensive approaches to understanding, preventing and treating addiction is necessary for these conversations to bear fruit. Currently, monthly meetings are taking place to enhance this understanding with research groups presenting their work and identifying areas that the group could assist individual centers.

Where is the science of addiction focusing?

  • The brain's pleasure centers? Certain brain activity?
  • Could the research impact other areas of study, such as pain?
  • How does translation happen from basic science discoveries?

The science of addiction is focused on understanding motivated behavior. How does the collection of cells in the brain function as a unit to make choices? How do addictive drugs hijack or subvert this choice system? Can we identify specific vulnerabilities within the brain that control the susceptibility to addiction? How is a drug-addicted brain functioning differently than a normal brain? Which of those differences can be reversed? What proteins and genes within the brain are important in controlling the transition from casual drug-user to addicted drug-user? Can those events be blocked or reversed?

The research has revealed an underlying connection between drug addiction and other common psychiatric disorders (depression and anxiety syndromes). Advances in addiction research and psychiatric research are likely to be synergistic. Drug addiction, compulsive eating disorders (obesity), are compulsive gambling all likely to be related. Advances in one area will benefit treatment in the others.

A common use of prescription opiates is for the treatment of chronic pain (neuralgia, chronic back pain, migraine, cancer pain). Diversion of drugs and overuse of opiates are pervasive problems currently. These pains are serious problems that must be treated, but a better understanding of the addiction process will help ensure that these drugs are used more safely.

While the genes, the brain and biology play an important role in increasing or decreasing the risk of addiction, these elements of the individual interact with the environment. Thus, understanding family life, peers, school and community factors is also essential to understanding addiction (Beyers et al., 2004). For example, while a family history of alcoholism increases the risk of alcoholism in offspring less than 30% develop alcoholism. Understanding the powerful modifiers of this biological risk factor is part of the 21st century study of addictions.

All of these areas are producing discoveries that need to be applied to the development of effective prevention and treatment programs. Several Confederation members have been developing, delivering and testing science based prevention and treatment programs for decades. This is the strength of the Confederation. Prevention programs have been developed and tested during pregnancy through young adulthood. Treatment interventions have been developed and tested with a variety of populations including adolescents, college students, and adults. The 21st Century addiction science that the Confederation hopes to catalyze is likely to provide the foundation for new prevention programs and treatments that can be rapidly tested due to the expertise and contacts with community based programs in Washington state and the country. For example, in the treatment area, Dr. Dennis Donovan is the PI of the Pacific Northwest Node of the NIDA Clinical Trials Network, a national network of scientists and practitioners in drug abuse treatment that is developing and implementing new treatment innovations in community settings. Dr. David Hawkins is involved in a randomized trial of community-based prevention in 24 communities across seven states. Andrew Saxon is connected to the Veterans Administration treatment programs that focus on substance use and psychiatric disorders. These and other members' links to community prevention and treatment ensure that Confederation scientific discoveries can be rapidly applied to the development and testing of new interventions.

What disciplines does the team span?

  • The basic sciences, including microbiology and pharmacology
  • Psychiatry, psychology, social work, nursing and community health
  • Neuroscience, neurology, biostatistics, and biochemistry

What is the breadth of this team's research?

  • Alcohol
  • Cocaine, Methamphetamine, Ecstasy
  • Heroin and other Opioids
  • LSD, Marijuana

What is the vision for this group?

We believe that exciting advances in the different areas of research are not being communicated efficiently to other research domains because of a lack of common language and opportunity. Many examples can be described to illustrate the problem, but to provide just a few:

  • Understanding how important stress is in the lives of the drug addicts, how poor stress-coping skills cause bad decisions, how the adverse effects of stress ar e magnified in the life of the addict, and how hypersensitivity to stress stimulates drug intake and precipitates relapse has only recently been articulated. Translation of these insights into more appropriate experimental models has generated new opportunities to understand the effects of stress on drug-use motivation. These models are now being used to identify new treatments.
  • Understanding how drug use and depression are linked with one causing or exacerbating the other, has stimulated research on t he common mechanisms and treatments. Again, translation of these insights into clinical and basic science research has recently begun. New therapies and interventions are being proposed and tested in the laboratory and clinic.
  • Although the problem of addiction is broad and multidimensional, our students are still being trained within the boundaries of traditional disciplines. Their thinking is constrained by those limits. New, creative approaches at the disciplinary boundaries cannot be imagined or d developed unless we more broadly train the next generation of clinicians and researchers.
  • Research is currently constrained by the training and skills of individual investigators, and the specialized skills required to excel in one discipline are inadequate when confronting a large, multidisciplinary problem. Collaborative teams need to be assembled in which the skills in different disciplines are coordinated and members can communicate effectively. For example, experts in modern genetics, clinical trial design, statistical analysis, patient recruitment and monitoring, psychiatry and pharmacology need to work together more effectively.

We imagine that the Confederation will provide the language, opportunity and training to accomplish these goals.

… and what will get you there?

  • Endowed professorships to help us recruit and retain outstanding researchers and leaders.
  • Seed money for innovative pilot projects able to generate new data able to support large scale NIH-funded trials.
  • Fellowships to support MD and PhD trainees while they obtain the interdisciplinary training not currently supported by conventional disciplinary sources of funding.
  • Funding for local conferences and lectureships to provide needed expertise in targeted areas to help us craft solutions or overcome obstacles to scientific progress
  • Creation of a Science to Practice Center which would review literature and keep abreast of effective prevention, treatment and aftercare interventions; evaluate widespread potentially effective but unevaluated prevention, treatment, and aftercare programs; and disseminate effective assessment tools for schools, primary care, and service system practitioners. In addition, the Confederation would track and report progress in addiction to community, state and national research and practice communities.

Are there other multidisciplinary programs in addiction that you know of, or are you forming what can be viewed as a national model?

The open and collaborative environment at the University of Washington is unique among the top research universities. We have a concentration of tremendous excellence and a culture of collaboration that is unrivaled.

 
Updated 2013  |   Confederation web site hosted by the Alcohol & Drug Abuse Institute
http://adai.uw.edu/confederation/overview.htm