Recent Developments in Addiction from NIDA

We are all fortunate for the ongoing work of the National Institute on Drug Abuse, a division of the National Institute of Health.  Dr. Nora Voklow, who has long been directing NIDA, certainly does not sit on her laurels, but is constantly monitoring all aspects of substance use disorder in the United States, and she has been vocal about how the addiction and addiction treatment scenes have been evolving during the pandemic. 

In this video recorded for the Psychiatry and Behavioral Health Learning Network and this video for the McLean Institute for Technology in Psychiatry, she notes that pathological substance use and substance-related deaths have increased quite significantly since COVID came into our lives, partly in connection with social isolation, as presumably the higher baseline level of anxiety we have all experienced, and partly because Fentanyl, the killer drug that has infiltrated the supply of opioids and caused so many overdose fatalities in the past 20 years or so, now appears in supplies of cocaine, meth, and even some ersatz prescription pills.  In addition, the chances of reversing overdoses via the use of Naloxone (Narcan) dramatically decline when drug users are in isolation, away from potential rescuers.  In addition, she presents evidence that individuals with substance use disorder, including those who use high amounts of marijuana, are quite significantly more likely to develop severe and potentially fatal levels of COVID.

 

On the other hand, as she notes, this has also been a time of creative development of strategies to potentially reverse these trends through various innovations such as more flexible availability of Suboxone (Buprenorphine) and Methadone, and telehealth.  (Unfortunately, and this is my comment, not hers, the use of telehealth is greatly thwarted by outdated rules that require clinicians to be licensed in the every state where they are reaching patients, and the process of obtaining these licenses is cumbersome, time-consuming, and expensive.)  She even sees signs that a treatment like Transcranial Magnetic Stimulation (currently used mostly for depression that has not yielded to other treatments) may help reduce addictive urges and behavior.

 

If there has been any upside to the opioid epidemic it has been a broader understanding that those with addictive disorders deserve treatment and support rather than blame; similarly, the widespread prevalence of anxiety and depressive symptoms that has come with the COVID pandemic and the measures taken to stay safe have brought widespread recognition that it’s a good idea to recognize and get help for mental health conditions that have so often been subject to stigma.

Is Cocaine Making a Comeback?

 

As most of my early addictions training (and indeed most of my professional addictions work) has revolved around alcohol, which of course is by far the most widely used drug, I recall how cocaine began to show up as an issue for my patients sometime around 1980.  At that time, believe it or not, cocaine was not regarded as addictive, even though we know that, a century earlier, Sigmund Freud had confronted its addictive qualities.  (What he first thought was a wonderful antidepressant for his patients became an consuming, addictive burden.)  In fact, during the early 1980s, snorted cocaine was fashionable and associated with the rich and famous.   

It didn’t take long, however, before treatment facilities began to fill up with cocaine addicts to the point that their numbers edged out those coming to the hospital wrestling with their inability to stop drinking.  (Much the same phenomenon has occurred in more recent years with opioid addicts becoming the majority population in many detoxes and rehabs.)  By this time, it became clear that cocaine was actually quite addictive, partly because of its quick, rewarding effect, followed by a steep drop-off, leading users to want to use it again.  Individuals’ early experiences with cocaine were highly reinforcing – they often felt much more confident (bordering on grandiose), energized, and productive.  Later on, when it became much harder to refrain from using, those rewarding effects diminished and continued use was driven by the addiction itself, sometimes resulting in consequences like paranoid psychosis, shredded nasal passages, and heart attacks.  I was working in an inpatient setting at the time, and many of those who sought help reported that they were motivated by the death of a co-user.  Others were inspired by what happened to some of the rich and famous, such as the death of basketball star Len Bias, or the severe injuries to comic genius Richard Pryor when he was “free-basing.”  (That method, like the use of “crack,” were ways to get even higher even faster by inhaling rather than snorting.)  

After a few years, if my recollection is correct, alcohol was back as the number one addiction represented in hospital settings – until the prolonged opioid crisis (delivered to us largely courtesy of pharmaceutical and medical interests who denied the dangers), which continues to this day, though thankfully the rates of prescriptions and hospitalizations seem now to be declining.  

In my own Boston-area practice, I frankly have not encountered cocaine addiction for at least 20 years, but apparently it’s been making a comeback.  What brought it to my attention, I’m embarrassed to say, was not keeping up with CDC or NIDA stats, but learning that cocaine addiction (as well as alcoholism) was the subject of the Intervention and 2020/21 rehab year of wonderful comedian John Mulaney.  
Indeed, it appears that cocaine is back.  According to the National Center for Drug Abuse Statistics, cocaine/crack was used by 6.3 million Americans in 2018, and, according to NIDA, cocaine was involved in over 19,000 deaths in 2020 (couldn’t find matching stats in the same year).  There is one crucial difference between the cocaine of the past and the cocaine appearing now – like much of the heroin, it is often mixed with fentanyl, which of course makes it much more deadly.  

If you or someone close to you has been seduced by the reinforcing properties of cocaine, be alarmed, be careful, and consider meeting with an addiction specialist.