The Opioid Crisis Hasn’t Gone Away: NIDA Director Dr. Nora Volkow on Addiction Epidemic Amid COVID-19

Dr. Nora Volkov

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Female : Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter, a show where we speak to the top thought leaders
in health innovation, health policy, care delivery, and the great minds
who are shaping the hea lth care of the future.

This week Mark and Margaret speak with Dr. Nora Volkow, Director of
the National Institute on Drug Addiction at the National Institutes of
Health, which just observed National Addiction Recovery Month. Dr.
Volko w is one of the early brain imaging pioneers whose work has
shown that addiction is a disorder of the brain . T heir recent research
has shown that those suffering from substance use disorder are more
likely to become infected with COVID - 19 and to have worse
outcomes.

Lori Robertson also check s in, the Managing Editor of F act Check.org,
and looks at misstatements spoken about health policy in the public
domain, separating the fake from the facts . We end with a bright idea
that's improving health and well being in everyday lives. If you have
comm ents, please email us at [email protected] or find us on
Facebook, Twitter, or wherever you listen to podcast. You can also
hear us by asking Alexa to play the program Conversations on Health
Care . Now stay tuned f or our interview with Dr. Nora Volkow here on
Conversations on Health Care.

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Mark Masselli: We're speaking today with Dr. Nora Volko w , Director of the N ational
Institute of Drug Abuse, NIDA, at the National Institute of Health,
which supports most o f the world's research on drug addiction. She
has pioneered the use of brain imaging technology to gain greater
insight into how addiction functions is a d isorder of the brain.

Margaret Flinter: Dr. Volkow was Director of Nuclear Medicine and Medical
Depar tment Chair at the Department of Energy ’ s Brookhaven Nuclear
Laboratory . She has published ne arly 800 peer reviewed articles,
earned numerous awards and distinctions including Time Magazine's
top 100 people who shape our world and Innovator of the Year by
U.S. News & World Report. Dr. Volkow , welcome to Conversations on
Health Care.

Dr. Nora Volkow: Thanks for having me.

Mark Masselli: Yeah, Dr. Volkow, we're in the midst of this pandemic. But it's also
overshadowed another deadly epidemic America has been grappling
with in substance use disorder and addiction . A n overdoses mostly
from opioids led to some 70,000 deaths last year in the US and at
NIDA, you recently conducted research on the connection between
those with substance abuse disorder and the suscep tibility to COVID -

Dr. Nora Volkov

19. Y ou found a distinct correlation and worse outcomes , and I'm
wondering if you could share with our audience and maybe put this in
some perspective, how the addiction crisis is dealing with the
backdrop of the pandemic, and what impact you were seeing .

Dr. Nora Volkow: Yeah, the origin for the story came about because of the concern that
people that were taking drugs and certainly in the case of opioid use
disorder, they will have many of the physiological abnormalities that
have been r ecognized to increase the risk for adverse outcomes of
COVID , such as pulmonary pathology, cardiovascular disease,
metabolic syndrome. But the other one, being the structural aspects
that relate to substance use disorder would make the persons much
more li kely to end up homeless , to end up in shelters , to end up in jail
or prison or places where infection disseminates very, very rapidly.
W e wanted to see based on electronic health records, whether there
was any day that would help us illuminate this. W hat t he analysis
showed was, indeed, individuals with substance use disorder have
high risk of becoming infected with COVID, and if they got infected
with COVID , they were much more likely to be hospitalized and to die.

Margaret Flinter: Well, Dr. Volkow , we've just marked National Recovery Month,
September, and this is a very good time to stop and talk about this
issue, because in addition to how addiction affects people being
infected with COVID, I think we've also seen with this complete kind
of up roar as you indicated in our social systems for isolation, the loss
of social network has really lead to , I would think, a higher rate of
relapse and perhaps even new onset addiction. Can you talk about
that this collision of a pandemic and the already existing epide mic of
drug abuse, how just the rates of addiction and substance use
disorder are changing during this period?

