2023 NIDA International Forum Executive Summary

June 8-9, 2023               
Virtual Meeting

The NIDA International Program’s leadership team of Dr. Tom Clarke and Dr. Lindsey Friend, co-chaired the 2023 NIDA International Forum, which was held virtually on June 8-9, 2023, in conjunction with the College on Problems of Drug Dependence (CPDD) Annual Scientific Meeting. Six hundred attendees from 80 countries participated in the Forum, and 99 posters from 40 countries were presented on the meeting’s virtual platform. Two virtual plenary sessions featured presentations by 25 researchers from 18 nations and 10 time zones. The NIDA International Program supported 12 travel awards to researchers to attend the in-person Annual CPDD Scientific Meeting in Denver, Colorado, held June 17 to 21, 2023.

Following are brief summaries of the topic sessions presented at this year’s International Forum.

Welcome and NIDA Update

After a welcome by NIDA Deputy Director Dr. Wilson Compton, Dr. Clarke and Dr. Friend opened the meeting with an update of NIDA’s programs. Dr. Clarke provided a high-level overview of NIDA’s research priorities, which include the following:

• Goals specified in NIDA’s 2022 to 2026 strategic plan, including (1) understanding drugs, the brain, and behavior; (2) prevention, treatment, and recovery; (3) the intersection of substance use and HIV; (4) implementation science; and (5) innovative health applications;
• NIH Helping to End Addiction Long-term® Initiative, or NIH HEAL Initiative® — an NIH-wide effort to seek scientific solutions to the opioid health crisis by enhancing pain management, improving treatment of opioid misuse and addiction, and preventing opioid use disorder;
• Large programs, such as the HEALthy Brain and Child Development (HBCD) study, Adolescent Brain Cognitive Development (ABCD) study, Harm Reduction Research Network; the HEAL Initiative’s Justice Community Opioid Innovation Network (JCOIN); and HEALing Communities Study;
• Development of pharmacological and nonpharmacological approaches for treating substance use disorders and overdose;
• Activities of the HIV Research Program Office;
• Psychedelic drugs as treatment for a variety of mental health conditions; 
• The emerging threat of increasing overdose deaths from the non-opioid veterinary sedative xylazine;
• Research gaps and barriers in substance use research, such as stigma, the persistent treatment gap, prevention infrastructure, provider training, reimbursement, medication development, continuity of care, and help for justice-involved populations. 

Dr. Friend summarized the activities of the NIDA International Program:

• Approximately 10% of NIDA grants support international research, primarily as grants to U.S. researchers partnering with foreign investigators.
• NIDA’s international training and research programs include:
• INVEST postdoctoral fellowships — 12-month fellowships for international researchers with a doctoral degree and a minimum of 2 years’ postdoctoral experience,
• Hubert H. Humphrey Fellowships — mid-career fellowships that include a 10-month research fellowship at Virginia Commonwealth University as well as 6-week professional affiliations.
• To date, fellowships have been awarded to 383 researchers from 101 countries.

Scalable Treatment and Care for Psychoactive Stimulant Use Disorders — Evidence, Clinical Practice, and Emerging Research

This session, chaired by Dr. Anja Busse (United Nations Office on Drugs and Crime [UNODC]), included five presentations:

