www.drugabuse.gov Volume 23, Number 1 U.S. Department of Health and Human Services | National Institutes of Health

Behavior Game Played in ALSO IN THIS ISSUE

Primary Grades Reduces Later Research Findings 8 Young Opioid Abusers Drug-Related Problems Benefit From Extended Buprenorphine-Naloxone Treatment Positive effects are most pronounced in disruptive boys. 10 Vouchers Boost Smoking Abstinence During Pregnancy BY NIDA NOTES STAFF in the Good Behavior Game (GBG), a classroom 11 Attention to Bipolar activity designed to inculcate appropriate behav- Disorder Strengthens Substance Abuse warding smiley-face stickers to ior during children’s first 2 years in school. Treatment teams of first-graders in Balti- “The GBG gives teachers an effective method more for the good behavior of the of managing behavior in the classroom and of Director’s Perspective 2 Helping Doctors Become individual team members greatly teaching children how to be students,” says Dr. First Responders to increasedA the likelihood that the students would Sheppard Kellam of the American Institutes for Substance Abuse experience an adolescence free of substance Research in Washington, D.C. Research in Brief abuse and dependence. Teachers gave out the Dr. Kellam and colleagues began the longitu- 3 • Some Teens Reporting stickers and other token rewards and penalties dinal study of the GBG while at Johns Hopkins Nonmedical Use of Prescriptions Develop University in close partner- Dependence Disorders ship with the Baltimore City • Peer Interaction AS THE TWIG IS BENT Young adults who had played the Good Enhances Adolescent Rats’ Behavior Game in first and second grade were less likely to smoke ciga- Public School System. Dr. Drug Reward • Stroop rettesr o abuse drugs than those who hadn’t played the game. Males Kellam suggests that the Test Identifies Patients whose first-grade teachers identified them as aggressive and disruptive at Risk for Treatment benefited the most. activity produces a broad Dropout • Genetic Overlap spectrum of long-term ben- Between Substance Abuse and Bipolar Disorder efits by steering 5- and 6-year- Good Behavior Game Control 4 NIDA at Work olds away from aggressive and 70% NIDA’s Genetics disruptive behaviors, which Workgroup Directs Search for Genes That Influence 60% have long been recognized as precursors of many negative Addiction

50% adolescent and adult out- Bulletin Board comes. The study found that 14 • Dr. Phil Skolnick Now 40% Leads NIDA’s Medications the GBG was protective not Development Efforts only against substance abuse • How-To Guides Provide 30% Tips for Publishing and dependence but also Addiction-Related Articles 20% against teenage delinquency, • Dr. James A. Inciardi antisocial personality disor- (1939–2009) 10% der, and suicide attempts. Tearoff 15 Reality Videos Bring NIDA Prevalence of Problem Behaviors at Age 19–21 Prevalence of Problem Behaviors at Scientists to Web Site for 0 HOW TO PLAY THE GAME Drug Abuse Smoking Drug Abuse Smoking Drug Abuse Smoking Teens Teachers first set the rules All Females All Males Males Disruptive in First Grade of the game, presenting a list 16 What the Numbers Say [ Continued on page 6 ]

NIDA Notes | Volume 23, Number 1 1 ■ DIRECTOR’S PERSPECTIVE By NORA D. VOLKOW, M.D., NIDA Director NIDA Notes

EDITOR David Anderson Public Health Advisor, Office of Science Policy and Communications, National Institute on Drug Abuse

DEPUTY EDITOR Julie Ann Miller, Ph.D. RTI International Helping Doctors Become First MANAGING EDITOR Andrew Keegan RTI International

Responders to Substance Abuse SENIOR SCIENCE WRITER Lori Whitten, Ph.D. RTI International

very day, the Nation’s primary care and family physicians see patients whose use SCIENCE WRITER Laura Bonetta, Ph.D. of addictive substances causes them problems. Too often, physicians cannot RTI International

appropriately diagnose and treat those problems because the patients do not ASSOCIATE EDITOR disclose their substance abuse. Patients’ fear of revealing sensitive and poten- Debra P. Davis RTI International tially stigmatizing information and the omission of the topic of addiction in many physi- E DESIGN/LAYOUT cian training programs lead to suboptimal medical care. Maggie Bray To remedy this situation, NIDA has developed RTI International NIDAMED, the Institute’s first comprehensive EDITORIAL BOARD David Anderson, Chair; Public Physicians’ Outreach Initiative. NIDAMED aims Health Advisor, Office of Science Policy to integrate screening and treatment for the disease of addiction with mainstream medi- and Communications cal care. A toolkit developed by NIDAMED guides doctors in assessing a patient’s risk Nicolette Borek, Ph.D., Research Psychologist, Division of Clinical Neuroscience of developing an addiction problem, advising patients on the health effects of substance and Behavioral Research abuse and, if needed, arranging a referral to specialty care. The toolkit contains : J.C. Comolli, Public Health Advisor, Division of Pharmacotherapies and Medical n NIDA-Modified Alcohol, Smoking and Substance Involvement Screening Test Consequences of Drug Abuse (NM-ASSIST)—This evidence-based instrument, available on an interactive Web site Jennifer Elcano, M.A., Science Writer, or in print, guides clinicians through a brief screening interview about use of addictive Office of Science Policy and Communications Lynda Erinoff, Ph.D., Associate substances, including illicit drugs, prescription drugs taken for nonmedical purposes, Director, AIDS Research Program, Division tobacco, and alcohol. of Epidemiology, Services and Prevention Research n Clinician’s Resource Guide—This accompanying online guide presents clinicians Jacqueline Lloyd, Ph.D., Health Science with more detailed instructions, directions on how to access further information on Administrator, Division of Epidemiology, substance abuse, and comprehensive referral resources. Services and Prevention Research Marsha F. Lopez, Ph.D. , Health Science n Screening Tool Quick Reference Guide—This pocket-size resource summarizes the Administrator, Division of Epidemiology, screening tool, risk levels, and followup actions. Services and Prevention Research Gerald McLaughlin, Ph.D. , Chief, Grants n Patient Information Card—This postcard-size handout for physicians’ waiting Review Branch, Office of Extramural Affairs rooms encourages patients to “Tell Your Doctors About All the Drugs You Use” to get Mary Ellen Michel, Ph.D., Deputy the best care and also offers Web links to more information. Director, Center for the Clinical Trials Network Ivan Montoya, M.D., M.P.H., Medical Another critical component of NIDAMED is outreach to medical students, residents, Officer, Division of Pharmacotherapies and and those who train them. Through a partnership with eight medical schools around Medical Consequences of Drug Abuse the country, NIDA’s Centers of Excellence for Physician Information provide innova- Mary Pfeiffer, Ph.D., Editor and Writer, Intramural Research Program tive, science-based curriculum resources on substance abuse, addiction, and their health Kenzie Preston, Ph.D., Chief, Clinical consequences. Pharmacology and Therapeutics Research Doctors can access the new tools at www.drugabuse.gov by clicking on the Branch Joni Rutter, Ph.D., Program Director, NIDAMED icon. The Institute also recently updated Principles of Drug Addiction Genetics and Molecular Neurobiology Research Treatment: A Research-Based Guide, which summarizes more than three decades of Branch, Division of Basic Neuroscience and Behavioral Research research. In addition, a poster that encourages patients to disclose their drug use is avail- Anna Staton, M.P.A., Public Health able by calling 1-877-NIDA-NIH. NIDA is collaborating with the U.S. Health Resources Analyst, Office of Science Policy and Communications and Services Administration, Food and Drug Administration, and New York City Health Cora Lee Wetherington, Ph.D., Department to place the poster in health clinics throughout the Nation. ■ Psychologist, Division of Basic Neuroscience and Behavioral Research This publication was produced and printed by RTI International, under Contract No. N01DA-4-1117 from the National Institute on Drug Abuse. 2 NIDA Notes | Volume 23, Number 1 ■ RESEARCH IN BRIEF Highlights of recently published NIDA-supported studies