Dr. Nora Volkow: Yeah, and it is a very worrisome situation because there are two
elements that make these combination of the COVID pandemic and
the opioid crisis so malignant . We recognize that one of the most
powerful tools that we have to help people overcome the urges to
take drugs and to cheap recovery is meaningful social interactions ,
and with a social distancing, that has become much harder to do.
Also , many of the treatment programs that existed or community
services that provide that social opportunity to be with others , to be
actually feel that you have value of some level has been eroded.
That' s one element.

The other element that also m akes it so dangerous is that one of the
other factors that leads to drug taking is stress , and that is one of the
main causes of relapse. Here we are, I mean, it's COVID with a lot of
uncertainties with the loss of jobs , with the loss of loved ones, with
o ur lifestyle completely changed and not knowing when it's going to
come back . T hat level of uncertainty is making everyone anxious. I

Dr. Nora Volkov

mean, to a greater or lesser extent, but one of the way that people
cope is by taking more drugs, whether it's alcohol, wh ether it's
smoking marijuana, whether it's vaping nicotine or by overeating. I
mean, if you have a problem with a substance use disorder, that
reaching out to take drugs can have very dire consequences.

Mark Masselli: Dr. Volkow, it has long been believed that addiction is the result of
moral failings. But it was your pioneering work in brain imaging of
people under the influence of many drugs dramatically flipped t hat
notion . Y our early experiments and neuroimaging opened our eyes to
the biochemical respon se at play. It's been first real window into the
altered brain process at play . I wonder if you could help us
understand what kind of breakthrough this has been for addiction
science, leading to really huge leaps in understanding how the se
syndromes work i n the brain .

Dr. Nora Volkow: It was very useful to have information that related to , first of all , clear
objective documentation that the brain of people that were addicted,
differ in very specific ways from that of individuals that were not
addicted. The y delineated through imaging the biochemical
abnormalities that happens in people that are addicted. It gave us
insight about why is it that people that are addicted to dr ug make
such poor choices, and why despite the catastrophic consequences
that come fr om taking these drugs, are unable to inhibit their strong
urges to take the drugs. Out of that research, it become clear that one
of the systems in the brain that is most profoundly affected is the
prefrontal cortical areas of the brain that are necessary for us not just
to make a decision on what our actions are going to be, but very
importantly, to carry them through. I t's not enough to say for me, no
I'm not going to do that. It is the subsequent step is my capacity to
stay on in the goal that I'm trying to achieve . T hose processes
require d a proper function of the prefrontal cortex and drugs erode
them. This provided an insight , not just that addiction is a disorder of
the brain , but also why is the presentation , the behavior al
presentation of addiction.

Dr. Margaret Flinter: I 'd like to add if we could to our conversation about opioids and
alcohol and nicotine, and that's food and food addiction, also a huge
problem in this country , and a particular risk factor for consequences
of COVID. We've certainly seen with obesity being implicated in that .
Y our brain imaging work has also helped us learn more about how the
brain drives our response to food . I wonder if you could talk a little bit
about the connection between brain activity or brain pathology and
fo od addiction, which takes such a heavy toll in people across
America. It's just shocking , the percent of the adult population that's
now obese in states across the country . What's the relation there
between brain addiction and a food addiction?

Dr. Nora Volkov

Dr. Nora Vo lkow: T he question that grows in my brain when we're doing all of these
studies in addiction, and we were delineating common areas that
were disrupted, regardless of whether it was alcohol or heroin or
cocaine or methamphetamine. What it seem to indicate w as that the
disruption of those regions of the brain was associated with inability
to exert self - regulation to inhibit its prepotent response to things that
we desire . I was curious to know whether this was just a function of
that chemical pharmacological effects of the drugs or whether other
conditions had similar type of disruption . That 's why we started to
st udy whether in people that were morbidly obese, which could
delineate their similar pathology . Definitively they are very significant
overlap betwee n the loss of control in someone that cannot stop
eating and that in addiction . But overall, it does identify that the brain
responds to very po werful reward in the same way.

