June 14-15, 2024
Montreal, Canada
After three years of virtual meetings, the 2024 NIDA International Forum returned to an in-person format. The meeting, which was held on June 14 and 15 in Montreal in conjunction with the College on Problems of Drug Dependence (CPDD) Annual Scientific Meeting, was cochaired by NIDA International Program’s leadership, Dr. Tom Clarke and Dr. Lindsey Friend. It was attended by over 200 individuals from 73 countries. The meeting included several plenary sessions, four breakout sessions, and an international research poster session featuring 90 posters presented by substance use and addiction researchers from 26 countries.
The Forum began on June 14 with two sessions on advancing quality of addiction study programs and on addiction neuroscience research in Bulgaria, as well as a workshop on how to get addiction research published in peer-reviewed journals.
Day 2 started with the official welcome and updates on NIDA’s programs. This was followed by four breakout sessions on addiction treatment and criminal justice systems, professional healthcare education regarding medical cannabis, addressing opioid stigma in pharmacies, and effective interventions to increase treatment access and intake in real-world settings across the globe. The meeting concluded with two plenary sessions that discussed substance use and associated health problems in humanitarian settings and addressed two current global topics, namely, emerging synthetic drugs in Latin America and the Caribbean and the treatment of children with substance use problems. Rounding out the program were a joint workshop conducted by NIDA staff and staff from the CPDD, as well as a poster session.
Following are brief summaries of the topic sessions presented at this year’s International Forum.
Welcome and NIDA Update
Dr. Clarke provided a high-level overview of NIDA’s research priorities. In the United States, the most pressing problem continues to be the opioid overdose crisis, which is currently driven by co-use of fentanyl and stimulants and disproportionately affects American Indian/Alaska Native and Black communities. Also highly concerning are continued high rates of unintentional fentanyl-related overdose deaths in youths ages 15-19. In response, NIDA’s 2022 to 2026 strategic plan has identified five core research priorities, 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 heath applications.
Dr. Clarke also introduced several large programs that NIDA supports — partly together with other NIH Institutes — to address the opioid public health crisis. One of these efforts is the Helping to End Addiction Long-term® Initiative, or NIH HEAL Initiative® — an NIH-wide effort to speed scientific solutions to the opioid health crisis that is jointly led by NIDA and the National Institute on Neurological Disorders and Stroke. Other major NIDA-supported research efforts include the longitudinal HEALthy Brain and Child Development (HBCD) and Adolescent Brain Cognitive Development (ABCD) studies, the HEALing Communities Study, the Justice Community Opioid Innovation Network (JCOIN), the Harm Reduction Research Network, and the NIDA Clinical Trials Network. Together, these efforts address challenges, such as emerging drugs (e.g., xylazine), increasing fentanyl and polysubstance use, persistent stigma, better care for hard-to-reach and underserved populations, continuity of care for substance use disorders (SUDs), and novel harm reduction approaches.
Dr. Friend summarized the activities of the NIDA International Program and its role in international policy development, information, exchange, research, and training. In particular, NIDA supports international research through grants awarded to U.S. researchers partnering with foreign investigators. NIDA’s international training and research programs include INVEST postdoctoral fellowships and Hubert H. Humphrey Fellowships. INVEST fellowships offer a 12-month postdoctoral research training with a NIDA grantee that includes professional development activities to establish personal relationships between the fellows and NIDA grantees and NIDA officials. They are for international researchers with a doctoral degree and a minimum of 2 years postdoctoral experience. Hubert H. Humphrey Fellowships are mid-career fellowships to approximately 12 individuals per year that include a 10-month research fellowship at Virginia Commonwealth University as well as 6-week professional affiliations, allowing fellows to make connections to advance their ongoing work. Additionally, NIDA offers the Distinguished International Scientist Collaboration Awards (DISCA) that fund innovative collaborations between international and NIDA-funded senior researchers. Dr. Friend also highlighted NIH’s Research Portfolio Online Reporting Tool, NIH RePORTER (https://reporter.nih.gov), as an excellent tool for learning about NIDA-funded projects or investigators funded in other countries.
Addiction Treatment and Criminal Justice Systems: Drug Policy Reforms and Implications
This breakout session was chaired by Dr. Gregory Bunt from the International Society of Addiction Medicine (ISAM), who introduced the International Consortium for Alternatives to Incarceration (ICATI). ICATI works with countries, organizations, professionals, and program sites to support the global development of treatment, care, and accountability as alternatives to incarceration for individuals who use drugs and become involved with the justice system. At various stages in the judicial process, the justice system can divert people to treatment and services in the community instead of incarcerating them. This has been shown to reduce recidivism. To help adopt and implement such measures, ICATI promotes and supports all phases of national and regional planning, training, technical assistance, evaluation, and implementation; identifies, develops, and provides resources; and helps establish international networks.
