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I have been in the Government for 17 years, and I have to tell you that in those 17 years I have never met two people who bring to the most complex problem facing us the kind of clarity of thinking, focused action, and courage that Secretary Shalala and General McCaffrey do. I salute both of you, and I thank you for leading us all.
I also want to take a moment to acknowledge our very important central collaborator in the Scholastic News magazine project that Secretary Shalala mentioned. Rick Delano, the director for the Youth Health Initiative at Scholastic News, is in our audience. He pointed out to me earlier today that it was about a year ago that we first started talking about holding a conference on prevention research. He actually posed it as a challenge back then when he said to me, "So you think you have such good science? Do it." Well, we are doing it.
My job is to try to set a broad context for this conference and, as much as I can, to lay some of the groundwork and spell out some of the generalizations that we have derived from prevention science over the years. Many of these generalizations may appear superficially to be common-sensible, but they are not. The problem is that science is the process by which common sense gets revised; that is to say, today's truth or common sense may not be tomorrow's common sense.
Those of you who work with children know this as well as anyone. Children are born a blank slate, and we have learned much about the ability of infants to acquire knowledge and their immediate perceptive and learning abilities.
We all need to keep in mind that drug abuse and addiction are among the top one or two issues facing this country and our society. The reason is that drug abuse and addiction affect everybody, either directly or indirectly: every family, every community, and all parts of society.
About 70 million adult Americans have used drugs at some time in their lives, and therefore they think they are experts on what to do about drug problems. It is a bit like the problem experienced by educators; everybody went to school so everybody feels free to tell their teachers how to teach. How many people in this room have not done that?
I am probably the only NIH Institute Director who goes to a cocktail party and the first 12 people who come up to me tell me how to fix the drug problem. The head of the National Cancer Institute does not have that conversation. The head of the National Heart, Lung, and Blood Institute might be told not to eat the high-cholesterol roast beef, but other than that, people are not giving him the same type of advice.
The problem is that we as a society, and frankly, many in the professional community as well, have tremendous ideologies, that is, tremendous beliefs and intuitions about the nature of drug abuse and addiction and what to do about it. The good news is that we also have scientific data that we can bring to bear on the problem. We need to talk about the data, and we need to figure out how to actually accomplish our goal.
When I first became the NIDA Director I went to visit the Partnership for a Drug-Free America, and I was struck by the Partnership's slogan: "Drug abuse is a preventable behavior. Drug addiction is a treatable disease." That slogan captures both the simplicity and the sophistication of what 20 years of science has taught us, and I want to spend some time talking about both sides of that.
I am going to start on the treatable disease side. Whenever we think and talk about drug use or the phenomenon of addiction - and you will notice that I never pretend they are the same word - I think it is important to understand the full complexity of the issue that we are dealing with.
Let me start with some simple points. Whether or not a group of people will use drugs is a function of a large variety of factors called risk factors. However, when you look at what we call the proximal cause, that is, the reason a person takes a drug at a particular point in time, we find that he or she takes that drug not because of a risk factor, but to modify his or her sense of well-being. They are taking that drug to modify their mood, their perception, and sometimes their motor skills. And what they are doing, in fact, is modifying their brains.
The truth is that people take drugs to modify their brains, and they like modifying their brains with drugs. Positron emission tomography (PET) scans, from work by Nora Volkov and her colleagues at the Brookhaven National Laboratory, graphically demonstrate the phrase, "This is your brain on drugs." What her scans show is the uptake of radioactive cocaine over time into the base of the brain. People take cocaine because of that; they love the concentration of cocaine in that part of their brain. And we have a sophisticated level of understanding about why they love it. What they are doing actually is pushing up the dopa-mine levels in that part of the brain. PET scan studies on rats given cocaine show spikes in dopamine, the neurotransmitter involved in Parkinson's disease and involved in most pleasurable experiences. When a rat takes the cocaine, there is a dopamine surge. We believe the major reason that rats take cocaine is to obtain that dopamine surge. It is true for nicotine, and it is true for marijuana, amphetamines, and heroin. They all lead to an increase in dopamine.
The problem with taking drugs to modify the brain is that people who take drugs have succeeded too well, and prolonged drug use modifies their brains in fundamental and long-lasting ways. PET scans show that there is a relatively permanent change in the brain that lasts at least 100 days after an individual has stopped taking cocaine. The question most of you are asking at this moment is, "Does it return to normal?" The answer to the question is, "I don't know." One of the sad things about science is that we often obtain half of the answer to a question and do not get the rest. We are working on the rest of the answer.