• Mr. Kamran Niaz, M.B.B.S., M.P.H. (UNODC), summarized the epidemiology of stimulant use — including cocaine, amphetamines, and ecstasy — across the globe.
  • Stimulant use is at least as common as opioid use; 0.7% of the global population in 2020 reported using amphetamines in the past year.
  • Stimulant use patterns and use of specific amphetamines differ among regions and countries; moreover, polydrug use is common.
  • While men generally are more likely to use drugs than women, the gender gap is quite narrow for amphetamines and nonmedical use of pharmaceutical stimulants.
  • Psychosocial and pharmacological treatment of stimulant use disorder is a key pillar in national drug policies of most countries; however, many countries do not have standard operating procedures and quality control.
• Dr. Steven Shoptaw (UCLA) reported on established and emerging psychosocial interventions for treatment of stimulant use disorders.
  • Contingency management was 40% to 60% more effective and acceptable than treatment as usual; its advantages include flexibility and adaptability to international settings, including low and middle income (LMI) countries.
  • For cognitive behavioral therapy and motivational interviewing, there is insufficient evidence for efficacy in the treatment of stimulant use disorder.
  • Making any kind of treatment available is important; each treatment may work for some clients but not others, and cost and chronicity also influence treatment decisions.
• Dr. Nadine Ezard, Dr. Brendan Clifford, and Dr. Krista Siefried (National Centre for Clinical Research on Emerging Drugs and St. Vincent’s Hospital in Sydney, Australia) reviewed emerging pharmacological interventions for the treatment of methamphetamine use disorder.
  • A 2020 systematic review yielded no convincing results for any of the 23 pharmacotherapies evaluated.
  • Agonist therapy, naltrexone, and topiramate yielded the most consistent positive findings.
  • Benefits of bupropion and mirtazapine were inconsistent; however, bupropion combined with naltrexone and mirtazapine has yielded promising results.
  • Emerging pharmacotherapies, such as lisdexamfetamine, are being investigated for methamphetamine dependence and withdrawal.
  • Agonist (dexamphetamine, lisdexamfetamine) therapy offers improved safety and can attenuate both methamphetamine’s negative reinforcing effects and tolerance to its positive reinforcing effects.
  • A pilot study of lisdexamfetamine showed good tolerance, and preliminary findings from a randomized controlled trial of the medication for methamphetamine dependence found similar rates of adverse events to placebo and greater retention in treatment.
  • In a pilot study of lisdexamfetamine for treatment of acute methamphetamine withdrawal, the drug showed good safety, high treatment acceptability, and improved withdrawal severity and craving.
  • Future research directions include use of these medications for cocaine use disorder, harmonization of outcome measures and eligibility criteria to allow for meta-analyses, and the relationship between pharmacotherapy and psychotherapy approaches.
• Three investigators described the current situation, practices, and challenges in stimulant use disorder treatment in Vietnam, Brazil, and South Africa.
  • Dr. Le Minh Giang (Hanoi Medical University, Vietnam) reported that in Vietnam, stimulant use has been increasing in the past decade, particularly in men who have sex with men, people with opioid use disorder, and female sex workers.
    • The country’s response emphasizes compulsory center-based rehabilitation.
    • An ongoing NIDA-funded trial seeks to identify optimal and cost-effective combinations of evidence-based interventions for methamphetamine-using people with opioid use disorder who are on methadone maintenance therapy.
  • Dr. Thiago Marques Fidalgo (Universidade Federal de São Paulo, Brazil) reported that more than 3% of Brazilians have used cocaine during their lifetime and 0.2% have cocaine use disorder.
    • Challenges to addressing this problem include difficulty implementing psychosocial interventions as well as lack of medications and trained staff.
    • Inpatient treatment with abstinence as the main goal and strong religious influences remains the primary treatment approach.
    • Recent research has evaluated other approaches, some of which showed some effectiveness for cocaine but not methamphetamine use disorder.
  • Dr. Goodman Sibeko (University of Cape Town, South Africa) reported that assessing the situation is challenging because only few data are available for the country.
    • According to some studies, methamphetamine was the second-most common substance overall and the most commonly used substance during pregnancy.
    • Local treatment studies found that contingency management can be efficacious and result in good outcomes, including cognitive benefits.
• Dr. Dzmitry Kruchanka (World Health Organization [WHO] Department of Mental Health and Substance Use) presented the WHO Mental Health Gap Action Programme (mhGAP).
  • mhGAP seeks to scale up services for mental, neurological, and substance use disorders, including stimulant use disorders, in nonspecialized settings, particularly in LMI countries.
  • For drug use disorders, mhGAP recommendations include:
    • Strong recommendation that adults using psychostimulants should be offered screening and brief interventions (SBIRT) and conditional recommendation that adults with hazardous psychostimulant use who do not respond to SBIRT should be referred to specialist intervention.
    • Strong recommendation for psychosocial interventions (cognitive behavioral therapy and contingency management) for people with cocaine and stimulant dependence and conditional recommendation against pharmacological interventions (dexamphetamine, methylphenidate, modafinil) for these individuals due to safety concerns.
    • Conditional recommendation that digital interventions should be considered for adults using drugs or with drug use disorders.