In lieu of Dr. Carl Erik Fisher from Columbia University in New York, who was not able to attend the meeting, Dr. Bunt also gave Dr. Fisher’s presentation on the “Portuguese model” of decriminalization as an alternative harm reduction approach for treating SUDs in minoritized communities. Decriminalization means elimination of criminal penalties for drug possession for personal use; it differs from depenalization, which generally means that criminal penalties are reduced or not enforced but are not legally eliminated, and from legalization of drug use. This approach was first implemented in Portugal, where drug possession was decriminalized in 2001 but people carrying a personal drug supply had to get mandatory treatment. This was accompanied by several other socio-medical and harm-reduction interventions for a holistic approach with wrap-around services. However, because existing laws against personal drug use had already been only loosely enforced, decriminalization may ultimately have formalized existing practices rather than drive new norms and attitudes. In the United States, a similar approach has been implemented in Oregon but has been less successful because people were not diverted to effective treatment. This suggests that even the best reform programs do not guarantee success because drug-related problems are shaped by additional factors, such as cultural attitudes, social support networks, or mental health resources.
Dr. David Martell from the Canadian Society of Addiction Medicine reported on Canada’s drug decriminalization efforts. Canada has a history of targeted exemptions from penalizing drug use, from prescription maintenance programs and wide availability of opioid agonist therapy to supervised consumption sites and drug checking programs. Dr. Martell also listed various legislative approaches to drug decriminalization, such as the 2017 “Good Samaritan Drug Overdose Act” or cannabis legalization in 2018, which legalized personal use but maintained criminal penalties for certain offenses. This legalization resulted in increased cannabis use for most age groups and a temporary increase in the cannabis industry, but more Canadians now get cannabis legally. A newer decriminalization pilot program started in 2023 decriminalizes use of small amounts of opioids, crack, cocaine, methamphetamine, or MDMA at certain sites (e.g., private residences, but also overdose prevention, drug checking, or supervised consumption sites). The aim is to eliminate the harms associated with drug seizure, help connect people who use drugs to services and support, and enhance public awareness and understanding. However, over the first 12 months, the project has not yielded benefits, and many issues are also still unaddressed. Dr. Martell concluded that Canada’s national drug policy landscape is still fragmented and the search for the best approach continues.
Dr. Hamed Ekhtiari from the University of Minnesota and ISAM Regional Council chair, discussed how the ISAM Global Expert Network (ISAM GEN) can contribute to global drug policy reforms. ISAM’s organizational hierarchy allows for representation and policy involvement across the globe through regional representatives, national ambassadors, addiction medicine societies, and 10 country experts for each country who represent the ISAM GEN. By eliciting information from these experts and conducting a range of global surveys, ISAM GEN can help map and reshape global policies. ISAM GEN has established a well-honed road map for conducting their surveys, from idea development and steering committee formation all the way to manuscript submission. ISAM GEN’s first global survey assessed treatment service provision for opioid use disorder by querying national addiction societies and organizations in 39 countries from six continents. It gathered valuable information on availability of different types of opioids and availability of different types of treatment services for opioid use disorder, harm reduction facilities, and 12-step programs. Researchers interested in establishing their own international working groups or developing surveys can contact ISAM for further information.
Medical Cannabis in Professional Healthcare Education: Multinational Policies, Perspectives, and Competencies
In this breakout session, which was moderated by Dr. Richard Isralowitz from the Ben-Gurion University of the Negev—RADAR Center in Israel, Dr. Richard Rawson, professor emeritus from the University of California, Los Angeles, first provided a historical overview of substance use training in professional curricula. He noted that information on substance use and its impact has only recently been integrated into professional healthcare training rather than being covered only in ad-hoc separate training events. Since 2000, training in substance use and its treatment has become more formalized, with exams and certification processes offered by national and international certification organizations. International training activities are coordinated by the International Consortium of Universities for Drug Demand Reduction (ICUDDR), which facilitates networking among universities to promote high-quality education and training for prevention, treatment, and public health intervention purposes. As a result, many universities now integrate alcohol, tobacco, and other drug content into their curricula, often within many specialty areas; however, cannabis and medical marijuana remain a new curriculum topic.
