Q&A: The Role of Research in Fighting Addiction
In a Q&A with Research!America, Kathleen Brady, M.D., Ph.D., Distinguished University Professor, Vice President for Research, and Director of South Carolina Clinical and Translational Research Institute, discusses the relationship between stress and addiction, the rise in opioid abuse, and the role research must play in addressing chronic pain and substance use disorders.
What is the focus of your current research?
My particular group is very interested in the connection between stress-- stressful life events, early life stressors, and then immediate day-to-day stress—and drug abuse. We are discovering some very interesting things, such as the fact that early life trauma can actually change people’s brains, their neurobiology, such that drug abuse is even more reinforced than in people who don’t have early life trauma. We are looking at ways to potentially reverse that and looking at medications and other interventions that act specifically on stress-responsive systems to see if we can help treat addiction.
What is your perspective on the recent rise in opioid abuse and misuse?
It appears that opioids are over-utilized in the treatment of pain, especially in chronic pain. Let me just qualify that by saying opioids are extremely valuable and useful drugs, particularly in the treatment of acute pain. The last thing we want to do is prevent or interfere with people who have legitimate pain conditions that can be treated by opioids.
Opioids are extremely valuable drugs, but the downside is that with chronic use, a couple of things can happen: (1) people build tolerance to the effects of the opioid, so it takes more of the drugs to get relief, and then (2) people can get physically dependent, which means when you stop the medication abruptly you go through a set of withdrawal symptoms. Now physical dependence is not necessarily a bad thing. Some people are physically dependent on blood pressure medication, and if they stop them abruptly, their blood pressure will go out of control. You can be physically dependent on a drug but still be taking it exactly how it was prescribed and not abusing it. People who take opioids for a long time are going to be physically dependent, but this does not mean necessarily that they are abusing or misusing the drug in any way; they may legitimately be using it to control pain.
Addiction is different than physical dependence. Some people who are addicted to something are physically dependent; they are not mutually exclusive. But addiction means you are using it in ways for which it is not prescribed, getting your supplies outside of the normal means, taking more than what is prescribed by your doctor, and not taking it for the reasons that led your doctor to prescribe it for you. Addiction is a compulsive use of a drug in a non-medical fashion.
Do you believe that increased understanding of the brain, through endeavors like the BRAIN Initiative, will provide us with the information we need to adequately address addiction?
I think we all know that addictions are a complex, bio-psychosocial disorder. Knowing about the brain and the brain’s mechanisms can certainly help you in the biological part of that, but we also need to be addressing some of the risk factors that occur in individuals, such as people who have depression or early life trauma, that make people vulnerable to the development of addiction. I think we would be remiss in thinking that we are going to find a magic bullet, and that all we need to do is find the right brain circuitry and address that. I think the problem is more complicated than that. Not to say that we don’t want to find the right circuitry and develop the right medications that can be very specific, but I think that that is not the only thing that we are going to need to address to get addiction under better control in this country.
In what ways can research aid in addressing opioid abuse, and substance use disorder in general?
I think we need to invest in research for better treatments of pain and for better treatments of substance use disorders, and then I think we need to invest in making sure the treatments we do have are made available to those who need them.
We really need to be looking harder and investing more in investigating alternative methods to control pain. Right now, other than opioids, there are some other medications, but they are either for mild pain and/or they are not as potent as the opioids. Looking at alternative methods for treating pain, in particular chronic pain, is an important role for research right now. Pain is an inevitable part of human existence, people are always going to want to relieve that pain, and it is always going to be part of the doctors’ role to help people relieve pain. Right now we have very few tools in our toolbox to help us with that. Opioids are one of the most powerful ones, and I think part of the reason they are now over-prescribed is that we have few alternatives.
For other substance use disorders, we need to be investing in research to help us find treatments. We do have some effective treatments for substance use disorder, we could always use more, and we can always use improvements on what we’ve got- and that is what research can help us with.
The other problem is that the effective treatments we know of are not accessible to many people. A lot of insurance companies do not provide coverage for them and the public health system for treating substance use disorders is inadequately funded.
Opioid crisis funding was passed in Congress as part of the 21st Century Cures package at the end of the 114thCongress. It sought to address some aspects of that gap in access to care. Do you have any insight about its impact so far?
Yes, the money that was sent to the states was spent on some very valuable things, like prescription drug monitoring programs that actually assess in real time how many opioid prescriptions are being written. Some of that money was used to distribute Naloxone, which is a drug that can reverse opioid overdose, to emergency providers. Some of the money, but probably not enough, went toward treatment of substance use disorders, particularly opioid use disorders. We could use more money in that direction and then more funds just focused on really discovering what the best treatments are, and how you deliver those treatments in rural settings. There are a lot of questions about treatment, treatment delivery and making treatment accessible that still need to be addressed.
Understanding the complex relationship between pain and substance use disorder is important as our nation seeks to address both of these pervasive health issues. To learn more about substance use disorder and the ways research is addressing the public health crisis, see our new Substance Use Disorder fact sheet. To learn more about pain how research has improved the lives of patients while reducing costs, see our new Pain factsheet.