Prevention Profiles: Take Five - Dr. Nora Volkow (National Institute on Drug Abuse)

Rich Lucey: Hi everyone, this is Rich Lucey with the Drug Enforcement Administration's Community Outreach and Prevention Support Section and welcometo this episode of Prevention Profiles: Take Five.

I'm very excited about today's guest, Dr. Nora Volkow who is the Director of the National Institute on Drug Abuse.

Let me tell you a little bit about her and then we'll welcome her to the podcast and get into our questions.

So Dr. Volkow is Director of the National Institute on Drug Abuse at the National Institutes of Health.

Her work has been instrumental in demonstrating that drug addiction is a disease of the human brain.

As a research psychiatrist and scientist, Dr. Volkow pioneered the use of brain imaging to investigate the toxic effects and addictive properties of abusable drugs.

She has published more than 780 peer reviewed articles, written more than 100 book chapters and non-peer reviewed manuscripts, coedited the Neuroscience for the 21st Century Encyclopedia, and edited four books on neuroimaging for mental and addictive disorders.

She has been named one of Time Magazine's top 100 people who shape our world, one of the 20 people to watch by Newsweek Magazine, Washingtonian Magazine's 100 most powerful women, Innovator of the Year by US News and World Report, and one of 34 leaders who are changing healthcare by Fortune Magazine.

With that, Dr. Volkow, welcome to the podcast.

Dr. Volkow: Hello, thanks for having me.

Rich Lucey: This is really exciting for me, personally, I also for DEA.

Kind of a nice bookend, if you will.

You were our very first guest when we launched this podcast series back in January of 2018.

And so it's very nice to have you as our guest as we wrap up our third season of this podcast series.

So thank you for making the time to be with us today.

Dr. Volkow: Oh, it's a pleasure.

Rich Lucey: Certainly, a lot has happened over those last three years and definitely over the last six or seven months.

We're actually going to talk a little bit about COVID later on.

But I'm going to revisit a couple of the issues we talked about in that initial podcast with you as it relates to drug use in among college students.

So let me just jump right into a first question.

The latest data from Monitoring the Future Study, which of course, NIDA supports through the University of Michigan, that study indicates that between 2017 and 2019, the percentage of full time
college students, those who are 19 to 22 years old, who vaped marijuana as least once in the past 30 days increased from 5 to 14 percent.

The study also shows that nearly 1 in 17 college students, that's 6 percent, use marijuana on a daily or near daily basis, which is near historically high levels over the past 40 years.

Obviously, these are numbers that none of us are happy with and we want to drive them down.

So, from your perspective, what does the prevention field need to be doing to reverse this trend?

Dr. Volkow: Well, I guess what you're reporting, that the Monitoring the Future is showing an increase in the regular use of marijuana by college students of up to 6 percent.

And the same thing, actually, we're seeing among high school students, that the regular use of marijuana has gone up across the country.

And it, in a way, reflects the changes in attitudes of people towards marijuana.

As marijuana becomes increasingly more accepted and there is legalization for medical purposes, there is the sense that, overall, it's a safe drug and therefore the normal constraints that would lead many of us not to do something that is harmful, will be harmful, are no longer there.

So this is what we actually believe is going on and as you saw, continuing the increase of marijuana in college age students but also high school students and you also see the other population in the United States that the use of marijuana is going up.

And of particular concern, I'm sorry, as you view from what we know is when the increase becomes regular use, because that's where you're likely to see the rate or probability of high increased from the use of marijuana, including becoming addicted to the drug as well as some of the medical consequences that can happen with its consumption.

So if these are changes in normative attitude, so to the question of what is it that we can do? 

I think it is very important to provide to the public with data that indicates what are the risks associated with regular use of marijuana without the need to exaggerate.

I think that one of the problems that we have faced when we communicate the effects of drugs is that many times, we're doing it in a way that says you take this drug and it's going to actually destroy your brain or destroy your health.

When in fact, we know that that's actually, there's tremendous variability in the way that people respond to drugs.

And that includes smoking, which does not cause cancer in everyone.

And so to the extent that we exaggerate, I think that leads to dismissal of that information because they see many situations where the consequences that are critical and will happen, did not.

So making the public understand what relative risks are and why it is ultimately not good for your health and it interferes with your outcomes to smoke marijuana, is something that I think can have a greater impact that just exaggerating.