56 days, on average, in the year include peer contact may more inhibited. In the Boston trial, under review, and those who closely mimic early stages of this difference—of about 30 were dependent on the drugs drug abuse, which typically seconds, on average—was 24 had used them for 87 days. occurs in a group setting percent greater among patients Girls were significantly more > Psychopharmacology 204(3):391- who dropped out than among likely to become dependent 402, 2009. those who completed therapy. on nonprescribed pain reliev- > Drug and Alcohol Dependence 96(3):202-212, 2008. > Neuropsychopharmacology Some Teens Reporting ers than boys, a finding that 33(4):827-836, 2008. Nonmedical Use of the researchers suggest may Prescriptions Develop reflect, in part, girls’ greater Genetic Overlap Disorders tendency to share prescribed Between Substance Dr. Li-Tzy Wu and colleagues pain relievers with friends. Abuse and Bipolar at Duke University and the > Journal of the American Disorder Pacific Institute for Research Academy of Child and Adolescent According to a recent literature and Evaluation found that 1 Psychiatry 47(9):1020-1029, 2008. analysis by Dr. Ranga Krishnan percent of the 36,992 respon- of Duke University Medi- dents age 12 to 17 to the 2006– Peer Interaction cal Center, more than half of 2007 National Survey on Drug Enhances Adolescent Stroop Test Identifies people with bipolar disorder Use and Health (NSDUH) met Rats’ Drug Reward Patients at Risk for also have a substance use dis- the criteria for a diagnosis of For adolescent rats, drugs Treatment Dropout order. New findings suggest abuse or dependence on opi- are better with company, and The Stroop test, a widely than genes contribute to this oid analgesics, which are pre- vice versa. Given the oppor- available, easily administered comorbidity. One-third of the scription pain relievers. The tunity to spend time in two assessment of a person’s abil- genes that have been linked teens reported one or more cage compartments, young ity to screen out distractions with bipolar disorder in four abuse symptoms—such as rats preferred the one in which and inhibit inappropriate recent studies have also been interference with school and they’d twice visited with a peer responses, may predict which associated with substance home life, exposure to physi- and also received a low dose of cocaine abusers are likely to dependence, according to Dr. cal danger, and problems with either nicotine or cocaine over drop out of therapy. In a study George R. Uhl and colleagues at family and friends—result- the compartment that had fur- of 74 cocaine abusers, Dr. the NIDA Intramural Research ing from the nonprescribed nished neither companionship Chris Streeter and colleagues Program. The team analyzed use of these pain relievers; or nor a drug. In contrast, they at Boston University School of data from comparisons of they reported symptoms of showed no such partiality for Medicine and Harvard Medi- genetic profiles of European- dependence disorder—such a compartment in which they cal School found that Stroop Americans with and without as experiencing pain-reliever had previously received only scores predicted treatment bipolar disorder. Bipolar disor- tolerance or withdrawal and companionship or only the low retention better than addiction der was linked with 69 genes, giving up activities. dose of drug. severity, symptoms of depres- and Dr. Uhl’s team had previ- Seven percent of the Dosage mattered: Rats sion, or other clinical and ously tied 23 of those genes to NSDUH teen respondents did gravitate to compartments demographic characteristics. risk for substance abuse (see reported that they had used where they had experienced The researchers suggest that “New Technique Links 89 prescription painkillers on a either a higher dose of drug programs might use the test to Genes to Drug Dependence,” nonmedical basis during the or more than two previous assign patients to appropriate NIDA Notes, Volume 22, Num- past 12 months. Of this group, social opportunities. Dr. Janet treatment interventions and ber 1). Variants of these genes 7 percent met diagnostic cri- Neisewander, graduate student intensities. may affect the two disorders teria for abuse and 9 percent Kenneth Thiel, and colleagues The Stroop test measures directly and may also interact for dependence; another 20 at Arizona State University say the difference in response to increase vulnerability to one percent had symptoms that did that their findings emphasize times between instances or both conditions. not reach the threshold for a the importance of examining where the automatic response > American Journal of Medical diagnosis. The teens who mis- drug reward in a social con- is appropriate and instances Genetics: Part B Neuropsychiatric used painkillers had done so for text. Animal protocols that where that response must be Genetics 150B(2):182-190, 2009.

NIDA Notes | Volume 23, Number 1 3 n NIDA AT WORK :

samples. Information on ongoing stud- NIDA’s Genetics Workgroup ies and data from completed studies can be found at the Center’s Web site (zork. wustl.edu/nida).