International Research and Training: Needs, Opportunities, and Challenges

This session moderated by Carly Michael Searcy (International Consortium of Universities for Drug Demand Reduction [ICUDDR]) included three presentations by recipients of NIDA mini grants to investigate barriers to research, address disparities, and improve research capacity in LMI countries.

• Dr. Stephen Asatsa (Catholic University of Eastern Africa, Nairobi, Kenya) conducted a survey on COVID-19 pandemic-related impacts and addiction severity among service users in selected substance use treatment facilities in Nairobi.
  • During the pandemic, treatment facilities as well as social places for drinking were closed to reduce infection risk.
  • Survey respondents reported significant increases on most measures of addiction severity during the pandemic (i.e., in early 2022).
  • Changes in physical health had the greatest impact on various indicators of addiction severity; work life, home life, social life, and emotional health also played a role.
• Dr. Gladys Bett (University of Kabianga, Kenya) examined the role of guidance and counseling in addressing cannabis use among university students in Kenya’s South Rift region.
  • Cannabis use prevalence in Kenya has increased 90% over the past 5 years; among youth, the main reasons for drug use include peer pressure, curiosity, stress, frustration, and feeling good.
  • A descriptive survey of 1,736 students using the Cannabis Use Disorder Identification Test (CUDIT) questionnaire found that about 10% of students used cannabis.
  • Prevention and treatment strategies and programs had been implemented in institutions of higher learning and had played a significant role in addressing cannabis use.
• Dr. U. Venkatesh (All India Institute of Medical Sciences, Gorakhpur, India) studied determinants of substance use (nonmedical use of prescription drugs, alcohol, tobacco, illicit drugs, and injection drugs) among people ages 10 to 24 years attending urban and rural primary health centers across India.
  • Among the 1,630 participants, substance-use prevalence was 32.9%, ranging from 7.5% to 89.0% among states.
  • The most commonly used drugs were tobacco and alcohol, followed by cannabis.
  • Risk factors for any substance use included male gender, living in urban areas, having a family history of substance use, being employed, and having low socioeconomic status; risk factors for high or moderate substance use included being employed and being divorced or widowed.

International Cannabis Policy and Implications for Research

This session, chaired by Dr. Gillian Schauer (Cannabis Regulators Association), compared cannabis policies in the United States, Canada, Uruguay, and France. Presenters identified a range of research gaps that need to be addressed in their countries.

• Dr. Schauer described cannabis policies in the United States.
  • Cannabis regulation occurs at both the federal and state level.
  • At the federal level, Cannabis Sativa plants with up to 0.3% delta-9 THC by weight are classified as hemp and are considered agricultural plants; plants with more than 0.3% delta-9 THC are classified as cannabis and are illegal.
  • Among states, cannabis policies differ greatly, and legalization of cannabis products continues to evolve; currently, about half the states have legalized both adult recreational use and medical use, whereas many others only have a legal medical cannabis program.
  • Guiding principles for state cannabis regulations are consumer safety, public health and safety, equity, market stability, and economic growth; focus is also on social equity, restorative justice, and parity in regulatory frameworks across all cannabis products.
• Dr. Hanan Abramovici (Health Canada) reviewed Canada’s current cannabis policies based on the 2018 Cannabis Act.
  • Cannabis use is high, particularly among youth and young adults, and a pervasive illegal cannabis market exists throughout the country.
  • The Act seeks to restrict cannabis access for youth and control it for adults, provide oversight over the legal cannabis industry, regulate the supply chain, and establish penalties for illegal activities to protect public safety; implementation occurs at the level of provinces, territories, and local governments.
  • At 4.5 years after the Act’s implementation (which included the COVID-19 pandemic), cannabis use and daily/near-daily use in youth remained stable, while cannabis consumption in general increased.
  • The Act succeeded in reducing the illegal cannabis market and increased purchases from legal sources.
  • The main negative outcome was an increase in accidental cannabis poisoning, particularly in children under age 5.
• Dr. Daniel Radío (National Drug Board of Uruguay) described the country’s perspective as a regulated cannabis market.
  • Uruguay protects the rights of the individual to possess substances and has never penalized substance possession for personal use; this approach has not resulted in greater cannabis consumption than in other countries.
  • All activities related to the regulated cannabis market are governed by a law that establishes rules on how adults can legally access cannabis for nonmedical purposes as well as mandates educational, awareness-raising campaigns, such as information booklets, audiovisual, and digital media. 
  • Implementation of these regulations did not change trends of cannabis use or demand for cannabis treatment; consumption of products associated with the illegal cannabis market has decreased, and people initiate cannabis use at a later age.
• Ivana Obradovic (French Monitoring Centre for Drugs and Drug Addiction) reported that France has not legalized any cannabis use:
  • All drug use, including cannabis, has been criminalized since 1970, even for medical use.
  • Nevertheless, France has one of the highest cannabis use rates for youth and young adults in Europe, although prevalence has decreased over the past decade.
  • Despite much debate, restrictions have not been relaxed to date and instead a flat-rate fine for simple drug use been implemented.
  • The illegal cannabis market has grown, and presence of synthetic cannabinoids, THC potency, and violent crime related to cannabis trafficking has increased.
  • A project for a strategic analysis of regulatory cannabis policies — the ASTRACAN Project — has been launched to provide more information for policy makers in Europe and France.

