New NIDA Research Reveals the Power of Social Reinforcement

From the Blog of Dr. Nora Volkow, Executive Director
NATIONAL INSTITUTE ON DRUG ABUSE
October 15, 2018

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When it is available and can be delivered appropriately and effectively, medication is a crucial part of treating addiction—but by itself, a pill or an injection may not be sufficient. Social support has long been known to be an important factor in a variety of recovery programs and treatment approaches. Now, for the first time, an animal study conducted by members of NIDA’s Intramural Research Program and a scientist in Italy illustrates just how potent social reinforcement can be, even in animals that are already “addicted” to drugs as reinforcing as heroin and methamphetamine. 

The new study led by NIDA’s Dr. Marco Venniro required rats to choose between social interaction with another rat or access to heroin or methamphetamine. The animals consistently chose social interaction when given the choice, and this was true when they were first given access to the drug or when they were experienced drug takers.

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To assess the level of addiction in their rats, the experimenters used a sophisticated set of behavioral paradigms that attempt to model the kinds of choices made by humans who are addicted to drugs. They include assessing how hard a rat will work for access to the drug and whether responding persists despite punishment (i.e., brief electric shocks). Individual differences emerge in these paradigms; but regardless, the social reinforcer always won out over the drug. Even when the rats were housed with other rats and thus lived in a social environment, they consistently chose further social contact over the option to self-administer the drug.

The experimenters manipulated the social reward by introducing delay and an aversive stimulus in some conditions. Addicted rats were only likely to choose the drug over social interaction (i.e., relapse) when access to other rats was sufficiently delayed or punished. It is a striking set of findings. Even though previous research had established that isolation led animals to self-administer drugs and that social housing was protective against drug use, no studies had given animals the ability to choose one or the other—conditions had always been controlled by the experimenter. (Some studies had used palatable food as a choice alternative, but not social contact.)

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Another surprise concerned the phenomenon known as incubation of drug craving. Rats that regularly self-administer a drug display an increase in drug seeking following a period of abstinence (usually forced), similar to what many human drugs users experience following withdrawal—and often what prompts relapse. However, rats that became voluntarily abstinent by repeatedly choosing social interaction did not demonstrate this incubation effect.

The authors of this study point out that our social needs as humans are far more complex than the social needs of rats. In addition to social interactions and companionship (more immediate forms of social gratification), we also need more distal social expectations like the promise of meaningful participation in our community or society. But the findings of the study provide valuable insight into how recovery programs centered on mutual aid, as well as treatment approaches that emphasize social reinforcement, might help individuals overcome drug problems.

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For example, one of the best-supported behavioral treatments is the community reinforcement approach (CRA), which centers on building a new social support system and increasing the value of other, non-drug rewards in the individual’s life. Other approaches like cognitive behavior therapy also seek to increase the salience of less immediate social rewards when patients are faced with the immediate temptations of drug use. Even recovery groups for people with drug or alcohol addictions based on 12-step or similar models depend in large part on building a new social structure in which the person can function. The new study’s authors argue that their findings lend weight to the argument that these kinds of behavioral approaches that incorporate complex social influences should be more widely studied and utilized.

Using Science to Address the Opioid Crisis in America

FROM THE BLOG OF NORA VOLKOW, MD
September 19, 2018

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The public health emergency regarding opioid misuse, addiction, and overdose affects millions of Americans and requires innovative scientific solutions. Today, during National Prescription Opioid and Heroin Awareness Week, we are sharing news of an important step towards these solutions through the HEALing Communities Study—an integrated approach to test an array of interventions for opioid misuse and addiction in communities hard hit by the opioid crisis.

Six months ago, the National Institutes of Health (NIH) launched the Helping to End Addiction Long-Term (HEAL) Initiative, a bold multi-agency effort to catalyze scientific discoveries to stem the opioid crisis. HEAL will support research across NIH, using $500,000 of fiscal year 2018 funds, to improve prevention and treatment of opioid use disorder and enhance pain management.

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Through HEAL, NIH will harness the power of science to bring new hope for people, families, and communities affected by this devastating crisis. The current menu of evidence-based prevention, treatment, and recovery interventions has not been fully implemented nationwide. An unacceptably low fraction – about one fifth — of people with opioid use disorder receive any treatment at all. Of those who do enter treatment, only about a third receive any medications—which are universally acknowledged to be the standard of care—as part of their treatment. However, even when medications are used as a component of treatment, the duration is typically shorter than clinically indicated, contributing to unacceptably high relapse rates within the first 6 months. 