Workgroup Directs Search STAGES OF GENE IDENTIFICATION The initial clue that some of the for Genes That Influence risk for drug abuse and addiction is inherited was the observation that the Addiction problems tend to run in families. NIDA- funded twin studies added support for the idea, by showing that siblings who BY DEBRA P. DAVIS mittee (NGCC), Individuals share more genes are more alike in NIDA Notes Associate Editor o v e r s e e s a l l with high-risk terms of developing or not developing genetic research genes might a drug disorder. High-risk genes may bout half of a person’s involving human have traits make individuals more likely to experi- risk for drug dependence subjects, ensuring that make ment with drugs or susceptible to drug them likely to resides in his or her genes, that it is designed effects that promote addiction. Some experiment with the rest attributable to answer impor- with drugs or high-risk genes may only manifest toA circumstantial and environmental under certain conditions, such as famil- tant questions susceptible to factors. Genes influence vulnerability and takes full drug effects ial abuse or neglect. to drug abuse by affecting personality advantage of that promote Early projects initiated and overseen traits, physiological responses to drugs, c o l l a b o r a t i v e addiction. by the Workgroup included studies of frequency of drug use, and the neu- opportunities genes related to biological pathways robiological mechanisms of learning, within NIDA and with other parts of the known to play roles in drug addiction, memory, and behavior. National Institutes of Health (NIH). such as the nicotine receptor and the NIDA funds a robust research port- The NGCC, chaired by Dr. Joni Rutter, dopaminergic neurotransmitter sys- folio to identify the genes and genetic associate director of human population tem. Comparisons of addicted versus processes responsible for these effects. and applied genetics for the Division nonaddicted individuals implicated The ultimate objective is to uncover of Basic Neuroscience and Behavioral specific DNA variations within such information and mechanisms that can Research, also coordinates the work of genes. be exploited to improve and personalize the NIDA Genetics Consortium. This Researchers also studied geneti- prevention and treatment of drug abuse is a group of approximately two dozen cally engineered animals to examine and addiction. investigators who conduct human how their behavior changed when NIDA’s Genetics Workgroup is subject studies. particular genes were turned off. For charged with overseeing and monitor- Under an agreement with NIDA and example, a NIDA-funded study found ing these efforts. Led by Dr. Jonathan NIH, Consortium scientists contribute that disrupting a mouse’s Clock gene Pollock, chief of NIDA’s Genetics and blood and DNA samples collected dur- increased its propensity to self-admin- Molecular Neurobiology Research ing research, as well as clinical data, to ister cocaine and seek out new experi- Branch, the Workgroup comprises an NIH repository; in exchange, they ences (“Manic Mice Show Heightened approximately 20 scientists representing receive access to the repository’s exten- Sensitivity to Rewards,” NIDA Notes, all NIDA divisions. They meet monthly sive collection. Scientists outside the Volume 22, Number 4). to review developments in the field and Consortium can also gain access to the Although research on single genes identify needs and opportunities for fur- collection if they agree to share their has yielded important information, ther research, then issue calls for grant own samples and data. The repository, complex brain disorders such as sub- proposals on promising approaches. which is located at Rutgers Univer- stance abuse and addiction likely reflect A Workgroup subcommittee, the sity’s Center for Genetic Studies, has a convergent effects of many genes. New NIDA Genetics Coordinating Com- collection of over 40,000 human DNA technologies are being exploited to

4 NIDA Notes | Volume 23, Number 1 identify these genes and the ways their MULTIFACETED VIEW NIDA’s Genetics Workgroup calls for projects applying a wide range combinations and interactions may of methods. alter risk. The Workgroup is fostering research and analytic methodologies that capitalize on ongoing NIH-wide Research Question Examples of Approach efforts such as the International Hap- Map Project (see hapmap.ncbi.nlm.nih. gov) and the 1000 Genomes Project Does a particular trait have a Twin studies (see www.genome.gov/27528684 and genetic component? www.1000genomes.org). Many projects apply the powerful Where in the genome are the genes Genetic marker study technique of genome-wide association that influence the trait? Genome-wide association study (GWA) scanning. Researchers simul- taneously test thousands of individu- Candidate gene study als’ DNA for hundreds of thousands of What specific genes are involved? genetic variants that may correlate to Fine mapping drug abuse. “Through GWA studies, we are finding associations with spe- How does the gene influence the Knock-out gene study cific genetic variants. Now, we need to organism? understand their functions,” says Dr. Rutter. This work is facilitated by data- Does variation in the gene influence Clinical study bases that compile findings from many human health? investigations of specific genes, their functions, and their links to disease. DNA methylation (see www.ncbi.nlm.nih.gov/gene). How does epigenetics influence gene expression? For example, researchers are using Chromatin modification GWA and other methods to compare the genetic profiles of smokers who have become dependent on nico- the epigenome is akin to the software of addiction,” says Dr. Pollock, who tine with the profiles of those who because it acts on top of the DNA to dic- organized the program. “It provided a have not. Of particular interest is a tate changes in gene expression.” She networking opportunity for both the family of genes that determine the says, “If we can better understand how structure and functions of nicotinic epigenetic changes take place, we can “The DNA is equivalent to the acetylcholine receptors, to which nico- create better treatment approaches.” hardware and the epigenome is tine attaches to produce many of its akino t the software...” effects (“Studies Link Family of Genes SHARING FOR OUTREACH AND ––Dr. Joni Rutter to Nicotine Addiction,” NIDA Notes, ECONOMY Volume 22, Number 6). The Genetics Workgroup’s mission The Workgroup also funds stud- includes keeping scientists up-to-date instructors and the participants.” Slides ies on the related topic of epigenetics. on advances in genetics as they apply to and videos of the course may be viewed Virtually every cell in the body contains drug abuse. For example, last year the at drugabuse.gov/about/organization/ the same genes, but the epigenome group sponsored a week-long course Genetics/geneticsepigenetics/index.html. determines which genes are active that drew 80 researchers from approxi- In July 2009, the Workgroup spon- in each cell at each moment in time. mately 40 universities to learn about sored the travel of nine junior investiga- Chemical changes, such as methylation, recent findings in the genetics of addic- tors to the 50th Annual Short Course on determine the epigenome. Dr. Rutter tion. “The course introduced addiction Medical and Experimental Mammalian uses a computer as an analogy: “The researchers who lacked genetic exper- Genetics at the Jackson Laboratory in DNA is equivalent to the hardware and tise to experts in the field of genetics Bar Harbor, Maine. n

NIDA Notes | Volume 23, Number 1 5 n GOOD BEHAVIOR GAME alleviate behavioral problems in the trols. The youths who played the GBG [ Continued from page 1 ] early grades. The Baltimore project is the were also less likely to smoke, to report first randomized field trial of the GBG’s alcohol use disorder or antisocial person- of behaviors, such as sitting quietly, that effectiveness, and the first to examine its ality disorder, or to have considered or will be rewarded. They then divide their impact on adolescent outcomes outside attempted suicide. classes into teams for the GBG. Later, of school. Dr. Kellam notes that the par- The GBG was more advantageous to when students are working indepen- ticipation of entire classrooms, represen- boys than to girls, except with respect to dently, the teacher announces that the tative of large areas of Baltimore, makes alcohol abuse, where the game’s impact game is in play. Teams whose members the results applicable across that city and was similar in both genders. The greatest maintain the stated behaviors during the perhaps similar ones. benefits were realized by boys whose first- game period receive prizes, such as stick- grade teachers classified them as aggres- ers. Students who act out or commit other LONG-RANGE BENEFITS sive and disruptive. Among these boys, infractions incur a checkmark, lessening In 1985, Dr. Kellam and colleagues 29 percent who played the GBG reported their teams’ chances for prizes. identified three to four schools in each of The game is played for brief intervals at five demographically distinct neighbor- first; the time and frequency are gradually hoods, ranging in ethnicity from mostly MALES BENEFIT ACROSS THE BOARD As they grew, boys who had partici- lengthened as the children gain practice African-American to mostly White and in pated in the Good Behavior Game in first and in controlling their behaviors. Eventually, economic status from very low to moder- second grade in 1985–1986 used fewer social to instill constant attentiveness to ate income. Altogether, more than 1,000 services than a control group. appropriate behavior, the teacher stops children from 41 first-grade classes in 19 Game announcing when the game is in play and schools either used the GBG or served as Controls Players awards the prizes to successful teams only controls in the study. at the finish of a GBG period. During the first weeks of school, School 9% 14% The GBG was devised in the 1960s teachers in both the GBG and the control Services* by Harriet H. Barrish, Muriel Saunders, classes assessed each student’s behav- Mental Health or 13% 18% and Montrose M. Wolf at the University ior; about 12 percent of the males and 3 Medical Services of Kansas. Its underlying concept is that percent of the females were classified as Drug Abuse team members, wanting to win, will pres- aggressive and disruptive. Teachers in the 4% 9% Treatment sure—and help—each other to meet the game-playing classrooms divided these behavioral objectives. high-risk students roughly equally among Social 1% 6% “When kids come to school, they often the teams. Services don’t know how to behave like students. The teachers using the GBG began by Criminal Justice They have to be taught. It’s not intuitive, implementing the game for 10 minutes 12% 20% System parents don’t always get it, and teachers three times a week; they then increased its aren’t being trained to deal with it,” says frequency and duration as the school year *For problems with behavior, emotions, drugs, or alcohol. Dr. Kellam. “This is the issue the GBG progressed. The same children contin- attempts to address.” ued to play the GBG or serve as controls And the stakes are high: Children who through second grade. The game did not drug use disorder, compared with 68 per- do not adapt to the student role early in cut into instructional time because it took cent of controls (see graph, page 1). their school careers risk rejection by place when students were at their desks “We did not anticipate that a single peers, failure to achieve academically, reading, completing work assignments, or intervention would have such a major and conflict with their teachers and other engaging in other quiet activities. impact,” says Dr. Kellam, who led the authority figures. The consequences of About 15 years later, the researchers study. “The key to the GBG’s efficacy these problems in the teen years include located and interviewed approximately 75 seems to be its effect on aggressive and increased risk for self-destructive and percent of children, now aged 19 to 21. The disruptive boys. These are the kids who antisocial behaviors, Dr. Kellam explains. proportion of GBG alumni who reported get sent to the principal’s office and even- Small-scale, more limited studies have a drug use disorder was 12 percent, com- tually expelled, so these are the kids who provided evidence that the GBG might pared with 19 percent among former con- most need help.”