Dr. Yuval Zolotov from the Albert Einstein College of Medicine in the Bronx, New York, summarized the results of an international survey among healthcare professions’ students in Israel, Malta, Greece, Cyprus, Russia, Belarus, Thailand, and the United States regarding their attitudes, beliefs, and knowledge about medical cannabis. Participants were 4,427 students (70% female) of medicine, nursing, social work, and psychology; 74% came from countries where medical cannabis was legal. Dr. Zolotov reported that, overall, respondents expressed relatively high levels of support for medical cannabis, but also concerns about potential risks and harms. Almost all respondents believed that medical cannabis should be included in their education and practical experiences, but almost 87% reported receiving no formal education in this area. As a result, about 70% of respondents felt unprepared to answer patient questions about medical cannabis. Dr. Zolotov concluded that a great need for formal education in medical cannabis exists and that standardized curricula can help bridge the existing gaps.
Dr. Mazen Sakka from the Substance Abuse Research Center, Palestine, summarized a similar survey among medical staff at two hospitals and students at four universities in the Palestinian territories (West Bank, Gaza Strip) about their knowledge, beliefs, and attitudes regarding medical cannabis. The survey also explored the roles of gender, religiosity, and legal status of medical cannabis on these domains. In the Palestinian territories, cannabis is considered a schedule I substance, together with other addictive drugs. The survey found that while most medical staff and many students believed that medical cannabis can help certain patients, they also saw a high risk of mental and physical health problems. However, many respondents had only limited knowledge on the subject. Additionally, attitudes and beliefs differed somewhat between males and females and were affected by religious views and the fact that cannabis is considered an illegal drug. Nevertheless, Dr. Sakka noted that most respondents seemed open to more information or training on medical marijuana, supporting efforts to enhance such activities.
Given the apparent need for and interest in professional healthcare education on medical cannabis, Dr. Mikhail Kogan from George Washington University and Dr. Leslie Mendoza Temple from the University of Chicago described a Delphi process to identify teaching standards and essential medical cannabis education competencies. The Drug Enforcement Agency in the United States is set to reschedule cannabis to a lower status, which would require all pharmacies in the United States to carry cannabis products. After a 2021 scoping review found that healthcare trainees lack proper education and knowledge about medical cannabis, implementation of expanded competencies-based curricula is essential. Drs. Kogan and Temple described the Delphi process methodology, which relies on synthesizing opinions among a group of experts via repeated rounds of discussion until a consensus is reached. In this case, the process involved 23 experts with different areas of expertise, who identified six core competencies to guide development of medical school curricula in the United States and Canada. These included (1) understanding the basics of the endocannabinoid system, (2) describing the main components of the cannabis plant and their effects, (3) reviewing the legal and regulatory landscape on cannabis in the United States, (4) describing the evidence base for health conditions that are commonly managed with cannabis, (5) understanding the potential risks of medical cannabis use, and (6) understanding basic clinical management with medical cannabis.
Addressing Opioid Stigma in Pharmacies — Developing Strategies for Pharmacy Professionals
This breakout session with Dr. Beth Sproule and Dr. Braiden Cutmore from the Canadian Centre for Addiction and Mental Health and Dr. Sarah Bhatti from the Public Health Agency of Canada (PHAC) centered on the stigma that people who use drugs and people with chronic pain frequently face. The session focused specifically on stigma from pharmacy professionals. As Dr. Bhatti noted, experiences of stigma may decrease use of treatment and social services as well as quality of care. A 2019 report by the Canadian Chief Public Health Officer concluded that responding to stigma in the health system requires a comprehensive approach through education, training, practice, and policy. PHAC conducted a literature review to clarify the nature and manifestations of stigma; assess stigma related to treatment with naloxone, opioid agonist therapy, harm reduction approaches, and opioid treatment for pain in pharmacy professionals; as well as anti-stigma approaches. The review identified several key ingredients for anti-stigma programs, such as repeated social contact, demonstration of recovery, myth busting, and enthusiastic facilitation. Dr. Bhatti also indicated that targeted education is more successful than general education.
