 Throughout recorded history, people have used substances to relieve suffering and change their moods. And every society has struggled with substance abuse and addiction. Because of their power, drugs were entrusted to priests or doctors or controlled by law. In the last 20 years, there's been a rapid increase in the amount of drug use and in the variety of drugs available. Today, every part of society is touched, rich and poor, young and old, in families, in schools and at work. Drug abuse is a public health issue which we can't ignore. The National Institute on Drug Abuse is part of the Alcohol, Drug Abuse and Mental Health Administration. It is the lead United States Agency for Drug Abuse Research. We have been asked to bring the best tools of scientific investigation to address critical questions about drug abuse and addiction. We need to know what causes drug abuse, how do we treat it, and most important, how do we prevent it. We need cooperation from scientists around the world to attack the problems associated with drug abuse. We need common research tools and definitions that will enable us to work together on this worldwide problem. The first step for all of us is to acknowledge that we have a problem. They start drinking and that puts you in a different crowd of people than if you weren't drinking, and then you start maybe smoking and then that puts you in an even more secluded crowd and then you maybe try marijuana at a party and that puts you even in another crowd and it's like a cycle, a vicious cycle and you get sucked into it. To break this cycle of drug abuse takes an effort that touches many areas. The first task is to gather accurate data. When the National Institute on Drug Abuse was formed in 1974, there was little information on the extent of the drug problem in the United States. Since then, we have applied the latest epidemiologic techniques to develop an accurate base of information and common language about drug use in our society. Developing a database takes time and patience, but once in place we have an ongoing source of accurate information about the health of our citizens. The foundation of our program is built on three large data collection efforts. The National Household Survey on Drug Abuse, the DAWN Network, and Monitoring the Future, the High School Senior Survey. The National Household Survey is our principal source of information about drug use in the general population. It is a survey of over 8,000 individuals administered every two or three years. The second data source is DAWN, the Drug Abuse Warning Network. It is a systematic survey of hospital emergency rooms and medical examiners to determine the frequency of drug-related emergencies and deaths. The third source of data provides information on a very important segment of our population, high school seniors. We call it Monitoring the Future. It is directed by Dr. Lloyd Johnston. Well, beginning in 1975, we started interviewing high school students around the country each year. We go into about 135 high schools a year. We survey students in classrooms much like this one. They fill out questionnaires on their own, and then we collect them. There are about 17,000 respondents each year. This is the age group in this society and in most societies, which is most at risk for involvement with illicit drugs. So we're looking right where the problem tends to lie. The friends that you hang around with are very, I mean, peer pressure is great here. It comes down to human curiosity, you know, and what your friends are doing and what's popular. You know, like, you might feel like you don't fit in if you're not doing drugs or something. Drug use is a phenomenon which is very hard to study because it's illicit and illegal in most countries. And surveys are one of the most effective means of gathering data on this kind of behavior. And generally, our indications are that the data is quite valid. It tells us something about the size of the problem, the types of people who are involved and with what drugs. And over time, it tells us something about how that's changing, what new problems are emerging, what progress are we making on old problems. The trends in the United States have been very interesting. Up through about 1980, we saw a continuous increase in most forms of illicit drug use among our young people. Since 1980, we've seen a gradual decline in illicit drug use among young people. The major exception, however, has occurred with cocaine. We find that although there has not been an increase in the number of people using, those that do use are using in more dangerous forms. They're smoking the drug more often, using crack in particular. We've seen a doubling in the number of young people who are using every day. And we've seen a doubling in the number of young people who say they've tried to quit and they've been unable. It's like the good can't make the, you know, the bad get better. The bad always seems to drag down the good. I don't want to have to look back 30 years from now and say, God, I wish I hadn't done that. Look what it's done to me, you know. Along with this broad social perspective, scientists are looking at the microscopic mechanisms of how the brain is affected by drugs. At NIDA, we initiate and support research on the cutting edge of what has to be one of the most thrilling scientific journeys of our time, the discovery of the actual workings of the brain. In fact, the initial investigation into the mechanisms of heroin addiction led to the discovery of opiate receptors and endogenous ligands. This opened up a whole new class of neurotransmitters for study and led to new ways of thinking about the brain. Now, we are in the midst of a worldwide revolution in neuroscience. At NIDA, we are pursuing molecular, cellular, and organ-level central nervous system research to determine the exact mechanisms through which drugs act, the changes they produce, and how to block these changes. We are looking at areas as various genetic regulation under our transmitters, the development of new treatment drugs, and the mechanisms of reward pathways in the brain. Other promising directions include the application of new technologies such as the PET scan. Dr. Edith London and Baltimore is investigating the value of this technique for studies into the localization of cocaine in the human brain. We're essentially studying the neuroanatomy of substance abuse. We're trying very hard to delineate those areas of the brain that are either turned on or turned off when a person has his mood altered