6 NIDA Notes | Volume 23, Number 1 Saving Money on Treatment and Social Services

By lowering teens’ rates of smoking, substance abuse and addiction disorders, antisocial personality disorder, and suicidal tendencies, the Good Behavior Game (GBG) yielded economic dividendso t public agencies that address those problems. Study recipients’ self-reports and researchers’ reviews of school and court records indicated that from first grade to age 19–21, GBG alumni, compared with controls, were assigned to fewer school- based services such as individual therapy or placement in spe- cial classrooms; they also has less involvement with juvenile and adult criminal justice systems.

The GBG’s effect on males accounted for the entire reduction in service use. Roughly 25 percent of males who played the game received one or more services, compared with 38 percent in the targeted interventions for children who have persistent behav- control group. In contrast, among females about 19 percent of ioral problems, and finally mental health treatment for an even both players and controls received at least one service. more selective group.

The greatest reduction was in the use of school services by Dr. Elizabeth Robertson, chief of prevention research in NIDA’s males who were classified by their first-grade teachers as Divisionf o Epidemiology, Services and Prevention Research, aggressive and disruptive. Among this group—who made up says the report shows that behavioral training in the elemen- about2 1 percent of all study participants—17 percent of those tary grades can place students on a more productive course who played the game used school services, compared with 33 and reduce costs for a wide range of social programs. “It is an percentf o those who did not play. “That’s twice the number examplef o why early intervention makes sense from an eco- of aggressive children that receive these expensive school ser- nomic standpoint,” she says. vices,” notes Dr. Jeanne Poduska, who oversaw the young-adult followup while employed by Johns Hopkins and has analyzed SOURCE the service data while employed at the American Institutes for Poduska, J.M., et al. Impact of the Good Behavior Game, a universal Researchn i Washington, D.C. classroom-based behavior intervention, on young adult service use for problems with emotions, behavior, or drugs or alcohol. Drug and Alcohol Dependence 95 (Suppl.1):S29–S44, 2008. Dr. Poduska and colleagues propose an overall strategy of using the universal intervention in early grades, followed by more

TRAINING REQUIREMENTS were 19–21 years old revealed that the mag- Jeanne Poduska of the American Insti- In 1986, the teachers who had imple- nitude of reductions in smoking and drug tutes for Research in Washington, D.C., mented the GBG in their classrooms the abuse were not as great as they had been continues to search for better ways to previous year did so again with another for the original 1985 cohort. According to train and motivate teachers. “The ques- cohort of over 1,000 first-graders. The the researchers, this falloff in efficacy of tion we’re trying to address is: What sup- teachers had received 40 hours of prelimi- the GBG indicates a need for continued port does a teacher need to learn a new nary training plus mentoring during the teacher mentoring and support. practice and sustain it over time?” Dr. first year, but none during the second year. The researchers have refined their Poduska says. Followup interviews when these children training methods since 1985, but Dr. [ Continued on page 9 ]

NIDA Notes | Volume 23, Number 1 7 n RESEARCH FINDINGS Young Opioid Abusers Benefit From Extended Buprenorphine-Naloxone Treatment

Despite shorter addiction histories, youths’ risk of relapse following detoxification resembles that of adults.

The study included BY LORI WHITTEN, EXTENDED BUPRENORPHINE-NALOXONE TREATMENT NIDA Notes Staff Writer 152 outpatients from HELPS YOUNG OPIOID ABUSERS Opioid-addicted 15- to rural and urban 21-year-olds who received counseling and continued buprenorphine- pioid-addicted youths ben- community-based, naloxone for 12 weeks with a dose taper in weeks 9-12 abused fewer efit from extended opi- opioids than others who received counseling and a 2-week detoxifica- C T N - a f f i l i a t e d tion. They continued to submit more opioid-negative urine specimens oid maintenance therapy, treatment programs throughout a year of follow-up. reports NIDA’s Clinical in Delaware, Maine, OTrials Network (CTN). In a study by Dr. Maryland, New George Woody of the Delaware Valley Mexico, and North Detoxification 12-Week buprenorphine-naloxone Node of the CTN, the Penn/VA Addic- Carolina. On aver- tion Treatment Research Center, and age, the participants Posttreatment Phase the Penn Center for AIDS Research in were 19 years old and 

Philadelphia, participating 15- to 21-year- had abused opioids  olds who received drug counseling and 12 for 1.5 years at the  weeks of therapy with buprenorphine and start of the study.  naloxone abused a wide range of drugs Fifty-five percent less often than others who received only primarily abused  counseling and a 2-week detoxification heroin, the majority  regimen. by injection; about 

Although buprenorphine-naloxone is 35 percent primar-  an approved medication for people age ily abused painkill-  16 and over, until now clinicians have ers; and 10 percent