But education of the public, I think, is fundamental in ways that are salient to them, and again, that don't per say, demonize the drug because I think that that generates a lot of reaction in the public.

Rich Lucey: So Dr. Volkow, thank you for bringing up the issue of the need to focus on the risks associated with marijuana use because I think that, you know, at the heart of the risk issue is the fact that people just don't think marijuana is harmful.

People's perception of harm related to marijuana has gone down a lot.

So that's perhaps central to the risks we need to focus on.

Dr. Volkow: Yeah, absolutely and I think that one of the elements too is because of the issue of all of the claims about the medical benefits from marijuana can actually lead, right now, that we are
leading with public people to actually believe some of those claims and use marijuana as a way to try to actually minimize the likelihood of having an adverse outcome with COVID.

And that would actually, we saw it in March, more negative consequence than what we are normally seeing.

But again, communicating in objective ways with the data that indicates what are the negative effects of marijuana and what are the riskier patterns of use and they speak for themselves.

I mean, we don't need to exaggerate just to put forth the association of marijuana with, for example, the cardiovascular events that are seen in young people across the United States, and counting too, anything from a cardio or myocardial infarction to stroke, are more frequent among young people that are consuming marijuana.

And this is not something that people, per says, recognize, that marijuana can negatively affect the function of the blood vessels.

And this is because we have an avenue of receptors that are regulating flow.

And so if you are consuming high content marijuana regularly, and you have a genetic vulnerability, it actually can have a very negative effect.

Just as, because we now recognize, for a long time, that if you have a vulnerability and are consuming high content THC of marijuana plants, you are more likely to have an acute psychotic episode.

In fact, if you consume high enough THC, you will have a psychotic episode, whether you have vulnerabilities or not.

And unfortunately for those that are vulnerable, that can lead to a chronic psychosis that can be very devastating.

We're also increasingly recognizing that the regular use of marijuana reduces a syndrome that is described as a hyperemesis syndrome, where you cannot stop vomiting and with very intense abdominal pain.

And that's actually not easy to treat and this is a new syndrome that we did not know existed because there, we had not seen that level of consumption in the past so it would never allow itself to emerge.

But now, as marijuana is very accessible, as high content THC is much more common, we starting to identify medical consequences that were unknown.

Rich Lucey: Well, certainly, I'm glad you brought up the THC content issue because that is an issue that certainly has changed with marijuana over the last couple of decades.

The marijuana of today is not at all like the marijuana just even of ten years ago because of the increase in the THC content.

Dr. Volkow: That's correct.

The THC content has gone up and as you mentioned at the beginning of your podcast, the other issue is that now, more people are vaping THC.

I mean, electronic cigarettes allow for a delivery system of drugs that is very, very efficient.

And importantly, you can actually concentrate very high content of drugs into the cartridges for the electronic cigarettes.

So whereas you can get plants of marijuana that may have, say very high content, 25, 29 percent.

With electronic cigarettes, you can get cartridges that can go up to 85, 90 percent.

So that exposes the user to very, very high THC content and that is delivered in a very efficient way.

And that, in turn, increases risks and medical consequences as well as we discussed before, the chances of becoming addicted.

So the higher the content of the drug, the more the risk for becoming addicted if you use it regularly.

So this is something else, it's not just that the plants have higher THC content, that's correct, but also that we're seeing new routes of administration in products that are delivering THC.

And too, people are combining them and that is another issue of concern.

So people smoke marijuana frequently report also taking edibles and for those that are not regular users that may want to start by taking an edible for example, one of the problems that has been
reported and was saw in emergency department visits reporting that these people take one dose and they don't really have any experience or they don't feel anything.

Then 15, 20 minutes and they take another dose and they don't feel anything and they take another dose.

And then when the edible is actually ingest and get into your circulation, they get a huge concentration because you have been just repeating the dosing and that's what results in the acute psychotic episodes that takes people to the emergency department.

So that's another component that is changing the way and the doses that people end up consuming.

Rich Lucey: So let me focus in on another issue that is of particular concern, not only for college students but the, quite honestly, the general population.

That is, of course, prescription drug misuse.

According to the American College Health Association's National College Health Assessment, approximately 11 percent of college students reported using one or more types of prescription drugs non-medically within the last three months.

And among college students, and we talked about this during that very first episode of the podcast series.

It seems the bigger concern is around the misuse of prescription stimulants since students think, think that it's going to help them get better grades.