Dr. Cutmore described several stakeholder roundtables organized by PHAC that discussed definitions of stigma, experiences of stigma, positive experiences with pharmacies, and potential messages for pharmacy professionals. The roundtables included people with opioid use disorder, people with chronic pain, and pharmacy professionals, respectively. Based on the feedback from the three stakeholder groups, six messages for pharmacists were drafted that addressed the main themes raised — for example, that pharmacy professionals need to see patients as a whole person and treat them with dignity and respect, that they need to understand the patient’s opioid medication experience and act as allies to support patients, or that they need to proactively engage and empower patients through education. Agreement with these messages was then assessed in an anonymous survey among roundtable participants. According to Dr. Cutmore, the roundtables and resulting messages highlighted that it is crucial for pharmacy professionals to challenge negative attitudes and beliefs by reflecting on their assumptions toward people taking opioids and recognize their impact. Additionally, they need to help empower through communication their patients who are prescribed opioids.
Dr. Sproule then presented a newly developed tool kit delineating strategies for pharmacy professionals to address opioid stigma in pharmacies. It highlights eight key strategies to support people who use opioids, such as respecting all customers equally, getting to know customers, offering support through education, explaining and reviewing pharmacy process, providing harm reduction services, delivering compassionate healthcare, respecting the right to privacy, and raising public awareness. The toolkit also provides tips on how to put those strategies into practice. One concept Dr. Sproule highlighted is the idea that “words matter” — that how one talks to or about people who use substances can either reinforce or, in contrast, counter stigmatizing attitudes, views, and actions. The toolkit also includes social media assets and posters to raise awareness of and address opioid stigma in pharmacies. Infographics, videos, courses, and other resources are also available. The toolkit was launched in February 2024 with a webinar attended by more than 250 pharmacy professionals and other stakeholders.
Successful Real-World Evidence-Based Interventions That Have Increased Treatment Access and Intake in Different Countries
This breakout session was chaired by Dr. Adrian Abagiu from the Romanian National Institute for Infectious Diseases and Dr. Matei Bals from the ARENA OST Center in Romania. Dr. Abagiu reported on a program in Romania to increase adherence to antiretroviral therapy (ART) among people living with HIV (PLWH) who were incarcerated. He described that some of these individuals refused ART due to restrictions according to detention regulations. To improve ART adherence, they developed an information program involving a 20-minute PowerPoint presentation, a 10-minute Q&A session, and information leaflets for small groups of PLWH at one of the prisons. The intervention improved adherence, but the effect declined after 4 months. As a result, the program was refined further and assessed in a study comparing 100 PLWH who received the intervention with 50 PLWH who did not in one jail. Before the intervention, ART refusal rates were the same in both groups. After the intervention, refusal rates declined in the intervention group, but remained relatively stable in the control group; again, the effect was lost at 4 months after the intervention. Based on these findings, the intervention was delivered every 2 months to all new PLWH arriving at the prison, and while it had to be halted during the COVID-19 pandemic, it was resumed after the end of the pandemic.
Next, Dr. Dace Svikis from Virginia Commonwealth University described the Expanding Medical Prevention and Outreach While Enhancing Recovery and Retention (EMPOWER) project that seeks to increase engagement and retention in SUD and HIV treatment for underserved Black people in Baltimore, Maryland. Dr. Svikis explained that Baltimore has one of the highest rates of new HIV cases and also has the highest fatal overdose rates among large cities in the United States, but is also a leader in SUD treatment and harm reduction approaches. EMPOWER was assessed within the Recovery Enhanced by Access to Comprehensive Healthcare (REACH) Health Services Program that offers comprehensive outpatient SUD treatment as well as mental health counseling. However, Black individuals in the program were less likely to engage in SUD treatment, more likely to drop out of care, and thus less access to HIV-related testing and care. The EMPOWER program seeks to address these disparities using tailored, patient-focused, evidence-based interventions to engage and retain Black individuals in treatment. Importantly, the EMPOWER team includes people who have lived experience and represent the population of focus, such as peer recovery specialists and nurse care managers. EMPOWER uses evidence-based interventions, such as motivational interviewing, continency management, safer sex skill building, and Seeking Safety, a cognitive behavioral therapy for post-traumatic stress disorder and SUD. The EMPOWER program started recruitment in February 2024 and will last 6 months, after which regular REACH services will continue. Preliminary findings indicate that EMPOWER can increase treatment retention at 3 months compared with the normal REACH program; additional data will be gathered in the coming months.