in response to a drug that he self-administers. This is a very exciting time to be someone looking at brain chemistry. We have tools at our disposal that we never had before. Human studies can now be performed such that we can, at the same time, ask our research subject what the effect of the drug is on his mood, how the drug is making him feel at every moment, and simultaneously we can do metabolic mapping studies in his brain. PET scans that we obtained give us pictures of slices of brain activity so that we can look at how the radio tracer is incorporated into different parts of the brain at the same time that the subject is feeling high. We have a major interest in how cocaine influences brain activity, and we're also quite interested in the effects of opioids. We're just beginning our studies with cocaine. In fact, today will be the day that we begin our second metabolic mapping study of cocaine's effects associated with cocaine euphoria. We have no idea what we'll find. We need to find out all we can about the biochemistry of drugs, but equally important, we need to know who is vulnerable. Long-term prevention requires that we look at the causes and conditions of substance abuse in the life of an individual. Can we predict who will be at risk for drug abuse? And if we can, how do we intervene to prevent it? For over 20 years, Dr. Shep Callum has been looking at early predictors of later substance abuse. We were able to determine several developmental paths, one of particular interests, namely the early aggressive behavior and the shy and aggressive behavior of children, which we found to be strongly predictive of heavy substance use by age 16 or 17. If you take marijuana use, for example, 45% of the shy, aggressive first graders were heavy users by our definition at age 16 or 17. Maybe 30% of the shy children alone were as low as 10%. Now, those children who were neither shy and aggressive were somewhere between 15 and 20%. One intervention is directed at the risk behaviors that we think are very strongly predictive of drugs later. That intervention is the good behavior game, and it consists of assigning children to teams, three teams per first and second grade classroom, and these teams get points for good behavior, points taken away for bad behavior. These two teams did very well. Only had to talk to those two teams only once, and that's the red birds and the yellow birds. That's good. So this is my very good teams. Okay, teams. The first intervention makes use, then, of positive peer pressure, that is, the teams of children get interested in each other and in their behavior, and they're rewarded together as a group. The other intervention is directed at reading itself, mastery of reading and other subject matter, but primarily reading. Read the sentence, please. Good. Now, how can we say the sentence in a different way, Craig? Good. The important thing to understand about prevention research on drugs is that the developmental paths are vital to map out. If you change the earlier course of a developmental path, generally speaking, you have a marked increase in the impact of that early change later on. If you teach a child reading, for example, the first 30 words are vitally important to the next thousands of words, so that a little bit of change early gets you, at least, hypothetically, a big impact later on. If you wait until later on, then you've got a major change to do in both the behavior leading to the drug taking and the drug taking behavior itself. The long-range research of Dr. Kellerman's colleagues will continue to yield results for years, but people need to know about prevention now. To reach the public in today's world, television is essential. What? You want some weafer? Upstounds? Anything. Yo! Man, just say no. No, man. Why don't you get out of here, man? I'm going late. Oh, you got to do it yourself. You got air. Anyone that says cocaine's not addictive, they lie. When you do cocaine, you lie to yourself about being in control. Cocaine's not hip. It's hype. Anyone who tells you it's okay is a liar. Cocaine, the big lie. These prevention efforts must reach all parts of society. The Household Survey shows that among 18 to 25-year-olds, the generation entering the workplace, 66% have used illicit drugs, 44% in the last year. The cost of drug abuse to all of us multiply when drugs enter the workplace. In some occupations, the results can be disastrous. Drug-impaired judgment by an air traffic controller or a missile control officer or a city bus driver can cause significant risks to public safety. But there are other long-term effects that are equally serious. Absenteeism, criminal behavior, and the loss of productivity affect both the individual employer and a nation's overall economic health. At the National Institute on Drug Abuse, we are working to establish a national policy concerning drugs in the workplace in order to help employers deal with this destructive health problem. One of the most basic issues is how various drugs and their after-effects change job performance. Dr. Ron Hearning is developing data on the effects of cocaine on performance at our Addiction Research Center. We're going to take this gentleman who is essentially a non-drug user and have him do some tasks as sort of a control for people we're going to bring in who will be coming off of cocaine and we're going to look at what we think are some performance deficits when people crash. We're also interested, of course, in the effects of cocaine itself on the task. This aspect has fascinated me to see people in withdrawal from a drug and just do more poorly on a number of cognitive measures. Since the people coming in will be totally withdrawing from cocaine as a part of this study, we need some controlled data with non-cocaine users, non-drug users to see how a normal person would respond. The non-drug user would respond. Can I do the air traffic controller task and just push the button when any square changes direction? But just identifying the problem is not enough. Our philosophy is to get the substance abusing employee into treatment, provide them with the help that they need and get them back on the job. To encourage this approach, we provide technical assistance to develop employee assistance programs. Treatment of the individual who has a drug problem is a difficult but essential part of our attack on drug abuse. From a treatment perspective, treatment is a chronic relapsing disease, often complicated by psychological problems and negative environmental conditions. We