Addiction is, in fact, a condition of changed brains. That is, you take drugs in order to change your brain. Sadly, you become too good at it, and over time it produces long-lasting, and in many, many cases, dramatically harmful effects on your brain. Addiction is a condition of changed brains, and I will tell you that it would be a lot easier if that was all it was. I could say, "It is just a brain disease." I could find a magic bullet. But I have to tell you, there will be no magic bullet. Those of you who are expecting a magic bullet - forget it. This is the most complex problem we have ever found, and we will have to find complex solutions.
We know that addiction is not just a condition of changed brains. It is also a result of a variety of factors that become embedded in the addiction itself. In this case I would refer you back to the concept of people, places, and things. The truth is that the circumstances that accompany the development of an addiction become what we in psychology call "conditioned." These circumstances become a conditioned part of the addiction, and they are able to elicit phenomenal cravings. The cues around drug use, not just the drugs, can elicit tremendous cravings.
Work from the University of Pennsylvania meas-ured the level of craving experienced by a cocaine addict. They compared levels of craving in response to neutral stimuli, like a nature video, with the level of the craving elicited by exposure to cocaine stimuli, such as the paraphernalia used for crack cocaine. No actual drugs were involved. Researchers found that exposure to the cocaine stimuli alone elicited phenomenal craving. This is why people in the treatment community know that you cannot just complete an inpatient treatment experience and dump the patient back in the community. You need to have aftercare that deals with the embedded social cues that occur.
PET scans show what I call the memory of drugs, or the activation of the part of the brain called the amygdala. The amygdala is a part of your brain, not surprisingly, related to all emotional experiences, and particularly the memory of emotional experiences. The scans show the activation of the amygdala in response to the cocaine video compared with the nature video. They show the quintessential biobehavioral disorder. That is to say, this is the epitome of biology and behavior coming together. We understand much of the brain mechanisms, and we understand the effects of the social and behavioral context and the behavioral expression. The PET scans tells us about the complexity
of addiction and they tell us about its solutions. And there are solutions. Addiction has to be seen as a condition of changed brains and trained or conditioned brains.
The task of drug addiction treatment becomes changing the brain back to normal. You can do it in a variety of ways, including pharmacologically in some cases, although we basically have medications only for heroin addiction and nicotine addiction. We have no medications for cocaine addiction, but we are working on it.
However, we do have a wide range of impressive treatment approaches. Drug addiction is treatable. A few weeks ago at the American Psychological Association, Dr. Marcia Lenehan from the University of Washington articulated the goals of treatment: enhancing the individual's capabilities, improving motivation, and assuring generalization to the natural environment. There are at least three approaches to accomplishing each of those goals that have been proven effective through clinical trials. This is science being brought to bear on the problem of addiction.
We have data to show that you can accomplish each of those goals, but we have a tremendous gulf between what we have learned from science and incorporating these approaches in some treatment settings. More and more treatment settings are being exposed to these scientific findings and are modifying their treatment approaches. But the fundamental point is that addiction is treatable, and we have a wide array of tools in the toolbox with which we can accomplish that goal.
But we are here today to discuss drug use as a preventable behavior. The big question is, how do you go about preventing drug use? The truth is that a tremendous amount of ideology exists in our communities, among our professionals, and, to be candid, among some of our scientists as well. It is one of the most frustrating problems that I have. We have people who do not understand that prevention can be science based. It is like any other phenomenon. There are two tasks: to design and test new prevention approaches, and to test the efficacy of existing approaches. Both of these tasks are scientific goals and are achievable goals.
So what is this science base that we are here to talk about? Primarily, you need to understand that prevention, although it is very complex, is fundamentally a process of education and of behavior change. Much of the science base that should and can be used in the development of drug use prevention approaches comes from the science of behavior change. It comes from the study of epidemiology, patterns of drug use, histories of use, and risk and protective factors. As I am fond of saying, prevention should be experimental epidemiology and experimental behavior change. We should take what we learn from basic science and translate it into prevention science, and we should take prevention science and translate it into practice. And that is what we are trying to do.