Number one, it's the aspect about it being a powerful reward and
drugs are very p owerful reward [inaudible 00:10:24] food can be very
powerful in the context of what other alternatives you have. I f you
don't have alternatives, that brain doesn't have much of a chance.
Y ou are much more likely to fall into a compulsive pattern that favo rs
that behavior , and that in turn triggers the neuro adaptations that
strengthen the links between what is salient and your actions, and it
can become almost an automatic behavior. That is what that studies
with in obesity revealed to us that were common with a process of
addiction . Not everybody has choices and the level of stress varies for
many of us. It's important to convey th is to people that one of the
ways that one may aim to escape to how to mitigate the state of
anxiety , may be overeating, o r o ve r drinking alcohol, or as I
mentioned, smoking marijuana. These are ways that we cope , that
could be ver y harmful to your health.

Mark Masselli: That's a great observation. We're speaking today with Dr. Nora
Volko w , Director of the National Institute on Dr ug Abuse or NIDA at
the National Institute of Health . She's pioneered the use of brain
imaging technology to gain insights into addiction as a disorder of the
brain. Margaret, w as just talking about the many addictions and
obviously food, but also nicotine addiction has been looming large
over many decades. But we've seen this dramatic drop in smoking in
this country , and yet 15% of the population still smokes leading to
nearly half a million preventable deaths each year.

We saw a great reduction in smoking for the youngest demographics
until vaping products hit the market, really leading to this really
dramatic rise in nicotine use in an addiction. The tobacco industry
understands all too well how nicotine works on the brain. I'm
wondering if you could talk about the work you're doing at NIDA to
assess the impact of this unfortunate uptick in nicotine addiction due
largely to vaping.

Dr. Nora Volkov

Dr. Nora Volkow: Yeah, and I mean, I'm glad you're bringing it up, because it's again an
example about how something that in p rinciple appear to be so
benign . L ike I mean, vaping nicotine, in principle had advantages over
using combustible tobacco because you were not burning tobacco,
which has many of the chemicals responsible for its carcinogenesis.
T hen we have come to realize , first of all, is not so safe in terms of
affecting negatively pulmonary function. But importantly, it's a
fantastic delivery system for nicotine, or for cannabis, or for any drug
that you can actually vaporize .

I mean, in terms of marketing the ability t o put a nicotine mix with
extraordinary diverse and appealing set of flavors in very slick devices,
like the jewel , make it extraordinary appealing for adolescents and
young people . W e've seen an embracing of that technology like we
have never seen increas es in drug use from almost nothing into one
out of four 12 graders having vape nicotine in the past month. Now
many , almost half of all teenagers having been exposed to it. T he
concern also is that when you vape, you can concentrate the fluid that
-- if y ou're vaping, nicotine has very, very high content. You can
actually go from never having taking nicotine whatsoever into very
high doses very rapidly, which is not what happens when you're
smoking tobacco because the harshness of that tobacco can be very
aversive. I t takes several months to get that higher levels , and that's
not what we're seeing with nicotine vaping . W e're seeing people
getting exposed to very, very high levels of nicotine very rapidly,
which makes it even so much more addictive.

Also tox ic , nicotine at high doses can be very toxic. W e are very
concerned that indeed, the uptick of nicotine vaping by teenagers and
young people will increase , again , the vulnerability that they turn into
combustible tobacco . I ndeed there's data from prospecti ve studies
that have shown that , that if you are vaping nicotine and they follow
you through, you're much more likely to then be as smoker of regular
tobacco that if you have never initiated with nicotine vaping.

Among young people, there's another issue o f concern and which is
nicotine is in that respect, it's a scary drug because what it does is
when you have nicotine on board, which by the way has a very short
half life, it makes anything you're doing so much more salient. If you
are working on a paper a nd you’re vaping, it will be able to drive your
interest so much more. If you have nicotine on board and you take
another drug , it will make that drug so much more exciting. I n that
way, i t’ s a substance that can enhance the re inforcing value of other
drug s.

Mark Masselli: It's a force multiplier.