Substance Use Disorder Issues and Rural Health

This session, which was co-chaired by Dr. Friend and Dr. Wendy Kliewer (Virginia Commonwealth University), included three presentations:

• Dr. Darika Saingam (current INVEST fellow, Johns Hopkins Bloomberg School of Public Health) described research on kratom use in rural areas of southern Thailand.
  • The use of kratom, one of the most commonly used drugs in Thailand, was controlled for 80 years but was legalized in 2021. 
  • Kratom is widely available; often home-grown; and used to increase energy, for recreational purposes, and in traditional medicines.
  • Use can cause intoxication, and long-term use can lead to dependence and withdrawal symptoms; however, most kratom users have no serious health, mental health, or social problems.
  • Kratom misuse in the form of “kratom cocktails” that also include codeine cough syrup and/or other addictive substances can lead to health problems and addiction.
  • Treatment often involves self-treatment with other herbs and massage therapy.
  • Kratom and kratom cocktail are frequently used by heroin users as a substitute drug, which may be associated with reduced withdrawal symptoms and heroin use cessation.
• Ashwag Abdulrahim (current Hubert H. Humphrey Fellow, Virginia Commonwealth University) described access to health care in rural settings in Sudan.
  • Great geographic health-related disparities exist in Sudan with respect to financial and human resources, access, and outcomes.
  • Several national reforms over the past 5 years have resulted in universal health coverage, but challenges remain in rural areas (e.g., related to infrastructure; workforce; availability of specialized services; and cultural, linguistic, and geographical barriers).
  • Efforts to address these challenges include measures to address workforce shortages, availability of mobile clinics and outreach programs, and implementation of community health committees to engage rural communities in decision-making processes as well as health education and awareness.
• Marcella Katjijova (MarKatjie Investment CC, Namibia; former Hubert H. Humphrey fellow), presented her project to address substance use problems by impacting society at the roots.
  • Poverty; intergenerational trauma (e.g., from colonization and Apartheid); and adverse experiences such as rape, molestation, teen pregnancy, and abortion are prevalent in Namibia; they contribute to use of alcohol and other substances to cope with adversity.
  • Ms. Katjijova’s project educates rural communities about the roots of substance use, including the influence of adverse childhood experiences on development, mental health, physical health, and drug use.
  • It includes talks and workshops for youth, adults, pastors/teachers, and police/first responders, as well as radio interviews or social media posts, addressing audiences at their level.

PAHO Media Campaigns Addressing Addiction Issues

Dr. Maristela Monteiro (formerly of the Pan American Health Organization [PAHO]) described recent media campaigns launched by PAHO to stem alcohol misuse.

• The COVID-19 pandemic was accompanied by an “infodemic” related to alcohol and other health issues, and it was important to provide accurate information.
• The first campaign, “Live better, drink less,” ran for 2 months in 2021 and focused on alcohol-related harms through videos, posters, radio spots, and fact sheets; the second campaign, “Live better, take action,” followed in 2022.
  • While the 2021 campaign reached more people, the 2022 campaign resulted in significantly greater engagement.
• The 2021 media campaign was linked with the launch of an interactive artificial intelligence (AI) health resource, Pahola, that provides anonymous and confidential information on alcohol-related topics and was intended as a cost-effective approach to enhance alcohol health literacy.
  • While the project reached more than 1.6 million people with its content, only few really engaged with it.
  • AI approaches like Pahola may need to be placed within health systems or close to specific target population to achieve greater effectiveness.