The third presenter was current Hubert H. Humphrey Fellow Thinzar Tun from Myanmar, director of the Asian Harm Reduction Network (AHRN) and Best Shelter Myanmar, who reported on a program she is spearheading to increase treatment access and intake for people who use drugs (PWUD) or inject drugs (PWID). She explained that Myanmar has about 93,000 PWID, about 35% of whom have HIV. AHRN provides facility-based harm reduction, treatment, and care, whereas Best Shelter offers community-based harm reduction, prevention, referral, and care. Specific services include outreach, health education, self-help groups, job creation efforts, peer education, counseling, and treatment. Some services are specifically aimed at women as a particularly vulnerable population, such as services to improve sexual and reproductive health, as well as pre- and postnatal care, and services to curb gender-based violence. Ms. Tun specifically described their needle and syringe programs, including efforts to return and safely dispose of used needles and syringes, as well as HIV testing and treatment. These are implemented either during outreach with mobile units or at fixed locations in clinics or in the community. Ms. Thun reported that for 2022, about 18 million needles and syringes were distributed, with a return rate of 86%. For HIV testing, the program brought testing closer to the PWID and their families, allowed for effective linkage to care and rapid ART initiation, as well as testing and treatment in hard-to-reach locations. The program reduced the proportion of PWID who were HIV positive and achieved high linkage to treatment and ART initiation for both PWUD and PWID and their sexual partners. Ms. Tun concluded that to address drug use and HIV in countries such as Myanmar, understanding the context and needs of clients is essential, and that community inclusion and harm reduction approaches work.
Substance Use and Associated Health Problems in Humanitarian Settings — Responding to the Needs of Affected Populations
This plenary session was started by Dr. Anja Busse from the United Nations Office on Drugs and Crime (UNODC), who provided an update on addressing substance use in humanitarian emergencies. Dr. Busse explained that humanitarian emergencies (e.g., disasters, armed conflicts, epidemics) threaten the lives and well-being of very large numbers of people or a very large percentage of a population, often result in displacement, and require assistance from multiple sectors. There is only limited evidence on substance use among displaced persons; however, there seem to be regional differences regarding the most commonly used substances. Displaced populations or people in humanitarian emergencies may face particular challenges related to drug use, such as sudden interruptions of patterns of drug use, disruption of treatment services, and resumption of drug use with increased risk of overdose; these compound social and mental health problems associated with humanitarian crises. Dr. Busse noted that substance use is included in humanitarian health guidance as part of mental health interventions. A Desk Review by the United Nations High Commissioner for Refugees (UNHCR) found that community-based, peer-led programs and training of healthcare workers in SUD treatment are feasible in low-resource and refugee settings and that brief interventions have significant potential. Opioid agonist therapy may also be possible in humanitarian settings with support from international donors and organizations. Several international policy documents have provided policy direction for addressing SUDs in humanitarian emergencies. UNODC and the World Health Organization (WHO) have a joint program for such situations, and the UNODC/WHO International Standards for Treatment of Drug Use Disorders can be adapted for humanitarian emergencies. A handbook by UNODC, UNHCR, and WHO will soon be published, disseminated, and field-tested. It creates an implementation framework for both the acute phase and the protracted phase of the emergency. It has identified two main principles — saving lives first (i.e., addressing life-threatening concerns such as overdose and withdrawal first), and full inclusion of people with SUD in other support available.
Dr. Dzmitry Krupchanka from the WHO described the organization’s approach to addressing substance use during humanitarian emergency responses. He noted that people in humanitarian settings have much higher rates of mental health problems than other populations; moreover, mental and physical health conditions are often comorbid with SUDs. Dr. Krupchanka mentioned a 2024 WHO draft resolution on strengthening mental health and psychosocial support (MHPSS) before, during, and after humanitarian emergencies. The resolution includes MHPSS as an integral component of preparedness, response, and recovery activities in all emergencies. He then reviewed the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings, which delineate key actions to minimize harm related to alcohol and other substance use. These measures aim to conduct rapid assessments, prevent harmful alcohol and other substance use and dependence, facilitate harm reduction interventions in the community, and manage withdrawal and other acute problems. An open, free course is available to learn about this, as well as some cultural adaptations. Additionally, several WHO resources to address substance use and its consequences in humanitarian settings will be forthcoming.
Dr. Karen Paul from the IASC Reference Group for Mental Health and Psychosocial Support in Emergencies talked about interagency collaboration regarding substance use and SUD in humanitarian emergencies. She emphasized that a multi-sector response is needed in such situations, and some of these sectors are also addressed in the IASC Guidelines mentioned by Dr. Krupchanka. Dr. Paul also described the IASC MHPSS Reference Group, which is cochaired by WHO, UNODC, and UNHCR and involves over 11 member agencies as well as five observers. Their current priority is developing materials for training and orienting various groups of humanitarian workers on substance use, from materials for basic communication to materials on advanced interventions. For example, orientation materials are being developed on SUDs as health conditions, how to provide support, life-threatening conditions related to substance use, and similar topics. These materials are currently being field tested, with an eye to adapting them to various cultures and contexts. A substance use module for integrating MHPSS into disaster risk management and preparedness training is also being developed, including a framework for assessment and action.
