Teaching Points– Christine Grella Comments on “Addiction Research”

Chris Grella Brings the Nuance

Editor’s Note: Yesterday, psychologist Chris Grella presented a syllabus that lays out the institutional history (or histories) into which new researchers will intervene as they pursue their work– whether as bench scientists or as service providers.  Today, the rationale behind the class, and the nuances it hopes to add to work that will take place in a rapidly changing policy and funding environment.

This course is the introductory seminar for pre- and postdoctoral trainees in our  training program, funded by the National Institute on Drug Abuse (NIDA), at the UCLA Integrated Substance Abuse Programs (ISAP).  The ISAP training program is focused on health services research to improve the quality of drug abuse treatment services, consistent with NIDA’s Services Research Branch. Our goal is to equip researchers with the skills needed to undertake research in the area of addiction health services, broadly defined to include: (1) organization and delivery of drug treatment services, including integration with mental health, primary care, and other health and social services; (2) workforce issues, organizational development, and implementation research; (3) economics and financing of drug treatment services; (4) criminal justice systems and interventions for offenders; (5) longitudinal drug use, treatment use, and recovery outcomes; and (6) treatment/services utilization among diverse groups, including women, racial/ethnic groups, impoverished/homeless individuals, youth and older adults, and individuals with or affected by HIV/AIDS.

We believe that our training program meets a critical need in addiction health services research, especially within the context of changes anticipated with the full implementation of the Patient Protection and Affordable Care Act (ACA), otherwise known as “health care reform.” Implementation of the ACA (by 2014) is expected to have a major impact on the organization, financing, and delivery of substance abuse treatment services (Buck, 2011). Our program is designed to equip addiction health services researchers with the conceptual models, research methodologies, and analytic skills to undertake scientific research evaluating the impact of these changes in the organization, delivery, and outcomes of addiction treatment services.

To meet this goal, the ISAP training curriculum is organized around a required seminar that meets for three academic quarters during the academic year. The 2-year curriculum provides an in-depth grounding in substantive areas in addiction treatment and health services research.  These include coverage of the major epidemiological  surveys tracking substance use and psychiatric disorders in the general population; the national treatment outcome studies sponsored by NIDA; clinical trials of behavioral and other interventions; health services research on the organization, financing, and delivery of drug treatment services; and the broader context of health services research and drug policy.  Courses are also dedicated to professional skills development, such as writing and reviewing manuscripts, developing grant ideas and proposals, understanding the grant review process, and preparing conference or job-related presentations.  In addition to the ISAP trainees, the courses usually attract several graduate students and postdoctoral trainees from other UCLA departments (e.g., Psychology, Public Health, Nursing, Education, Sociology, Social Welfare, Public Policy, Neuroscience).

The series begins with an “anchoring” course “Psychiatry 295A:  Addiction Research:  History, Policy and Practice.” This course takes a big-picture view of research on addiction and its relationship to social interventions and policies that aim to  address problems related to substance use. The goal of the course is for participants to understand the history and evolution of the field of substance abuse research as well as the influences that continue to shape research priorities. The course examines the evolution of policies on addiction in the United States; multidisciplinary influences on the development of addiction research; social policy influences on the current addiction treatment system, including health care reform; determination of “treatment effectiveness”; qualitative research on addiction and the role of the “drug user” in addiction research; influence of public advocacy on addiction research and policy; and historical development of human subjects issues in addiction research. Course reading includes Nancy Campbell’s (2007) text on Discovering Addiction: The Science and Politics of Substance Abuse Research, which provides a thorough grounding in the historical development of addiction research as a scientific field of inquiry in relation to governmental drug policies and the developing pharmaceutical industry.