Percent Opioid-Negative Urine Test Results Test Percent Opioid-Negative Urine  had little research to guide them on its abused multiple opi- use in teens and young adults. A com- oids. The research-  Baseline       mon approach, offering only short-term ers used randomiza- medication and counseling to young tion procedures to Week Month Study Time people, is based partly on the expectation assign approximately that youths, with their shorter duration equal numbers of of addiction, do not require extended participants to receive either a detoxifi- per week for 12 weeks, with more sessions medication-assisted treatment, as many cation treatment of 2 weeks of outpatient available if necessary. adults do. However, the CTN findings buprenorphine-naloxone (up to 14 mg/day The impacts of the two interventions suggest that risk of relapse following for 3 days, followed by a tapering of the diverged quickly. At the first assessment, detoxification and the potential benefit of dose) or extended treatment of 12 weeks 2 weeks after the end of the detoxification extended buprenorphine-naloxone ther- of buprenorphine-naloxone (up to 24 mg/ regimen, 74 percent of the participants in apy are similar in youths and adults. The day for 9 weeks, followed by dose taper- the extended-maintenance group and findings are timely: Rates of opioid abuse ing that ended in week 12). All patients 39 percent of those who had received among young people have risen during were scheduled to receive their clinics’ only detoxification submitted opiate- the past 10 years, increasing the need for standard counseling interventions in one free urine samples (see graph above). A effective treatments for this population. individual session and one group session similar gap continued through week 8 but

8 NIDA Notes | Volume 23, Number 1 narrowed to 57 percent versus 49 percent response to treatment, his or at the 12-week assessment and widened her commitment to achieving LONGER MEDICATION REGIMEN LEADS TO BETTER RESULTS Extended treatment with again to 60 percent versus 25 percent at full remission without medica- buprenorphine-naloxone improved retention in therapy the final assessment, which took place 1 tion, and whether he or she has and reduced abuse of several drugs by the 12-week year after the start of therapy. Extended attained a sustained period of assessment. therapy still yielded superior results at abstinence and a stable over- Percentage of Percentage every assessment when the researchers all living situation.” Detoxification of Extended- Patients Therapy Patients tallied any missed visit as a positive urine Clinicians need additional Dropped Out of 79 30 sample. Patients in the extended therapy long-term evaluation of opi- Therapy group also stayed in drug counseling lon- oid addiction treatments for Abused an Opioid 55 38 ger, required less additional addiction young people—including During the Past Week treatment, reported less injection drug intensive behavioral therapy, Abused Marijuana 26 16 abuse, used less cocaine, and smoked less buprenorphine-naloxone, and During the Past Week Abused Cocaine marijuana. the opioid-blocking medica- 12 2 “The results of our study suggest tion naltrexone—to identify During the Past Week Injected a Drug During that there is no hurry to stop provid- the regimens that are most 33 16 the Past Month ing buprenorphine-naloxone, an effec- effective over the long haul, tive medication, regardless of a patient’s Dr. Woody says. adolescents and young adults who are short duration of opioid abuse,” says Dr. Dr. Betty Tai, director of NIDA’s Cen- addicted to opioids, including prescrip- Woody. “In my experience as a clinician, ter for Clinical Trials Network, says tion painkillers.” n most opioid abusers—adolescent or that Dr. Woody’s findings suggest that SOURCE adult—prefer to get off medication even- “extended treatment with buprenorphine- Woody, G.E., et al. Extended vs. short-term buprenor- tually. When to stop medication is an indi- naloxone is safe and effective and phine-naloxone for treatment of opioid-addicted youth: vidual decision that depends on a patient’s expands the treatment options for A randomized trial. JAMA 300(17):2003–2011, 2008.

n GOOD BEHAVIOR GAME of outcomes, especially for the children at SOURCES [ Continued from page 7 ] Kellam, S.G., et al. Effects of a universal classroom behav- highest risk. Dr. Kellam says that the study ior management program in first and second grades is the first to link a universal childhood on young adult problem outcomes. Drug and Alcohol In addition to improving student out- intervention with reduced frequency of a Dependence 95(Suppl. 1): S1–S4, 2008. comes, Dr. Kellam notes, the GBG gives psychiatric disorder. Kellam, S.G., et al. Effects of a universal classroom behav- teachers a method of managing classroom Dr. Elizabeth Robertson, chief of pre- ior management program in first and second grades on young adult behavioral, psychiatric, and social outcomes. behavior. He says that many teachers vention research in NIDA’s Division of Drug and Alcohol Dependence 95(Suppl. 1): S5–S28, 2008. find that their preparation for behavioral Epidemiology, Services and Prevention Petras, H., et al. Developmental epidemiological courses management is insufficient, and struggles Research, calls the study results “stun- leading to antisocial personality disorder and violent with class behavior are a primary cause of ning.” She says, “What we are seeing is a and criminal behavior: Effects by young adulthood of a universal preventive intervention in first- and second- teacher burnout. change in the life-course trajectories of grade classrooms. Drug and Alcohol Dependence 95(Suppl. Overall, the researchers conclude, these kids as a result of putting them on 1): S45–S59, 2008. their recent work supports “real opti- the right path early on.” If the GBG were Wilcox, H.C., et al. The impact of two universal random- mism” that a single early, inexpensive to be widely adopted in schools, she adds, ized first- and second-grade classroom interventions intervention can improve a wide variety the public health impact could be huge. n on young adult suicide ideation and attempts. Drug and Alcohol Dependence 95(Suppl. 1): S60–S73, 2008.

NIDA Notes | Volume 23, Number 1 9 ■ RESEARCH FINDINGS Vouchers Boost Smoking Abstinence During Pregnancy

Benefits of therapy include improved fetal growth.

BY SHARON REYNOLDS, drug use, the rewards in the intervention quit smoking from their obstetricians. NIDA Notes Contributing Writer reinforce abstinence from drug use.” After the first week, the research- In the Vermont study, the women ers changed the reward criterion. To hen obstetricians’ chose a day, shortly after their recruit- earn vouchers, the VBRT women now advice was reinforced ment, to stop smoking. To enhance needed to submit a urine sample con- with voucher payments motivation during the difficult early days taining less than 80 ng/ml of cotinine, a for not smoking, preg- of quit attempts, the researchers sched- nicotine metabolite. This more exacting nantW women attained much higher absti- uled monitoring appointments daily for criterion required a longer duration of nence rates, a recent NIDA-funded clini- the first week after each woman’s quit abstinence. The researchers also moni- cal study found. In addition, the women date. At these appointments, the women tored the women only twice weekly and who earned vouchers scored higher than exhaled into a machine that measured eventually reduced the visits to every a control group on two out of three mea- levels of carbon monoxide, a component other week. Each lengthening of the inter- sures of third-trimester fetal growth, a of cigarette smoke, in their breath. The val between monitoring sessions reduced predictor of newborns’ health. The pay- 42 women randomized to VBRT received opportunities for the women to earn vouch- for-proof approach has helped patients a voucher worth $6.25 for their first car- ers and increased the relative importance of addicted to smoking and other drugs in bon monoxide reading below 6 parts per a session in terms of reward. After delivery, previous trials; it was adapted to motivate million. Each successive time they met when women who quit smoking for their pregnant women and new mothers. this criterion, the value of their voucher infants’ sake might have been vulnerable to increased by $1.25. A control group of 40 starting again, the monitoring interval was A LITTLE ADDED INCENTIVE received vouchers worth $15 for show- shortened to once a week for 4 weeks. From Dr. Stephen Higgins, Dr. Sarah Heil, ing up for monitoring, regardless of the weeks 5 to 12 postpartum, the every-other- and colleagues at the University of Ver- results. All women in both groups also week monitoring schedule was resumed. mont recruited 82 pregnant low-income received advice and encouragement to The women in the VBRT group main- smokers for a trial of voucher-based [ Continued on page 13 ] reinforcement therapy (VBRT). Origi- nally developed to treat cocaine abuse, ABSTINENCE AT END OF PREGNANCY QUADRUPLES WITH VOUCHERS More women receiving voucher-based reinforcement therapy, compared with women in the control group, VBRT dispenses cash-value vouchers to were not smoking at the end of their pregnancy and were abstinent 12 weeks after giving birth, patients when they meet objective criteria when the intervention ended. However, the difference between the groups was smaller later. for treatment progress. The value of the voucher awarded mounts with each con- secutive favorable test result but resets Voucher-Based Reinforcement Therapy Control to the base amount if the patient fails to  meet the assigned monitoring criterion. 