Finally, Dr. Mustafa al’Absi from the Duluth Global Health Research Institute and the University of Minnesota discussed the implications of traumatic stress and substance use in the context of humanitarian emergencies. He noted that trauma exposure, particularly in children and adolescents, is associated with an increased risk for SUD; moreover, substance use can impact the course and severity of traumatic stress symptoms. Increases in political conflicts as well as natural disasters have led to rising mental health and substance use problems. Consequently, it is important to integrate mental health and substance use services in emergency responses and increase capacity for trauma-informed care among humanitarian workers. Dr. al’Absi presented case studies from recent conflicts and natural disasters, such as the conflicts in Syria, Yemen, and Afghanistan, or the an earthquake in Turkey. Each of these has unique features regarding substance use that need to be considered. The crisis in Afghanistan also provided an example of partnerships between WHO, UNODC, and others for treatment of SUDs to improve the health and well-being of vulnerable populations. Dr. al’Absi concluded that guidelines informed by epidemiological, intervention, and implementation knowledge are needed to address the challenge of SUD in humanitarian settings. He also issued a call to action for improving substance use services capacity and integration in humanitarian emergencies in order to help prioritize the well-being of affected populations in emergency response efforts. These efforts also must address the issue of stigma in order to be effective.
Current Global Topics: Synthetic Drugs in Latin America and the Caribbean and Treating Children for Substance Use Problems
In this session moderated by Dr. Andrew Thompson from the Bureau of International Narcotics and Law Enforcement Affairs (INL), Dr. Marya Hynes from the Inter-American Observatory on Drugs reported on emerging synthetics and new psychoactive substances (NPS) in Latin America and the Caribbean. She noted that synthetic drugs have proliferated in those drug markets, particularly since 2013, and that NPS also have become more common. Of concern are amphetamine-type stimulants (ATS), such as amphetamines and prescription stimulants, methamphetamine, synthetic hallucinogens, and synthetic opioids. Information on NPS is coming from drug seizures and early warning data that are reported to the Early Warning System for the Americas. These notifications have highlighted several trends, such as appearance of “pink cocaine” (a mixture of various synthetic compounds); increasing prevalence of benzodiazepines in females in every population studied; greater presence of stimulants, particularly among females; synthetic cannabinoids; and a variety of synthetics sold as other drugs. As Dr. Hynes emphasized, even at low prevalences, these trends are concerning because they indicate that people are using more and more mixed and adulterated substances that have unknown composition, unknown effects, often high potency, and often rapid onset and long duration of effects. The most severe implications are for countries with fragile health care systems. These developments affect particularly teenagers and young adults, including health risks and mental health issues that drive drug use and are themselves driven by drug use. These developments need to inform efforts for detection, treatment, and prevention.
Dr. Antonio Pascale from the University of Montevideo further described the health impacts of NPS and increasing availability of adulterated drugs among younger users. For example, adulterants may potentiate the toxicity of the original drugs or induce unintended toxic effects. ATS are associated with harmful effects, such as hyperthermia, which can be exacerbated by the settings where these drugs are often consumed (e.g., clubs with high temperatures, poor ventilation, and intense physical activity); serotonergic syndrome; and hyponatremia. Synthetic cannabinoids, which are increasingly used by young people as well as other vulnerable populations, can be associated with acute toxicity as well as greater morbidity and mortality in the context of polydrug use. Synthetic opioids (e.g., fentanyl and its analogues, nitazenes) are an increasing problem in Latin America with the associated acute toxicity and risk of fatal overdoses. An emerging concern is illicit use of benzodiazepines (often as adulterants of other drugs), which is associated with acute intoxication and altered consciousness that increases vulnerability to sexual crimes and other harms. Dr. Pascale concluded that to address this public health problem effectively, it is essential to strengthen networks involving government agencies, clinical and forensic laboratories, universities, toxicology centers, and nongovernment agencies with access to PWUD.