Dr. Nora Volkow: It's a force multiplier, that's a very good way of describing it . T hen our
greatest concern always goes with young people because their brain

Dr. Nora Volkov

is so much more neuroplastic and changes much more rap idly. T he
transition from initiation of drug taking into loss of contro l and
addiction is much faster.

Margaret Flinter: I wonder if we c ould expand on that to some of your work looking at
the links between substance use disorder and other mental and
behav ioral health issues. Your research has been quite expansive, and
you've looked at conditions such as schizophrenia, to ADHD, complex
conditions that can be difficult sometimes to properly diagnose and to
manage. What are we learning from your research in t hese other
brain disorders, and hopefully finding better ways to treat them?
Certainly, there's been lots of advances, what are we learning now ?
What's the most current?

Dr. Nora Volkow : We 're expanding our knowledge very, very rapidly a s we’re actually
ge nerating these large databases of these disorders. One of the
reasons why I basically not just limited the work on research in terms
of addiction and obesity, is that since a lot of the work that I've done
is focused very much on the brain dopaminergic sys tem. The brain
dopaminergic system is just brilliant . I t actually is a solution by nature
to actually motivate our actions, to do things that will keep us alive,
but to prevent us from those things that would hurt us. B y that very
simple way of making some thing positively reinforcing and making it
negatively reinforcing the things that are bad , n ature can
accommodate a widespread set of behaviors.

D efinit ively i n terms of food re quiring it tastes good, it feels good
[inaudible 00:17:43] pain, you basically avoid it. And so that has
worked. I t also exten t in our social interactions and our ability also to
learn things. Learning is very reinforcing, understanding something is
extraordinary pleasurable. T hat's why we have games and -- but there
-- and that's wh ere, for example, the question as it relates to ADHD . I
mean kids or adults that have ADHD cannot sustain attention . It
doesn't grab them unless what they are doing is very appealing to
them. The issue being that to what exten t the problem in their
attenti on is in fact driven by a motivation deficit , s o that you need to
energize whatever action that that person has to do with ADHD in
order to sustain the effort. T hat's what stimulant medications do .
They enhance dopamine , but also it opens up the door on sa ying if a
kid with severe ADHD can spend hours video gaming, why is it that we
don't learn what video gaming is doing in order to apply to
educational material, so it becomes more salient.

T he dopaminergic system which is at the essence that creates habits
with addiction is fundamental for our activities as humans, for many,
many organisms , b ut for us it is crucial . D isruption of those system
can set the balance in ways that can be very negative. F or example,
working with schizophrenias , what they have show n is that the

Dr. Nora Volkov

saliency of the dopaminergic system is ascribe to delusional thinking ,
to hallucinations, and so that has a higher weight in your brain . T he
moment that you imprint a dopamine signal at the same time that
you're exposed to something else that becomes salient. T hat's where
th e thinking has been going on. As we know very clearly the main type
of medications that we use to treat psychosis of schizophrenia are
drugs that interfere with dopaminergic signaling to the dopamine D 2
receptor. T his is ho w crucial the system is for our well - being and our
survival and how important it is for mental illnesses and for
neurological disorders.

Mark Masselli: Well, Dr. Volkow that was a wonderful illumination of so many things ,
a nd thank you so much. Y ou've said this so well, and you did in your
well received TED Talk. Y our testimony to Congress in regards to
addiction is we know what to do, we're just not doing it. P olicy play
such an important role in driving necessary public health
interventions that will bett er treat addiction and hopefully prevent it ,
r ight ? I ’m wonder ing if you could talk about what you know works,
and where you'd like to see policymakers, payers and health care
institutions really focus their resources, and where is the greatest
need, but a lso the greatest opportunity to make a meaningful impact
on addiction?

Dr. Nora Volkow : Well, we know many evidence based interventions that work for
prevention, but in general terms I would say, again, that children and
adolescents are at it’s more plasti c, a nd those -- it's not surprising that
adverse events, whether it is stress, neglect, drug exposures,
improper nutrition, have much worse consequences when they
happen during childhood and on adolescence. T hose doing
interventions that can protect and bu ffer the situation, the
environmental situations that put these children at greater risk is
fundamental. T here is , to me, and as you think about it, and says,
w ell, how do you bring forward prevention that's going to be
effective ? W hat would be some of the elements that you want to be
certain that you're working with ?