Patients exchange vouchers for retail  goods of their choice.  “VBRT uses the same basic principle to treat dependence that’s operative in  Percent Abstinent Percent producing dependence,” explains Dr. Hig-  gins, the developer of VBRT. “Whereas  the rewarding effects of drugs reinforce Middle of End of 12 Weeks 24 Weeks Pregnancy Pregnancy After Birth After Birth

10 NIDA Notes | Volume 23, Number 1 ■ RESEARCH FINDINGS Attention to Bipolar Disorder Strengthens Substance Abuse Treatment

Integrated group counseling improves outcomes in a difficult-to-treat dual-disorder population.

BY NIDA NOTES STAFF majority had both alco- PEOPLE WITH BIPOLAR DISORDER REDUCE ubstance abuse compounds hol and drug disorders; SUBSTANCE USE MORE WITH INTEGRATED the problems of people with the most common pri- GROUP THERAPY bipolar disorder. Individuals mary drugs of abuse, in Drug IGT * with this comorbidity get less order of prevalence, were Counseling benefitS from their mood disorder treat- marijuana, cocaine, seda- Average days of substance use per month ment, recover more slowly from mood tives, and opioids. The Before group therapy 10.2 13.3 swings, spend more time in hospitals, and researchers randomly During group therapy 5.3 10.0 commit suicide more often. They also are assigned them to receive During the 3 months after 6.0 12.0 less responsive to drug abuse treatment either IGT or standard, group therapy than noncomorbid individuals, but a new manual-based substance Average days of alcohol use per month psychosocial intervention may partially abuse counseling once Before group therapy 9.3 7.8 alleviate this disadvantage. The inter- per week in groups of six During group therapy 4.4 6.5 vention, called integrated group therapy to eight. The two treat- During the 3 months after 4.5 7.8 (IGT), simultaneously focuses on sub- ment groups did not dif- group therapy stance abuse and bipolar disorder. In a fer in terms of patients’ Average days of illicit drug use per month recent NIDA-funded clinical trial, IGT diagnostic categories, Before group therapy 6.7 9.7 reduced patients’ substance use more mood-stabilizer regi- During group therapy 2.1 5.2 than standard substance abuse group mens, baseline substance During the 3 months after 3.4 6.5 counseling did. use problems, or concur- group therapy

“People with these disorders often feel rent participation in indi- *Integrated Group Therapy hopeless about ever getting better,” says vidual counseling and Dr. Roger D. Weiss, professor of psychia- 12-step programs. try at Harvard Medical School and chief of The IGT intervention is based on stance use without providing explicit ref- the Division of Alcohol and Drug Abuse at a cognitive-behavioral therapy model erences to bipolar disorder signs or symp- McLean Hospital in Belmont, Massachu- for relapse prevention. In each session, toms. When patients raised mood-related setts. “They often feel that no matter what patients reported on their previous week’s issues, counselors responded briefly and they do, it doesn’t help; so they may stop substance use, mood swings, medication referred them to the physicians who had trying.” Dr. Weiss and colleagues devel- adherence, and high-risk situations. Clini- prescribed their mood-stabilizing medi- oped and tested IGT with support from cians addressed the connections between cations. Counselors responded to mood- NIDA’s Behavioral and Integrative Treat- bipolar disorder and substance abuse, related emergencies, however, with clini- ment Development Program. covering topics such as methods to deal cally appropriate interventions. with depression without using alcohol or During the 20-week trial, recipients of TESTING THE APPROACH illicit drugs. both therapies reduced their alcohol and All of the study’s 62 participants had In the standard group drug counsel- illicit drug use as assessed by urine toxi- both bipolar disorder and substance ing format, sessions began with patients’ cology and self-reports (see table). The dependence, and all were taking mood- reports on substance use and craving. IGT group showed greater reductions, and stabilizing prescription medications. The These groups focused primarily on sub- those in the group who achieved a month-

NIDA Notes | Volume 23, Number 1 11 Community-Friendly Version of Integrated Group Therapy Shows Promise

Although their research demonstrated that integrated group Both treatments helped patients reduce their days of substance therapy (IGT) can foster recovery in abusers with bipolar dis- use. Comparing results from the month before treatment began order, a group of Massachusetts scientists recognized barri- to the last month of treatment, drug use dropped from 18.6 ers that might prevent community programs from adopting dayso t 4.4 days in the modified IGT group and from 17.9 days the treatment. Now, they report that during a 12-week study, to 6.5 days in the group receiving standard drug counseling. Of patients who received a modified IGT therapy, designed espe- the patients who received modified IGT, 71 percent attained at cially for delivery in community addiction treatment programs, least 1 month of abstinence from both drugs and alcohol during were nearly twice as likely as those in standard drug counseling treatment, compared with 40 percent of those in standard group to attain 1 month of abstinence from illicit drugs and alcohol drug counseling. Modified-IGT patients also achieved their first and nearly three times as likely to abstain for the entire period. monthf o abstinence sooner than those in group drug counsel- ing. Moreover, 36 percent of the men and women who partici- Dr. Roger D. Weiss, professor of psychiatry at Harvard Medical patedn i modified IGT were abstinent throughout all 3 months School and chief of the Division of Alcohol and Drug Abuse at of treatment, compared with only 13 percent of the patients in McLean Hospital in Belmont, Massachusetts, and colleagues standard counseling. made three major changes in their IGT treatment: •o T increase the likelihood of insurance reimbursement, About0 7 percent of patients reported depression, mania, they decreased therapy from 20 to 12 group sessions. or a mixture of the two during treatment. Patients receiving • Rather than using counselors with experience in both modified IGT, however, were more than twice as likely as those substance abuse and psychiatric disorder treatment, the in group drug counseling to be abstinent and to report no mood modified IGT program was delivered by addiction counsel- disorder episode during the final month of treatment. ors who had received general information on bipolar dis- order and the cognitive-behavioral therapeutic approach “If the findings are borne out in future studies with larger num- but who had little experience in these areas. bersf o patients, community addiction treatment programs • Rather than participating as a single group for a pre- could benefit from adding modified IGT to mood-stabilizing defined 12-week period, patients could join ongoing group pharmacotherapies for people with co-occurring substance therapyt a any time, which is the usual practice in most abuse and bipolar disorders,” says Dr. Lisa Onken, chief of NIDA’s community treatment programs. Behaviorial and Integrated Treatment Branch. “This approach might not only improve outcomes in this difficult-to-treat group Allf o the new study’s 61 participants were taking mood- but o also d so in a community-friendly way,” she adds. stabilizing medications. They were randomly assigned to one of SOURCE two treatment groups and further divided into groups of six to Weiss, R.D., et al. A “community-friendly” version of integrated group therapy eight members led by clinicians who provided either the modi- for patients with bipolar disorder and substance dependence: A randomized fied r IGT o standard, manual-based substance abuse counseling. controlled trial. Drug and Alcohol Dependence 104(3):212–219, 2009. long period of abstinence did so earlier alcohol problems. “There was more room received higher scores on two measures than participants in the standard counsel- for improvement and perhaps greater of mood symptoms than did members of ing group. In the 3 months following the motivation among patients to address the drug counseling groups. “It is unclear therapy, substance use remained lower their drinking,” Dr. Weiss says. whether this reflects true mood differ- in the IGT group but returned to baseline Although IGT focuses on mood disor- ences or an increased awareness among levels in the standard counseling group. ders as well as substance abuse, IGT group IGT participants of mood symptoms more Alcohol use dropped more than illicit members experienced mood disorder epi- subtle than those that cause a bipolar epi- drug use in both groups. This result may sodes as frequently during and after treat- sode,” Dr. Weiss says. He notes that IGT reflect the greater severity of the patients’ ment as they had before. In fact, they also encourages early recognition of mood