Dr. Hendrée Jones from the University of North Carolina at Chapel Hill provided an overview of the Child Intervention for Living Drug-free (CHILD) program to treat children under age 12 for substance use problems. Dr. Jones explained that children are increasingly victims of drug trafficking and drug use within their families and communities, leading to children as young as 5-12 years having an SUD. The CHILD intervention was developed to respond to this growing threat. It is a global, evidence-based program with an integrated health approach, full spectrum of services, and family involvement. It includes professional development and a tailored program for each country that uses techniques (e.g., motivational interviewing, mindfulness, dialectic behavior therapy, art therapy) that can be translated into language and activities appealing to children. The program has been disseminated to numerous countries through “training of trainers,” webinars, and “Echo” training. Dr. Jones also shared information on a randomized clinical trial of the CHILD intervention in children ages 7-12 in India. Preliminary results indicate that it reduces substance use in these children at 12 months after treatment better than usual care.
Advancing Quality in Addiction Studies Programs
In this session chaired by Dr. Carly Searcy from ICUDDR, Mr. Jordan Turner, also from ICUDDR, provided an overview of the current state of quality assurance in specialty addiction studies programs. He shared results from a survey of 322 ICUDDR members that assessed program quality along six dimensions of care in members’ curricula. Among the 88 respondents, 63% addressed quality improvement through their curriculum plans. However, qualitative data indicated a minimal focus on quality of care among institutions; barriers within member institutions that prevented quality of care to be addressed, and a need for ICUDDR’s assistance in curriculum building. Mr. Turner concluded that the study positioned ICUDDR to work with members to create frameworks for addressing quality and quality improvement.
Dr. Amelie Lososová from the Charles University in Prague presented previous research on establishing quality assurance at the university level. Several organizations, such as the Substance Abuse and Mental Health Services Administration, American Society of Addiction Medicine, and American Psychiatric Association in the United States, as well as the WHO have addressed quality standards in education programs. Similarly, two projects (WAVE project and FENIQS-EU project) have been conducted in Europe, and for the WAVE project, several project papers will be published soon. Dr. Lososová noted the importance of making education a research focus and highlighted several future research questions and challenges—for example, whether international standards are really needed, what areas of addiction research should be included; which educational programs should apply the standards; and how regional, cultural, and communication differences can be accommodated.
Dr. Dennis McCarty from the Oregon Health & Science University discussed what kind of research is needed. Examples included integration of research into educational standard development, integration of outcome measures into training processes and systems of care, assessments of the impact of standards on care delivery and outcomes, and cross-national comparisons of training and training standards. Dr. McCarty pointed out that each country is unique, and it is therefore important to determine which facets of addiction studies programs are replicable and generalizable. The relatively new areas of dissemination and implementation research are also crucial to determine how research findings can be translated into standards of practice on an international scale.
In the final presentation, Dr. Victor Capoccia from the Technical Assistance Collaborative discussed the development a certification framework for addiction studies programs as a documentation of program quality. He also highlighted questions that would need to be addressed in this process. For example, what should be included in a certification according to international standards (e.g., minimum content for the curriculum, minimum hours of exposure to content, number and qualifications of faculty). Equally important is an understanding of factors that drive differences in standards across the globe. Levels of education and credentialing desired (e.g., nondegree certification, associate, baccalaureate, master’s), cultural and historical contexts of drug use, governmental/legal context, health system infrastructure, and medical traditions all need to be considered. In fact, one set of standards may not be appropriate for all international scenarios. Thus, development of any certification or accreditation process must first determine what components are nonnegotiable and must be uniform and what country or regional characteristics might be accommodated in variations from the standards.
Twenty Years of Addiction Neuroscience Research in Bulgaria: Lessons Learned and Future Directions
This session presented the results of three sets of studies conducted by a large multinational team of researchers in Bulgaria over the past 20 years. As the first presenter, Dr. Jasmin Vassileva from Virginia Commonwealth University, explained, Bulgaria is well suited for their studies of people who use opiates and stimulants because it is located on one of the main heroin trafficking routes into Europe and is a major center for amphetamine production. Dr. Vassileva is investigating which dimensions of impulsivity are associated with addiction in general or specific drug classes. Her team used computational approaches to address this question, including data-driven, machine learning processes for classification and prediction, as well as theory-driven cognitive modeling to increase precision of neurocognitive phenotyping. Dr. Vassileva presented results of several of their studies that have been published in recent years. The findings indicated that some dimensions of impulsivity are common across addictions, whereas others are unique to specific drug classes. The studies also demonstrated that computational approaches have significant potential as phenotyping tools, for identifying markers for addictions, for increasing precision of neurocognitive assessments, and for prognosis and diagnosis. They may also help refine neurocognitive phenotypes and identify different biotypes of addictions with different underlying mechanisms, which may have implications for prevention and intervention.