To take on this challenge, as part of the broader HEAL initiative, NIH has partnered with the Substance Abuse and Mental Health Services Administration (SAMHSA) to launch the HEALing Communities Study. This study will evaluate the impact of implementing an integrated set of evidence based practices for prevention and treatment of opioid use disorders in select communities with high rates of opioid overdose mortality, with a focus on significantly reducing opioid overdose fatalities by 40%. Targeted areas for intervention include decreasing the incidence of opioid use disorder, increasing the number of individuals receiving medications for opioid use disorder treatment, increasing treatment retention beyond 6 months, receiving recovery support services, and expanding the distribution of naloxone.

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Toward this goal, today NIDA issued funding opportunities for cooperative agreements for components of the HEALing Communities Study: a data coordinating center and up to three research sites to measure the impact of integrating evidence-based prevention, treatment, and recovery interventions for opioid misuse, opioid use disorder, opioid-related overdose events and fatalities across multiple settings, including primary care, behavioral health, and justice. We also encourage evidence-based interventions for prevention and treatment that involve community resources such as police departments, faith-based organizations, and schools, with a focus on rural communities and strong partnerships with state and local governments.

The evidence we generate though the HEALing Communities Study, the most ambitious implementation study in the addiction field to date, will help communities nationwide address the opioid crisis at the local level.  By testing interventions where they are needed the most, in close partnership with SAMHSA and other Federal partners, we will show how researchers, providers, and communities can come together and finally bring an end to this devastating public health crisis.

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/Treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org. We also have step by step guides on what to do to help yourself, a friend or a family member on our Treatment page.

Ambitious Research Plan to Help Solve the Opioid Crisis

From the blog of Dr. Lora Volkow, National Institute on Drug Abuse Posted June 12, 2018

NIDA Banner Science of Abuse and Addiction

In spring 2018 Congress added an additional $500 million to the NIH budget to invest in the search for solutions to the opioid crisis. The Helping to End Addiction Long-term (HEAL) initiative is being kicked off June 12th with the announcement of several bold projects across NIH focusing on two main areas: improving opioid addiction treatments and enhancing pain management to prevent addiction and overdose. The funding NIDA is receiving will go toward the goal of addressing addiction in new ways, and creating better delivery systems for addictions counseling for those in need.

NIH will be developing new addiction treatments and overdose-reversal tools. Three medications are currently FDA-approved to treat opioid addiction. Lofexidine—a drug initially developed to treat high blood pressure—has just been approved to treat physical symptoms of opioid withdrawal. Narcan (naloxone) is available in injectable and intranasal formulations to reverse overdose. Regardless, more options are needed. One area of need involves new formulations of existing drugs, such as longer-acting formulations of opioid agonists and longer-acting naloxone formulations more suitable for reversing fentanyl overdoses. Compounds are also needed that target different receptor systems or immunotherapies for treating symptoms of withdrawal and craving in addition to the progression of opioid use disorders.

Much research already points to the benefits of increasing the availability of treatment options for Opioid Use Disorder (“OUD”), especially among populations currently embroiled in the justice system. Justice Community Opioid Innovation Network is working to create a network of researchers who can rapidly conduct studies aimed at improving access to high-quality, evidence-based addiction treatment in justice settings. It will involve implementing a national survey of addiction treatment delivery services in local and state justice systems; studying the effectiveness and adoption of medications, interventions, and technologies in those settings; and finding ways to use existing data sources as well as developing new research methods to ensure that interventions have the maximum impact.

The National Drug Abuse Treatment Clinical Trials Network (“CTN”) facilitates collaboration between NIDA, research scientists at universities, and a myriad of treatment providers in the community, with the aim of developing, testing, and implementing addiction treatments. As part of the HEAL initiative, the CTN Opioid Research Enhancement Project will greatly expand the CTN’s capacity to conduct trials by adding new sites and new investigators. The funds will also enable the expansion of existing studies and facilitate developing and implementing new studies to improve identification of opioid misuse and OUD. Further, it will enhance engagement and retention of patients in treatment in a variety of general medical settings, including primary care, emergency departments, ob/gyn, and pediatrics.

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A great tragedy of the opioid crisis is that there are a number of effective tools not being deployed effectively in communities in need. Only a fraction of people with OUD receive any treatment, and of those less than half receive medications that are universally acknowledged to be the standard of care. Moreover, patients often receive medications for too short a duration. As part of its HEAL efforts, NIDA will launch a multi-site implementation research study called the HEALing Communities Study in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA). The HEALing Communities Study will support research in up to three communities highly affected by the opioid crisis, which should help evaluate how the implementation of an integrated set of evidence-based interventions within healthcare, behavioral health, justice systems, and community organizations can work to decrease opioid overdoses and prevent and treat OUD. Lessons learned from this study will yield best practices that can then be applied to other communities across the nation.

The HEAL Initiative is a tremendous opportunity to focus taxpayer dollars effectively where they are needed the most: in applying science to find solutions to the worst drug crisis our country has ever seen.

Find Help Near You

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/Treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org. We also have step by step guides on what to do to help yourself, a friend or a family member on our Treatment page.