can't look to a vaccine to provide a cure. A drug-dependent individual needs a continuum of services. Treatments in use such as methadone maintenance, drug-free outpatient clinics, and therapeutic communities achieve significant and lasting results for many patients. In terms of drug abuse and a wider spectrum of the population involved, research into new treatments and new treatment combinations is a high priority. At Yale University, Dr. Herb Kleber is working on a wide range of treatment possibilities. We have a variety of treatment approaches that we use in treating the cocaine abuser, the heroin addict, the poly-drug user, and our first premise is that we don't have the answer. We need to keep coming up with new techniques and to evaluate the existing approaches that we use. Part of evaluation is not just seeing what treatment works, but what treatment works for what patient. Patient treatment matching is one of the most important and exciting parts of doing treatment evaluation. When I see an addict, I try and keep in mind that there are problems in the whole biopsychosocial sphere and an adequate treatment program may need to plan on appropriate interventions in all of those three spheres. The biologic, the psychologic, and the social. This is a complex disease and so it is not likely that any one discipline is going to be able to come up with all the answers. I'm not depressed anymore. I just feel really anxious, like irritated. I'm getting to a point now where I just seem to, I just can't stop taking cocaine. In the 1970s, cocaine was primarily believed to be a psychological problem. There was relatively little research into the physiologic aspects of the cocaine addiction. We have a project, we call the Cocaine Challenge project, in which we're looking at the interaction of cocaine with both drugs that may be used to treat cocaine and with drugs that people who use cocaine may take that may cause them even more trouble if they take the two in combination. The treatment paradigms we've been able to set up here enable us to quickly move to test new drugs so that if we have some bright ideas about a new agent that may be helpful, we can both test it with patients and test it in a challenge laboratory. Likewise, if someone else comes up with what sounds like an exciting idea, we can test that. Our surveys and our experience show that drug abuse is constantly changing. We face the new challenge of different kinds of drugs, new patterns of use, and new problems associated with drug use. Most recently, the tragic onset of the AIDS virus as a grave international health problem is testing our ability to respond to this challenge. The emergence of intravenous drug use as a major risk factor in AIDS infection and transmission has placed NIDA in a unique position to attack the spread of this perplexing and deadly killer. Dr. Benny Prem is a leader in this effort. We have around 2030 people in treatment for intravenous drug use and just through treatment alone we are stopping them from using the needle which is a vector for the transmission of the virus. Furthermore, we're doing AIDS education programs. I want you to understand the intricacies of it. Now maybe you just want to know, well, what happens? I mean, a lot of people don't want to go through this. There's a bunch of bullshit that that doctor's running. I don't understand it anyway. What I want to know is, look, do you take this test and it come back positive and do I have AIDS? You may or may not have AIDS but most likely you don't. But what the test means is that you have been infected and that you can infect somebody else. So that's why we got to change our whole behavior. We can't share needles. When people are educated about this virus and the effects of this virus transmitted, they seem to change their behavior. And it is that goal that we are trying to reach. And we have found that 64% of our patient population is positive for the antibody to the HIV virus or whopping 64%. And that is an incredible figure. Street information is very slim. It's not too much street talk out there. They really don't even discuss it or try to really get into it. You know, it's just like everybody's still shooting up. They're not cleaning their words. I've been to galleries recently. They're still the same. It's no change. They just don't know what they're doing and I think if more people get out there and make them realize this is going to kill us, it'll be much better. What's the system taking the test for? They ain't got no cure for it. I don't even want to know that I got it. I'm not just dying like I am. I'm going to be bothered being hooked up, found positive. Now you got this variation on your mind and you're walking around and you know you're going to die and there's no hope for you. Why be fatalistic? Why be fatalistic to the point you say, well, I'm positive for this virus and I'm going to die anyway so I don't need to know. Let me tell you why else you need to know. You need to know so you don't give it to your woman. Right? Or vice versa. So your argument is out the window if you care about life. We know what life is. But nobody ever came back and told me what death was. I've seen a lot of people die but nobody ever came back and say it's good. I really didn't take time to know about it because to me it wasn't important until my brother died from it. That's when I really realized it shouldn't have to take for you to have death close to you to want to know about something The National Institute of Drug Abuse is uniquely positioned to handle the problem of AIDS because they have always had both bench scientists and clinical scientists that is people who are aware of what is going on on a day-to-day basis out there in the street and they have combined both basic science research and clinical research to the point where they were very much aware that this problem could be transmitted through the use of needles and certainly among intravenous drug users. So in that instance certainly we are using research methods to see whether the teaching has resulted in a lesser transmission of the virus to other individuals. And it's really frightening. I really just shook it off as something like but this is very serious. Drug abuse is not going to go away easily much more needs to be known about its cause treatment and prevention. Our understanding however is growing through basic science and clinical research our continued search for knowledge is essential for the effective control of this worldwide public health problem.