O ne of them that is crucial is providing alternative for children to
develop, providing alternative for children to educate, and providing
alternative to children and , of course, young people to have
meaningful social relationships . T he moment that you curtail the
opportunity to support a person, where that individuals feel that they
don't have any mission that they are not appreciated, that is opening
up the door for a much greater vulnerabili ty for substance use
disorders, mental disorders, and other behavioral conditions. A s I see
i t one of the key components is education , providing quality
education to every single child, a young person is one of the most
effective prevention interventions t hat we can do while ensuring
family support to those subpopulations that are very disenfranchised,

Dr. Nora Volkov

that don't have the resources to pay attention to the children , t o give
them that incentives and the belief that they actually are unique and
create th at sel f - confidence. Supporting families in order to be able for
someone to take care of the child and not having to work two or three
shifts every single day, so that the children are n’t neglected.

One of the most adverse things that you can do to th e human brai n,
on a child , is neglected . T he brain is extraordinary complex, and it's
building itself. I f you do not provide with the challenges, guess what ?
It doesn't develop, and that puts that child a t a terrible disadvantage.
C reating a system that will buffer in dividuals that come from systems
that are socioeconomically very stressed, that don't provide
opportunities is probably one of the most important things that we
can do for the next generation. W hen we do it for th at next
generation, guess what ? That next g eneration, their children won't
have to grapple with these problems. I t's an investment that they see
into the future. T hat's why sometimes it's so frustrating , I say we do
know that it works a nd it has an enormous impact , b ut it's not
immediate. T hat's I think, part of the problem, the challenges .

Our brain favors things that gives you an immediate gratification,
whether it's individual or as a population. T hose policies that can
show a huge return into the future are dismissed on the basis of
policies tha t can give you an immediate sort of result right away even
though that effect will be very, very limited. I think that as a society
we need to grapple that we have to change our priorities and
recognize the need to invest into goals that are into the futur e, but
with much greater payoffs, such as prevention for substance use
disorders.

Margaret Flinter: Well, that is a great note to end on. We've been speaking today with
Dr. Nora Volkow , Director of the National Institute on Drug Abuse at
the National Insti tutes of Health. You can learn more about her vitally
important work by going to drugabuse.gov or follow her and her
colleagues on twitter @NIDAnews or Facebook @ NI DA NIH. Dr.
Volkow , we want to thank you for your incredible contributions to the
field of ne uroscience leading to a greater understanding of the
complexities of addiction and other disorders of the brain and for
your forward focus on making things better for the next generation.
Thank you for joining us on Conversations on Health Care today.

Dr. Nora Volkow : Well, thanks very much for having me.

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Mark Masselli: At Conversations on Health Care, we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy. Lori Robertson is an award winning journ alist and Managing
Editor of FactCheck.org, a nonpartisan, nonprofit consumer advocate

Dr. Nora Volkov

for voters that aim to reduce the level of deception in US politics. Lori,
what have you got for us this week?

Lori Robertson : At a CNN Town Hall in September, Democrati c presidential nominee
Joe Biden misleadingly claimed “ The President of the United States
said that no longer would we in fact provide masks for schools . P ay
them to have the masks in school because it was not a national
emergency. ” One federal program to pay for masks ended but
another aims to distribute up to 125 million masks for schools. NPR
st
reported on September 1 , that the Federal Emergency Management
Agenc y’s Assistant Administrator for R ecovery told state and tribal
th
emergency managers that FEMA wo uld stop on September 15 ,
reimbursing states for cloth masks and other personal protective
equipment for places that are deemed non - emergency locations,
including schools. But that doesn't mean the federal government isn't
providing any masks to schools.