12 NIDA Notes | Volume 23, Number 1 changes, and he suggests that reduced dropouts, they were surprised to find that “In addition, because IGT is group substance use may temporarily worsen 11 were smokers. (Of the 49 participants therapy, it’s more likely to be used in com- mood in people with bipolar disorder. who completed the study, 24 were smok- munity drug treatment centers, providing ers.) The researchers say that smokers more individuals with comorbid bipolar APPRECIATION AND ENGAGEMENT with bipolar disorder may represent a and substance use disorders access to According to Dr. Weiss, the partici- subgroup that requires special efforts to an evidence-based treatment that was pants in the IGT group appreciated hav- engage in substance abuse treatment. designed specifically for their needs,” Dr. ing a treatment program tailored to their “IGT shows a lot of promise,” says Onken adds. n needs. “Many of our people had bounced Dr. Lisa Onken, chief of NIDA’s Behav- S O U R C E S back and forth between specialty pro- ioral and Integrative Treatment Branch. Weiss, R.D., et al. A randomized trial of integrated grams for substance abuse and bipolar “Before Dr. Weiss and his colleagues began group therapy versus group drug counseling for disorder, and in each program they felt their work, we had many questions about patients with bipolar disorder and substance depen- dence. American Journal of Psychiatry 164(1):100–107, that only some of their issues were being how to treat people with bipolar and sub- 2007. addressed,” Dr. Weiss says. stance abuse disorders. The finding that Graff, F.S., Griffin, M.L., and Weiss, R.D. Predictors Twelve study participants dropped out IGT reduces days of substance use disor- of dropout from group therapy among patients with of therapy. When Dr. Weiss and colleagues der indicates that this program is a mean- bipolar and substance use disorders. Drug and Alcohol analyzed the characteristics of these 12 ingful step in the right direction. Dependence 94(1-3):272–275, 2008.

n VOUCHERS the control group. “It’s known that smok- likely to be a one-size-fits-all approach to [ Continued from page 10] ing retards fetal growth, but demonstrat- quitting smoking during pregnancy. “We tained abstinence for 9.7 weeks of their ing that a treatment actually increases anticipate needing an array of interven- pregnancy, on average, compared with growth is pretty rare,” says Dr. Higgins. tions tailored to these women,” he says. 2.0 weeks in the control group. Forty-one “These findings are quite exciting, pro- The impressive increase in absti- percent of the VBRT women but only 10 viding promising preliminary evidence of nence among women in the VBRT group percent of the control group were absti- an association between higher abstinence during pregnancy dropped by 24 weeks nent at their last assessment before giv- rates in the third trimester and greater postpartum: 8 percent remained absti- ing birth. Twenty-four percent of women fetal growth,” says Debra Grossman of nent, compared with 3 percent of the in the VBRT group sustained abstinence NIDA’s Division of Clinical Neuroscience control group. However, an earlier study throughout the entire third trimester of and Behavioral Research. “In addition to by these investigators using the same pregnancy, compared with only 3 percent the health benefits observed, VBRT may conditions showed a bigger disparity: of women in the control group. The clin- also provide cost savings, given the high 27 percent of women in the VBRT group ic’s outlay for vouchers to the women in medical costs for infants associated with remained abstinent at 24 weeks post- the VBRT group averaged $461 per partici- maternal smoking.” partum compared with none in the pant and ranged from $0 to $1,180. Although the success rate for this inter- control group. vention was high relative to conventional Although abstinence may have been MORE ROBUST FETAL GROWTH therapies, Dr. Higgins notes that 59 per- short-lived, VBRT benefits were substan- The researchers obtained ultrasound cent of the women who received VBRT tial, especially in terms of fetal health. measurements in the 30th and 34th weeks continued to smoke throughout their “Even if the effects only lasted while the of 57 women’s pregnancies to ascer- pregnancies. The researchers are cur- intervention was in place, that would be tain whether VBRT also promoted fetal rently testing whether offering greater a good thing for these women and their growth. While previous studies found cor- rewards at the start of the intervention babies,” Dr. Higgins concludes. n relations between smoking abstinence, or making changes in the voucher sched- greater fetal growth, and higher neonatal ule could help more women quit. “Based SOURCES Heil, S.H., et al. Effects of voucher-based incen- birth weight, experimental evidence of the on what we know from our research and tives on abstinence from cigarette smoking and relationship has been considered weak. that of other researchers in the field, the fetal growth among pregnant women. Addiction The ultrasound results showed greater amount of the reward for changing behav- 103(6):1009–1018, 2008. fetal growth in the 29 women in the VBRT ior matters a lot,” says Dr. Heil. Higgins, S.T., Silverman, K., and Heil, S.H. Contingency Management in Substance Abuse Treatment. New York, group, compared with the 28 women in Dr. Higgins notes that there is not NY: The Guilford Press, 2008.