Science has taught us a lot. We have had at least 20 years of scientific research on the principles of drug use prevention, and we have learned a tremendous amount. Our colleagues and you who are the users of prevention science will work together to put details on the generalizations that I will discuss. What is sophisticated here is understanding how to move from generalities to specifics and understanding how to do some things and not do other things.
Let us start with some understanding of risk factors for drug abuse. Science has identified more than 70 risk factors for drug abuse, and they are very powerful. However, they are not equally powerful, and I am not going to go through all of them in detail. They operate at multiple levels: the individual level, the family level, the peer group level, and the community level. Those
70 risk factors are the same risk factors for everything bad that can happen to somebody.
I am a public health official and a parent. The truth is that if I could modify any of those bad things through a prevention program, I would be pretty happy. But my job is to deal with the issues of drug abuse per se, and therefore we have to select the most powerful risk factors and the most powerful interactions among these complex behaviors. We also need to understand that the level of risk, that is, the variation in level and the form of risk, must dictate the form and the intensity of the prevention effort. The one-size-fits-all approach never works. Anybody who thinks a single approach is going to work for everybody is naive.
Not only is it true that the higher the level of risk, the more intensive the prevention effort must be, but also the earlier we need to begin those efforts. Another critical point and fundamental principle is that prevention programs must be age specific. That is, you cannot speak to young children in the same way you speak to older children. You cannot speak to younger teenagers in the same way you speak to older adolescents. It is a tough lesson to learn, but science has taught us this over and over again. The advertising industry figured this out 30 years ago. Where have we been? All of our programs must be age appropriate and age specific, and they must also be culturally appropriate. They must speak to the people to whom they are directed and not only to the people who are doing the speaking.
It also is true that just dealing with risk factors is not going to be sufficient. A heartening fact is that most of the children considered to be at highest risk do not use drugs. Why is that? What circumstances prevent drug use among the most high-risk kids, and are there insights to be derived from understanding why this occurs? This could be useful in the prevention arena.
We have come to believe, on the basis of research that you will hear throughout this conference, that the best prevention approaches take into consideration both risk factors and protective and resiliency factors, and they overlay protective or prevention factors onto an understanding of the risk factors. We have been trying to figure out the best way to conceptualize this. The truth is that you also need to, as we say in science, titrate one or the other as one varies. As risk factors vary, you need to modify the protective factor approach, and as you change the protective factor approach, of course, you often will reach different groups of people.
Let me give you an example. Science has taught us that one of the most powerful protective factors is family involvement in the life of the child. You will notice that I did not say family involvement just in the child's drug use. There is an important difference. It is not very effective for daddy to come home from a hard day's work, walk in the house, say, "Hi. I am home. Do not use drugs." This is not going to work. What is needed, and what we have come to understand, is that family involvement in the life of the child is a powerful protective factor. There is a technical term I actually do not like very much, "parental monitoring," but the concept is important. Parents need to be involved in their children's lives and ask them questions such as "Where
are you? What are you doing? Who are your friends? How are you? What are your problems? Do not use drugs. What else is going on? Did you do your homework? We love you." This involvement has to be part of a constellation of interactions.
To the point of titrating risk and protective factors, we know that approaches to strengthening the family must be changed and adapted as we move to more and more high-risk situations. In the most high-risk situations, concentrating on the family alone is not going to be sufficient. You need to adjust or titrate the relationship between risk and protection.
Another point is that prevention programming has to match the nature of the problem in the local community. This is another area in which one size does not fit all. It will never happen. One of the things NIDA has slowly begun to do is more systematic, local epidemiologic research. We need to match the programming to the particular situation in the community.
We need to focus on drug use and not just individual and specific drugs. Sometimes we need to address a specific drug. For example, we are all concerned about the use of methamphetamine beginning to rise. Our Institute is mounting a major methamphetamine initiative. Other parts of the Government also have mounted methamphetamine initiatives to do a preemptive strike on the increases that seem to be occurring in methamphetamine use. But prevention programming in general must deal with drug use and not just individual drugs.
I am a basic scientist by background, and I worked for many years at the laboratory bench and at the National Science Foundation. My wife is the head of child welfare services in Montgomery County, Maryland. One night she told me about case management, and I was really intrigued. Then I thought for a few minutes and said, "What do you mean? How could you not case-manage?" This is sort of a truism. The problem is you have to move from that truism to how do you "do" case management. And it is not just "doing" case management because that does not mean anything. Do you do it assertively or passively? Do you do it with one person or with a team? Do you do it this way, or do you do it that way? That is what science teaches us in detail. The same is true with comprehensive drug abuse prevention strategies.