What's the important messaging that we need to be getting out to college students about this issue?

Dr. Volkow: Well, I think that we actually first, have to convey to college students that there is no evidence that stimulant medications like amphetamine Adderall improves your cognitive performance in general.

And in fact, if you are already someone that is implement, has good cognition and has a good focusing and attention abilities, the use of a drug or medication like Adderall can lead you to worse performance.

And that has, in fact, been shown.

What it does, though, it gives you the sense, what Adderall or other stimulant drugs do is they give you the sense that you are performing better that what you're actually doing.

And so it makes you overconfident and that is actually too, very well described.

Because in some instances, like for example, if you are a soldier, that may have some beneficial effects because it makes you confident that you can do it.

But in some, in other instances, if you are for example, a physician and you're performing a very difficult surgery, that may have detrimental actions.

So there are, there's the sense that there is the association between how you are performing and how you perceive you are performing that is actually disrupted by the use of stimulant medications.

Stimulate medications are particularly useful under conditions when you are extremely tired and fatigued and the stimulant medication can improve your performance under those conditions.

But you have to also recognize that improving in performance is related to paths that are repetitive.

So if you need change the strategy or the way that you're addressing a problem, assuming it's a cognitive problem, if you are on a stimulant medication, that will be jeopardized because you tend to persevere on the same action, repeat yourself.

And this is actually something that you see even when you are using the use of the stimulant medication sometimes for the treatment of attention that is a hyperactivity disorder or syndromes
of inattention that that person, when they are taking stimulants are just, repeats and repeats and perseveres and perseveres and creates a state of inflexibility of your brain.

And that, of course, can be detrimental.

So making college students understand that stimulant medications are far from being the panacea that while they may have some beneficial effects if you're very, very tired, if you have not slept.

It is also very much constraint to certain cognitive processes and but, others may be actually deleterious and that too, that there is going to be the association between how you are perceiving you are doing and the way you are actually doing.

So overall, the dataset, I say is very weak in providing evidence that stimulants actually perform on individuals cognitive, on individuals cognitive abilities.

It would be wide remarkable and wonderful if they did but unfortunately, that is not, the data doesn't seem to support this.

Rich Lucey: So the message I heard in what you just said, and I always try to take something new when I hear you and other leaders talk.

It's this issue of overconfidence and so you know, what we hear from college students, whether it's in interviews, focus groups, what have you, they are absolutely convinced that, you know, taking a stimulant, whatever it is, absolutely helped them get a better grade.

And is that really the overconfidence, then, talking, if you will?

Dr. Volkow: Well, and again, I don't want to speak on generalities because I, if you haven't slept at all, the whole night, and you have an exam the next day and you basically are going to fall asleep and if you take a stimulant, you don't fall asleep and therefor you perform better...

I mean, there are, so without context, it's very difficult to state.

Overall, what the data shows is that there is no evidence of benefit.

The data also shows that there is an increase perception that you are performing very well when you are on stimulant medications.

And an aspect of it that I think is actually, could have negative effects and I want people to think about it, is if you do believe that, as is, okay, I did very well on this test because I'm on a stimulant medication.

And then the next time that you have an exam, you actually are going to rely on the stimulant and you start to create this ritual, a sort of narrative in your brain that leads you to believe that, that at one point, if I'm not on that stimulant, I'm not going to do well.

So in that process, you become dependent on having a stimulant in order to feel that you can perform well.

And that could be very, very negative because you do not want to remove that confidence that by yourself, you can actually able to do these challenges that are required through your education
and that you can do them properly without necessarily having to use a stimulant medication.

And that, I think, is a crucial message to send to students, whether they are high school or college or whichever stage on their education or on their work, professional life they are at.

They don't want to be dependent on that belief that without that medication, they are not going to do properly.

Because very likely, they can do properly.

Rich Lucey: Very important.

Yes.

It's a very important distinction and I'm really glad that you made it.

So thank you for bringing that up.

I'm going to switch our attention to COVID.

It's been certainly squarely on the minds of all of us around the country for the last, you know, seven, eight months or so.

So NIDA was the first organization to make a clear statement about the increased risk of COVID-19 for those who vape or smoke tobacco or cannabis.

And in prevention, we know that the science and clear messaging are critical components to success.