Dr. Elena Psederska from the New Bulgarian University presented on studies assessing the interplay of personality and neurocognitive function in stimulant and opioid use disorders. Specifically, the team studied the effects of psychopathy on neurocognitive domains of impulsivity in people who previously had used heroin and amphetamine. They assessed the effects of the interpersonal/affective domain and the impulsive/antisocial domain of psychopathy on impulsive choice and impulsive action in both groups. The analyses identified an interaction between the two dimensions of psychopathy and dependence on specific classes of drugs. Some profiles were common across SUDs, whereas others were unique for specific drugs. Another investigation assessed neurocognitive impulsivity in people who used heroin at different times of abstinence. These analyses demonstrated that while some deficits in impulsive choice and impulsive action may only occur in early abstinence, others may persist even with sustained periods of abstinence. Overall, Dr. Psederska concluded that personality influences both common and unique profiles of impairments in neurocognitive impulsivity in people who use opioids or stimulants, and that these impairments may persist even with sustained abstinence. Thus, extended treatment and rehabilitation approaches that are tailored to individual personality profiles are needed.
The final presentation by Dr. James Bjork from Virginia Commonwealth University addressed similarities and differences in brain recruitment by reward, inhibition, and memory in people with different SUDs. The study included individuals with opioid, stimulant, or polysubstance use disorder as well as controls and compared individual differences in brain activation as measured by MRI while participants were conducting three different tasks. The study is still ongoing, but there is preliminary evidence that brain areas activated by specific tasks can be correlated with characteristics determined in addictions neuroclinical assessments, such as emotion-related impulsivity, cognitive difficulties in daily life, or inattention.
Publishing Workshop: How to Get Your Addiction Research Published in Peer-Reviewed Journals
In this workshop, Adam Gordon and Casy Calver from the International Society of Addiction Journal Editors (ISAJE) highlighted three essential aspects to publishing addiction research: choosing a journal, submission and peer review, and authorship. They noted that there are over 100 peer-reviewed addiction journals, and journals from other disciplines also publish addiction articles. They listed 15 factors to consider when choosing a journal as well as questions to ask of a journal (e.g., whether it reaches the specific audience authors want to target, the journal’s mission and content area). Practical aspects, such as editorial support provided or cost of publication/open access, are also important, as are various metrics associated with the journal. These include journal metrics (e.g., impact factor), public impact metrics (e.g., Altmetric attention score), editorial efficiency metrics (e.g., time to first decision, acceptance rate), and author metrics.
For submitting manuscripts, authors first need to check author guidelines, select an appropriate article type, and obtain approval from all authors to submit. Once a manuscript is submitted, a multistep peer-review process follows that may include one or more author revision steps. Peer review is essential to advise the editorial decision-making process, justify rejections, improve the quality of acceptable manuscripts, and identify instances of ethical or scientific misconduct. While the reviewers make recommendations, the editors make the final decision and may even disagree with reviewer recommendations. If the decision is to revise and resubmit the paper, authors should decide if they want to resubmit the paper and, if so, respond to each criticism by either modifying the manuscript or debating/refuting the criticism.
The issue of authorship is increasingly important. The authors on a manuscript certify a public responsibility for the truth of the publication. Authorship also is an indicator of productivity, promotion, and prestige, and credit should be assigned equitably. Especially in addiction research, inclusion of people with lived experience (e.g., patient coauthors in case studies) is important but authors also need to be aware of and sensitive to ethical considerations. Several measures can be taken to avoid authorship problems (e.g., early agreement on the precise roles of all contributors; periodic review of authorship credit status, and adherence to authorship guidelines). Overall, authors must avoid the “seven deadly sins” of carelessness, redundant publication, unfair authorship, undeclared conflict of interest, human subjects’ violations, plagiarism, and other fraud. To avoid plagiarism, all sources must be appropriately acknowledged and permission for use of large amounts of others’ written or illustrative materials obtained. This also applies to self-plagiarism, as authors are not allowed to reuse previously published materials when rights have been assigned to the publisher. The ISAJE provides author resources on their website (https://www.isaje.net/); additional information is available in the JAMA Users’ Guide to Medical Literature and from the Committee on Publication Ethics (COPE) (https://publicationethics.org).