The obverse of this is true too; simple strategies do not work. You need to have a comprehensive strategy with multiple goals to be accomplished simultaneously. You will hear today about norm-setting, alternative activities, and an entire constellation of activities, and you will have an opportunity to discuss the implications of trying to conduct more comprehensive programs.
Next, we need to have comprehensive approaches that involve the entire community. Families, schools, whole communities, and the media need to work together. I believe that one of the most effective things to happen in this country is the development of local antidrug coalitions, and not just because they are talking together. It is because they are getting their acts together. They all are working in correlated, integrated ways and, we hope, are singing the same song, because another lesson from prevention science is that we need to get our messages straight. We all need to give the same messages, and that is very difficult. Because of different viewpoints about ideologies, common sense, intuition, and a number of issues, this is actually one of the most complex tasks. How do we get people to say the same thing over and over again, and say it in simple, understandable terms? The messages that we convey and the content of the messages are critical. Those messages have to be credible and based on scientific facts.
I offer you the auspices of NIDA to help provide those scientific facts. However, we may not abuse the data because when we do, we lose our credibility. Hyperbole is useless. Children are not stupid, and they understand when you exaggerate. We need to give them realistic, science-based information. "Drugs are not good for you." You do not have to exaggerate.
Long-term prevention programs have a more long-lasting impact on the groups most at risk for drug abuse. That means that longer is better, which seems obvious but it is not. I have been teasing Gil Botvin about the principle "boosters are better," because that is what some people hear when they learn about programs that give booster sessions over time. Let me tell you, it does not just mean the more exposure, the better. It means that one-shot programs and single exposures often do not work. But most people want a one-shot program. They have a sports hero talk to sixth graders and say, "I did drugs. It was bad, and it ruined my life. Do not do it." Then they think they have taken care of drug prevention and want to move on to the next thing. It is not going to work. We need prolonged intervention, and we need to understand that the only way to accomplish this is through message repetition and emphasis, and through booster sessions.
All of this, I hope, tells you that tremendous progress has been made in drug abuse science. We have learned a tremendous amount, but what I have told you is only part of the answers. The truth is that we do not have all the answers, and part of what we need from you today are the questions. We have brought people together not just to hear about drug abuse science but to talk about drug abuse science. We have to find out what people on the front line need to know to improve their programs and to make their efforts more effective. We have the power of science that we can bring to bear on improving prevention programs.
We need ways to move from the generalizations that I have been giving you to specifics. You will all receive a copy of a draft booklet that we are preparing. We hope it will educate you a little, but we want get your reactions to it as well. We are shaping a publication that we hope will reflect the outcomes of drug abuse prevention science and will provide some guiding principles and ways to implement those principles. It is stamped "draft" for a reason. We want you to tell us what in this document works and what does not work for you so that we can fix it*. We have done it before, and we will do it again. We need to move from generalities to specifics. We need to find the best ways to put prevention science to work in our communities.
I agree with General McCaffrey. We can get a handle on this country's drug abuse and addiction problem. I see it as the most complex problem facing our society, and I believe that we need to develop complex strategies that acknowledge these problems. To do so, as General McCaffrey said, science has to replace ideology as the foundation for what we do. We have to acknowledge that the science exists. We have to pay attention to it, and we may have to change the way we do some things because this is an interactive process.
Science learns in many ways, and the informing of science involves a two-way communication process. Scientists learn from people's experiences. We certainly learn the nature of the questions to be answered from people's experiences, and we have to base our research agenda on your experiences.
We challenge you to give us the guidance of your experience, not in generalities but in specifics. Please use some of the time that we have today to work together to help us set our research agenda.
To get a handle on this problem, we are going to have to work together: the scientific community, prevention community, public community, and society at large. All of us in American society have to have a common commitment to preventing drug abuse, and we have to do it in systematic rather than ideological ways. I hope that this conference provides the kind of forum where that can be accomplished. If it does not, you need to tell us that it does not. We have brought together a very diverse group of scientists, practitioners, and the lay community, and I hope that this conference becomes, in fact, a forum for communication.
*The draft booklet has since been modified, published, and disseminated as Preventing Drug Use Among Children and Adolescents: A Research-Based Guide, NIH Publication No. 97-4212, March 1997.
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