Building a Global Quality Assurance System for Treatment Services and Systems 

This session chaired by Brian Morales (Bureau of International Narcotics and Law Enforcement Affairs at the U.S. Department of State) included four presentations.

• Dr. Marica Ferri (European Monitoring Centre for Drugs and Drug Addiction [EMCDDA]) reviewed European efforts in quality assurance of treatment services.
  • In Europe, quality assurance is based on the 2011 European Drug Prevention Quality Standards (EDPQS), which are available in several languages and include 16 aspirational standards for prevention, treatment, and harm reduction, with the goal of implementing a client-centered approach.
  • EMCDDA has developed a six-step guide to implementing quality standards for drug services and systems. These are: (1) diagnosis of need, (2) identification of scope, (3) mapping and selection of applicable standards (e.g., international, national, service-related, human resource-related), (4) assessment of systems and services, (5) sharing and using results, and (6) preparing for the next cycle to ensure continuous evaluation.
  • EMCDDA has developed a training program on quality standards, including two core modules and four drug-specific modules that include e-learning and a virtual community of practice (VCP) platform.
• Dr. Busse (UNODC) discussed key quality standards for service appraisal when conducting quality assurance in treatment for drug use disorders.
  • While U.N. member states have committed to providing treatment services, these services often are ineffective or even harmful and may violate human rights.
  • “International Standards for the Treatment of Drug Use Disorders” were published in 2020 to assist member states in developing and expanding evidence-based, effective, and ethical treatment services and systems; these Standards have become a reference point regarding quality drug use disorder treatment.
  • Key Quality Standards for Service Appraisal were created that specify criteria for (1) effective service management; (2) individualized, patient-centered treatment and care; (3) timely access to evidence-based interventions; and (4) patient health, safety, and human rights.
  • Combined with other quality assurance tools and technical as well as financial assistance, the Key Quality Standards can help increase and improve treatment.
  • Quality assurance needs to address treatment outcomes; a 2023 scoping review found that timely access to treatment, greater satisfaction with treatment, and continued access to treatment all were associated with better outcomes.
• Dr. Mariano Montenegro (Colombo Plan office for Latin America and the Caribbean) introduced the Program for International Quality Assurance in Treatment (PIQAT), which provides assistance with practical implementation of quality assurance in countries.
  • PIQAT, which is based on the Key Quality Standards, rates countries based on the degree to which their quality assurance systems are in line with the International Standards and seeks to advance them to the highest level.
  • Implementation of this process occurs in three stages that each encompass several steps, some of which may be repeated in several cycles:
    1. Agreeing and creating a team — this stage generates interest, ensures country commitment, and results in creation of a quality assurance team.
    2. Conducting system assessment and developing an action plan — this stage includes a system evaluation, development of a 3-year action plan, and training of a quality assurance workforce
    3. Developing, testing, integrating, and maintaining quality assurance — this stage involves several cycles of technical assistance, implementation, and evaluation until the country has achieved a sustainable quality control.
  • To date, five international agencies offer quality assurance for treatment and rehabilitation.
• Dr. Rita Notarandrea (International Consortium on Quality Assurance in Treatment [ICQ]) described the Consortium’s goals and work.
  • ICQ was launched in April 2022; its work is motivated by the belief that people should expect to receive effective, high-quality services, regardless of where they are.
  • It includes organizations seeking to improve quality of drug use disorder treatment by creating a hub for peer-led resources and processes; it unites organizations responsible for ensuring treatment quality, treatment services, and patient/family advocacy groups.
  • It seeks to improve treatment quality by creating a hub to share good practices, develop a peer-led Quality Seal Award, and develop and share resources such as briefings or webinars on good practice in quality assurance.
  • Achievements to date include recruitment of five quality assurance organizations plus other quality assurance experts and relevant international organizations, establishment of an initial advisory board, and first steps for developing the Quality Seal Award.
  • Next steps will include evaluation of the first applicants for the Quality Seal Award as well as efforts to recruit additional participant organizations and establish the three stakeholder groups.