So what is your advice to our listeners on how best to navigate through various messages they might be receiving and stay focused on more than three decades of prevention science that helps inform our work?

Dr. Volkow: Well, I think that the first message that I would want to basically pass to the listeners is that as we are facing [inaudible] the COVID, we're facing uncertainty, stressors.

And under those conditions, I mean, we all try to adapt and by the way that we adapt to these uncertainty and stress, many times, is to actually look for ways of feeling better or less anxious.

And that's one of the reasons why when you have a stress situation, that use of drugs goes up and that is both for alcohol, marijuana, tobacco, illicit substances, I mean, it's been recognized and known.

So for the listeners to know that right now, we are in a period where it could be relatively easy for anyone of us to start taking drugs and if we're taking drugs, to escalate the use of those drugs.

Recognizing this is a period of risk for all of us and, in fact, you see the numbers in the United States are showing that again, the consumption of alcohol, the sales of marijuana, all have gone up.

And so is one, I would want them to know.

Now why do we take these drugs?

Because when you take them, temporarily, the anxiety is decreased, do it disappears.

And then that creates a sense of temporary wellbeing.

The problem is that you're, if you do these regularly, you start to become tolerant to these effects and you need higher and higher doses and you become more and more dependent on the drug.

That's one, and the other issue too is that amidst the high, the increases in the rates of COVID infections, the use of certain drugs can increase the likelihood of you getting exposed to the virus.

And for example, if you are dependent on consuming illicit substances, that will require that you're going to neighborhoods or areas where you're more likely to be outside of the social distancing
norms, that normally serve to protect all of us from getting infected.

And if you are actually someone that has already, a history of smoking or of vaping or of taking cocaine or opioids, those drugs have effected your physiology; they don't just go into the brain, they go to the heart, they go to the lungs, they actually go to the kidney; they basically attach to blood vessels, and in ways that produces inflammation and damage to the organs.

And so if you already have dysfunction of these systems because of the use of drugs, that makes it then, more vulnerable if you do get exposed to the virus, for the virus to infect them and to have negative consequences.

And I think that, an agnostic that we don't really understand and I haven't seen it carefully discussed is that there is a dose effect, I mean, like how, how much viral low do you require in order to have an infection.

And then, one virus my not produce an infection.

But the dose of the virus that is required for you to get an infection is likely very much to vary from person to person and depend on your immune system, but also on the physiology of the tissues that are being targeted by the virus.

And the respiratory system is one of the ones through which it is believed that the virus actually infects the rest of the body.

And that's why, if you are smoking, whether its marijuana or whether you are smoking nicotine or whether you're vaping, which are producing inflammation into the upper respiratory tract.

That's what makes you more vulnerable to get infected and if you do get infected, you have more adverse outcomes.

So this is what I would basically want to communicate over to the listeners.

And to the same extent, I mean, there is evidence that alcohol drinking because it does effect negatively, just like opioids also effect negatively as well as marijuana, that the function of your immune system, that can also jeopardize the ability of your body to fight the virus.

And that's why, even though it may be tempting for people right now, with the anxiety and the stressors, to say okay, how bad can it be for me to smoke this or that or; to be cautious, to be cognizant, that there are these unfortunate adverse effects of these drugs on systems that are required to fight the viral infection.

Rich Lucey: So the follow up question that I have actually leads into the next question.

We know that, and you've alluded, you've mentioned this, we know that alcohol and drug use can tend to go up or its certainly effected by a traumatic event or during stressful times and certainly,
you know, the current pandemic in which we are living would qualify as that and you made mention that alcohol use, the marijuana use has gone up during this time.

What is it that we might expect to see regarding drug use, and it's not only among college students but certainly among even the general population.

In the aftermath of this pandemic, we know that data drives programming, so should we not be surprised if the data shows us that rates have gone up following this period of time?

Dr. Volkow: Yes, I think we will be very surprising if the data and the surveys don't show an increase, an uptake of drug taking across, and alcohol taking, across the country.

And the surveys that have already come out, which tend to be regional or local, do report that.

And CDC had reported, I think it was in June, I don't recall exactly when, where they actually, I think, document that by then, 13 percent increase in the rate of substance use.

But I don't recall exactly, the details, I'm just bringing it up because we already have surveys that have indeed, indicated that that is the case.

And I think that the sales of these or whether its marijuana or whether its alcohol where we do have information, indicate that they have gone up.