NIDA Notes | Volume 23, Number 1 13 n BULLETIN BOARD

Dr. Phil Skolnick Now Leads postdoctoral fellows, young investigators, and others who are NIDA’s Medications Development new to publishing. Efforts The tutorial, partly funded by NIDA and the World Health Organization, is accessible at www.parint.org/tutorial.cfm. Dr. Phil Skolnick has joined NIDA as Each of its 10 modules is based on one or more chapters from director of the Division of Pharmacother- the book, Publishing Addiction Science: A Guide for the Per- apies and Medical Consequences of Drug plexed, 2nd Edition. Chapter topics range from how to choose Abuse. Dr. Skolnick, who has extensive a journal to how to avoid the “seven deadly sins of scientific experience in corporate and academic publishing.” One chapter, devoted to the special challenges drug research, will lead a NIDA team that faced by researchers from developing and non-English-speaking stimulates and conducts all phases of countries, discusses ways these researchers can improve their medications development and supports chances of publishing in English-language journals and deter- clinical trial infrastructure. mine when the public interest is best served by publishing in “We are delighted to have Dr. Skolnick join our team of their local languages. scientists looking for solutions to the management of drug The book can be read or downloaded at no charge from www. addiction,” says NIDA Director Dr. Nora D. Volkow. “His many parint.org/isajewebsite/isajebook2.htm. Hard copies of the book remarkable years of innovation and leadership in both public can be ordered from Multi-Science Publishing Company, Ltd., and private research arenas will strengthen our complex medi- 5 Wates Way, Brentwood, Essex CM15 9TB, United Kingdom; cations development process and enhance our search for phar- fax: +44(0)1277 223453; www.multi-science.co.uk/addiction- macotherapeutic and immunological treatment agents.” science.htm. ISAJE is a London-based international organization Prior to joining NIDA, Dr. Skolnick was a research professor devoted to improving the quality of publishing in addiction and of psychiatry at New York University Langone Medical Center. related sciences, particularly in the areas of publication ethics He served as Chief Scientific Officer at DOV Pharmaceutical, and research integrity. Inc., from 2001 to 2009 and led the discovery and development of compounds that may ultimately help treat a variety of James A. Inciardi (1939–2009) neuropsychiatric disorders. Dr. Skolnick’s appointment marks a return to the National Institutes of Health, which he first Dr. James A. Inciardi, founder and co-director of the Center for joined in 1972 as a staff fellow and in which he later held vari- Drug and Alcohol Studies and professor of sociology and crimi- ous leadership positions in neurobiology and neuroscience. Dr. nal justice at the University of Delaware, died on November 23 Skolnick left government service in 1997 when he accepted a after a long battle with cancer. A pioneer of drug abuse and crim- position in the private sector at Eli Lilly. inal justice research, Dr. Inciardi’s research influenced policy “I am delighted to return to the NIH community, which was and program development in these fields. a wonderful professional home for 25 years,” says Dr. Skolnick. Before receiving his doctorate in sociology in 1973, Dr. “My new position at NIDA will enable me to take what I have Inciardi worked as a jazz drummer and a New York City parole learned in the private sector about medications development officer. As a researcher, he conducted seminal studies on the link and apply it to the challenging field of drug abuse and between drug abuse and criminal activity and developed thera- addiction.” peutic interventions for criminal offenders—work that formed a treatment model now used internationally. His research on the How-To Guides Provide Tips for connection between drug abuse and HIV infection and trans- Publishing Addiction-Related mission, and later on interventions for people at high risk of the infection, led to programs in probation and community settings. Articles Until his death, Dr. Inciardi continued working on studies of Students and practitioners of addiction science who are inter- prescription drug abuse, approaches to case management for ested in publishing their studies in scholarly journals can find vulnerable women, and a new ethnography of drug abuse in tips for doing so in a book and online tutorial developed by the Brazil. He published over 500 articles, chapters, books, and International Society of Addiction Journal Editors (ISAJE). monographs and was a fellow of the American Society of The book and related tutorial are targeted to graduate students, Criminology. n

14 NIDA Notes | Volume 23, Number 1 ■ TEAROFF Information to clip, save, and share

Reality Videos Bring ONLINE VIDEOS INFORM STUDENTS AND PARENTS ABOUT DRUG ABUSE In the “New Media” section of NIDA’s Web site for teens, Dr. Ruben Baler of NIDA’s Office of Science Policy and NIDA Scientists to Web Communications speaks to teens as he works out (top frame), and Harlem students and their parents pose questions to NIDA Director Dr. Site for Teens Nora D. Volkow (bottom frame).

n fast-moving, 2-minute video clips on NIDA’s Web site for teens, NIDA staff scientists pause in the midst of vari- ous recreational activities to speak about the dangers of Idrug abuse. In NIDA’s version of reality television, accessible at teens.drugabuse.gov/new_media/video.php: n Dr. Redonna Chandler and Dr. Gaya Dowling, while shoot- ing pool, react to a cloud of cigarette smoke left behind by a poolroom patron. Dr. Chandler asks the viewer, “Did you know that nicotine is one of the most widely used addictive drugs?” A title card pops up displaying the information that 60 percent of smokers report starting before age 18. “That’s scary because teens respond differently to nicotine than adults do,” Dr. Dowling says as she sets up a shot. “And that’s why it could be harder for you to quit,” she adds, driving the eight ball into the pocket. The two scientists continue to pro- vide information in the course of their play and conversation. n Dr. Ruben Baler, attired in sweats, works out at a gym. “Steroids can weaken your body’s ability to defend against germs and diseases,” Dr. Baler tells the viewer as he lifts and lowers a barbell. “The fact is that, after a while, people on steroids can become aggressive or even depressed . . . but that’s not all. If you’re a guy, steroids can lower your testos- terone levels, reduce your sperm count, and even shrink your testicles.” He winces in pain at the thought. This video is presented in both English and Spanish. n Dr. Joe Frascella, while perusing snack bar offerings in a movie theater, contrasts the depiction of marijuana in many films with the drug’s real dangers. Taking his seat, he tallies the drug’s potential adverse effects, including addiction. n Dr. Cindy Miner and Dr. Joni Rutter duel as pitcher and n Detailed answers to frequently asked questions about how batter on a softball field. A beanball prompts discussion of the common drugs of abuse affect the brain and body. value of painkillers when prescribed by a doctor versus their n Stories from teens who have experienced or witnessed the potential consequences when taken otherwise. devastating effects of drugs and addiction. The site also features longer videos of NIDA Director Dr. Nora n Word games and multimedia activities that test knowledge of D. Volkow answering students’ drug-related queries at a Harlem, drug abuse and addiction. New York, high school and responding to questions from their parents about how and when to talk with kids about drugs. Teens can download freebies from the site as well, such as sticker designs, T-shirt iron-ons, and computer icons. The site The NIDA for Teens Web site (teens.drugabuse.gov) is also provides links to Facebook, other social networking sites, designed to appeal to youth between ages 11 and 15 and to be use- and NIDA’s home page, www.drugabuse.gov. In addition, teach- ful to teachers and parents. Visitors can choose from many fea- ers will find downloadable quizzes to test their students’ knowl- tures and activities, including: edge of drugs and their effects. ■

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i o o f ime t ypical t The se rug njection f nset rom nfection o i t u d 

Injection Drug Users Acquire Hepatitis C Infection Later in Developed Countries Countries Developed in Later Infection C Hepatitis Acquire Users Drug Injection

WHAT THE NUMBERS SAY NUMBERS THE WHAT ■