Indeed, the very history of the field of addiction research is reflected in the diverse backgrounds of the class participants.  Most trainees have a background in psychology or another social science, or in public health (although we do have an occasional exception, such as a recent PhD in history!).  Some trainees have a fairly good background in addiction-related research, including those who have conducted, or plan to conduct, research on an addiction-related topic for their dissertation research. Others have related research interests in closely allied areas (e.g., epidemiology, anthropology, developmental psychology) and want to expand their expertise to include substance abuse issues.

As Campbell notes in her book, addiction researchers often lack a sense of having a common history as a field, although her book and the recent commemorative articles for NIDA’s 35th anniversary published in Drug and Alcohol Dependence have helped researchers gain a better understanding of their field’s history.  The Campbell text does require students to stretch beyond their “comfort areas” in terms of terminology and conceptual frameworks; few students will have previously encountered the analytic approaches undertaken by science historians and used in discourse analysis.  The analytical concept of “laboratory logics,” which is used to deconstruct the influences on the process of conducting addiction research, requires students to step outside of their unique disciplinary training and embrace a larger understanding of the field.  Many of the historical topics that Campbell addresses continue to be topics of debate and to influence the field, such as ethics in conducting human subjects research, particularly with individuals in the criminal justice system; use of animals to model the processes and consequences of addiction; the relationship of drug research with industry; and the ways that addiction research may (or may not) inform drug policies.

By bringing in guest speakers who discuss their research programs, we attempt to tie these past issues with current research. Hopefully, by the end of the course, students have a better understanding of the scientific struggles and achievements that paved the way for the emergence of the modern era of addiction research, including their own specific areas of interest, as well as the institutional structures that undergird the current addiction research infrastructure.  Indeed, their very participation in the course and in the NIDA training program exemplifies this infrastructure.

My own entry into the field of addiction research may serve as an example.  After finishing a postdoctoral training program in mental health services research, I was hired as a project director on a study that was part of a larger NIDA-funded initiative of demonstration/research projects that aimed to develop HIV risk-reduction interventions for high-risk substance users.  Among the luminaries I met who were part of this initiative were Barry Brown, Carl Leukefeld, Joseph Brady, Linda Cottler, Dwayne Simpson, Jim Inciardi, and James Maddux (Tims & Leukefeld, 1986, p. 49)—all of whom have distinguished careers in the field of addiction research, and whose research helped to establish a foundation for understanding the effectiveness of various treatment intervention strategies (of which I was ignorant).  From them, I learned about the early history of the field, including the federal “narcotics farms” at Lexington and Ft. Worth; Jerome Jaffe’s role as the director of SAODAP, in the Nixon administration, and the establishment of NIDA and ONDCP; and Dole and Nyswander’s research that established the efficacy of methadone as a treatment for heroin addiction.

Another example of our shared ignorance of the history of addiction research can be seen in current discussions about the nature of addiction as a “disease.”  To an emerging generation of addiction researchers, this concept may seem novel, particularly within the context of neurobiological research on the mechanisms of addiction within the brain.  I am indebted to historians who have established that the beginnings of the “disease concept of addiction” can be traced to the “cultural emphasis on abstinence and temperance that emerged as early as the 1780s” (Campbell, 2007, p. 13).  The course examines the permutations of how problems that stem from substance misuse have been characterized, defined, and studied in the past, as well as the continual reinvention and packaging of core constructs in line with current modes of thought, technologies, policies, and social influences. Thus, when our students/trainees embark on writing literature reviews in their areas of research, we are confident they will not, as others have, blunder into making the oft-mistaken statement that “little [or no] research has been conducted in this area,” a declaration that betrays an ignorance of work from generations ago that investigated similar clinical and treatment-related issues, albeit with more limited research designs and analytic techniques.

In sum, the goal in the class is not just to have students look to the history of addiction research, but to obtain a deeper understanding of how past research has laid the foundation for our current field of addiction research.  To that end, we hope that the diverse array of future addiction researchers will better understand the influences that shaped their own specific interests in the field, whether it is epidemiology, clinical intervention, or organization and delivery of treatment services.