We don't know about the sales of illicit substances, but we go and ask the researchers in the communities, in general, not everywhere, actually, in some communities, they're saying well,
there's evidence that they, access to drugs may have gone down.

In most of the others, the sense is that it has been also an increase in uptake of illicit substances.

But that, because there are no databases on sales, it's much more stealthy, the information that we have, regarding the consequences across the country.

Rich Lucey: Absolutely.

Certainly something we'll definitely be all keeping an eye on as this continues to play out.

So as we wrap up our interview, I tend to ask this of all my guests in terms of this last question.

And that's to give you an opportunity.

What is it that you would like to say to encourage the professional who are working to prevent drug use among college students as well as the students themselves who are listening to this podcast?

Dr. Volkow: Well, I think that first of all, we are all living in a situation that's very, very difficult.

And in these situations that are so difficult, that's when we have ultimately a greater opportunity of bringing us together and recognize the challenges that people are living.

And that's because of that, does require us a sort of basically, a prioritization of strategies to implement prevention messaging and alternative support systems.

Because, and I always say this about prevention, I mean it's very easy to say, don't take drugs.

But you need to provide alternatives of what that person can look forward to that can help them buffer some of the difficulties that people's lives have.

And I think that there upon lies many of the challenges of prevention interventions.

How can we come together to provide that support as a community, as clinicians, as friends, as family members because that what, thoroughly, one of the most powerful sources that we have for
a sense of meaning, for a sense of belonging, that someone cares and there is this reaching out.

And so I, my message in terms of those professionals that are involved with prevention is that there, they actually, their work is fundamental and that to the extent that they also can bring others to participate with them in the prevention interventions and their implementation, they're likely to be much more successful.

And the message to the public in general is yes, its normal to feel right now, sometimes the stress and perhaps a little bit hopeless, but the notion is not to dwell on that, on that thought because it doesn't really lead you anywhere.

But instead, reach out of your own self and then figure out a plan in terms of what are the activities that are meaningful to you?

What are the things that you enjoy?

And recognize that we are going to have to make changes, that our life has changed and the way that we can derive fresh or a sense of wellbeing has forced, has been changed.

We've been forced to change.

But there are many ways of growing out of that state and that taking drugs is, in a way, jeopardizes that because it's an easy escape.

It's an immediate regret at the expense of longer terms, bigger regrets and think communicating these while providing a sort of a perspective about what are those positive alternative other components that can lead you to feel, yes, it's definitely worth doing it because I do want to be part of this.

I do want to experience this.

I think that's where we all can contribute and reach out to others and help them if they need it.

be aware that, that things are tough and that drugs are just a temporary escape that I always like to say this because I think it's the right metaphor; that mortgages yourself, sense of wellbeing and motivation.

You're mortgaging yourself to having the stress in the future to just have a temporarily relief.

And that's what I would, want my message to be.

Rich Lucey: That is, I've written down so many takeaways just from what you just said and I love every one of them.

I think that the first one I heard, you know, living through this difficult time, it provides us with an opportunity and that opportunity to come and work together.

I loved what you said that, you know, for our prevention professionals to hear the message that their work is fundamental.

And I know I have said it in various presentations over the past few months, that because we know drug can tend to go up following a traumatic event and during stressful times,
that prevention is more important than every right now.

I mean, now is not the time to put prevention on the sideline or to put it on the back burner.

We need to focus on prevention.

And lastly, it is so hard, I know it can be very hard to watch the news, read the papers, look online, it can get very depressing, there's a lot of negativity.

And I liked what you said, that we really need to reach out from that negativity and try to find some positives to focus on because focusing on the negativity doesn't really get us anywhere.

So your messaging is so important for us.

I really do appreciate that.

Dr. Volkow: Well, thanks very much for giving me an opportunity to speak with you.

Rich Lucey: This has been great. Dr. Volkow, again, I, it's been a nice bookend, if you will, three years after we first interviewed you for this podcast series.

I want to thank you on behalf of DEA and coming onto the podcast.

I want to thank you for your leadership and your messaging and the profile you give to our issues.

It's so very important for the professionals who are working on this issue around the country.

So thank you for that.

Dr. Volkow: Well, thanks, its, it's a pleasure.

Rich Lucey: And for our listeners, I hope you have enjoyed this episode of Prevention Profiles: Take Five.

And with that I am going to say thanks for listening and have a great day.