The same NPR story noted the Department of Health and Human
Services would provide up to 125 million masks to schools. HHS ’s
public health emergency webpage includes that information, saying
HHS would provide the mask to states for distribution to schools . “ The
administration intends for these masks to support students, teachers
and staff in public and private schools reopening with an emphasis on
students who are low income or otherwise with high needs and
school i s providing in person instruction. ” NPR a lso said states may
stock up on such protective equipment before the FEMA policy went
into effect. That's my fact check for this week. I'm Lori Robertson,
Managing Editor of FactCheck.org.

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Margaret Flinter: F act C heck.org is committed to factual acc uracy from the country's
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you'd
like checked, e - mail us at www.chcradio.com . W e'll have
FactCheck.org’s Lori Robertson check it out for you here on
Conversations on Health Care

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Margaret Flinter: Each week Conversation s highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Daniela T udor
had a revelation a few years ago waking up on the cold floor of a jail
cell, she could ask for help for her drug and alcohol addiction or she
could die. She chose the former . Tu dor then launched not only on her
own recovery journey, but on a broader q uest to develop tools that
can help all people grappling with addiction recovery to avoid relapse,
which is so common, especially in the early days of sobriety . She
realized that there needed to be more readily accessible tools for

Dr. Nora Volkov

those in recovery to sta y connected to their treatment goals beyond
the 12 step meeting s and the talk therapy sessions.

Daniela Tudor: I am in long term recovery. I went through a four week inpatient
treatment program, where at the end of that four week program, all I
received wa s a piece of paper that listed an enormous amount of
things I'm supposed to do on a daily and weekly basis for the rest of
my life to stay in recovery. I knew that building something on our cell
phones that are with us 24 /7 , regardless of where you're from and
who you are would be a way to bridge that gap and keep people
accountable through an app to those activities.

Margaret Flinter: So she founded WE c onnect a relapse prevention on the go mobile
application that can be downloaded on a smartphone. The plat form is
designed to keep people engaged in their recovery plan using daily
reminders and a reward system for when you perform the tasks that
are essential to recovery.

Daniela Tudor: The individual along with the support of our certified peer recovery
supp ort specialists are able to input those activities into the app.
W hen it comes time for that activity to start, you simply check into it.
You see at the top of the app, how you're earning your incentives. B y
the way, this incentive program is based on evid ence based research
called contingency management. I t's actually proven to show that it
keeps people accountable to their recovery plans or their care plans.
The way that we've digitized it a n d the immediacy of that incentive
keeps people accountable to ch ecking into those activities on the go.

Margaret Flinter: And the digital platform also allows everyone who's connected to the
person's health care ecosystem to see in real time activities that are
enhancing recovery , and a lso when one migh t be at higher r isk for
relapse.

Daniela Tudor: We have trained peer recovery support specialists all across the
country. T hey get to leverage a tool that we developed called a data
dashboard, where they can see in an instance if someone needs
additional support or outrea ch, and that is built through the app with
keeping them accountable to those activities and the peer having
insights on how they're staying accountable to those activities in real
time. I t really allows for this connection of support 24 /7 and visibility
so that when someone needs that added support, not days or weeks
go by which is without this program is what happens, but rather gives
insight and gives the option for connection in real time.

Margaret Flinter: Since the pandemic hit , Tu d or says the WEconnec t platform has been
a lifeline for those in recovery. Those now often cut off f or meetings
and in - person sessions during the shutdown .

Daniela Tudor: Actually, when the pandemic hit, immediately, my heart went out for ,

Dr. Nora Volkov

w ow , none of us have support meetings to go to any more in - person.
W e immediately stood up with a set of partners , these mutual aid
meetings that are online that are led by certified peers. W ithin just a
couple months, over 200,000 people join ed from all states and several
countries.

Margaret Flinter: WEconnect a downloadable app designed by people in recovery for
people in recovery, to help maintain sobriety with a support system in
the palm of their hand, keeping them on track with health goals,
staying connected to a care team and avoiding r elapse. Now that's a
bright idea.

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Mark Masselli: You've been listening to Conversations on Health Care. I'm Mark
Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Peace and Health.

Female : Conversations on Health Care is recorded at WESU at Wesleyan
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