NIDA Director Calls Abstinence-Only Approach “Catastrophic” for OD Crisis

A top federal health official is offering some pointed critiques of the United States drug criminalization model, stressing how politicizing substance use disorder (SUD) has fostered a system of incarceration that increases overdose risk while biasing research that could reveal the benefits, as well as the risks, of substances such as marijuana and psilocybin. She also rebuked treatment approaches that focus exclusively on abstinence.

National Institute on Drug Abuse (NIDA) Director Nora Volkow made the comments in an October appearance at the International Drug Policy Reform Conference, speaking on a panel with Drug Policy Alliance (DPA) Executive Director Kassandra Frederique.

One of the conversation points touched on the dangers of focusing on abstinence in SUD treatment, rather than meeting people who use drugs where they’re at. The “inflexibility” of abstinence-only “costs a lot of lives,” Volkow said.

If a person wants to get treatment and abstain from drug use, “that’s great” as a “theoretical ideal,” the official said. “But to basically impose that as a reality for everyone—who have very different backgrounds and opportunities—I think it’s sort of like a magical thought and not practical.”

In general, the policies and strategies the US has historically pursued to combat drug use are “not helping to address the overdose crisis,” evidenced by the fact that “overdose fatalities are continuing to rise,” Volkow argued.

“What it tells us is whatever we’re doing is clearly not sufficient. What do we need to do to change this?” she said at the panel, a recording of which was shared with Marijuana Moment. “This very polarized categorical perspective, that it’s either you go abstinent or we don’t pay any attention to you and we send you to jail, is catastrophic. I mean, it has basically contributed to what we’re seeing as a horrific problem in our country with horrible fatalities like we’ve never seen.”

She also discussed how research has increasingly identified a strong relationship between SUD and “adverse” social environments, including cultures where drug use is stigmatized. One example of a “commercial determinant” that’s compounded SUD issues, Volkow said, is the US carceral system itself.

“What are the commercial determinants of health? What are the commercial determinants of addiction?”

“What are the commercial determinants of health? What are the commercial determinants of addiction?” she said. There are commercial detriments intertwined with the marketing of substances like alcohol and tobacco, she said. However, “we also have jails—and those are commercial entities.”

Volkow also expressed her frustration with policies that lead medical professionals to report pregnant women when they’re seeking treatment after testing positive for illicit substances. That practice—which she said takes place in half of the states in the country and can lead to incarceration in five—is significantly contributing to why mortality rates for pregnant women are increasing.

“What’s happening is these women are desperate. Because [they are saying], ‘I wouldn’t go [to treatment]. I don’t want to end up in jail, and I wouldn’t want to lose my child,’” she said, echoing points she made in a 2023 op-ed for STAT News. “So of course you don’t seek treatment, and you are in a very dangerous [situation] right now. Illicit drug markets. And that makes you more desperate.”

The NIDA director said that when she goes to testify before Congress on drug policy issues, she tries to make abundantly clear that “you don’t want to politicize science” to inform policymaking.

“Unfortunately, we have seen—and you saw during the COVID pandemic—a horrific politicization of science, which is very, very unfortunate because it negatively affects everyone and so that permeates a lot of things,” she said. But my belief is certainly, science should be outside the political or ideological world.”

DPA’s Frederique pointed out, however, that it has long been the case that politics and individual ideologies do permeate the type of research that’s being funded into drug issues.

“The kind of research that is prioritized is not happening in a vacuum, right?” she said. “It is shaped by what people want to know, what questions are put forward and who gets to ask the questions. So I think part of the thing that we want to engage and interrogate is how do we change up the questions?”

There’s a relative lack of research on the benefits of drug use, which typically isn’t prioritized for funding.

Specifically, Frederique said that the type of research that’s typically prioritized and funded focus on identifying the harms of drugs—a reflection of the drug war mentality that’s shaped public policy. There’s a relative lack of research on “how drugs operate in society” and “what are the ways that drugs help people.”

“I agree 100 percent,” Volkow replied. “I mean, I think that that notion—very much that focus in terms of ‘drugs are harmful, harmful, harmful’ is an ideological one. And in many ways, it’s actually, from our perspective of what is our role as an institute, is to also understand what are the effects of drugs.”

There are people who use currently illicit drugs like cannabis to derive medical benefits, for example, she said.

“We need to investigate them so that we can understand whether they have benefits or not, and that information needs to be given to the public,” she said. “So this is very obvious when it comes to, for example, cannabis—but we’re seeing it right now also expanded to the interest on psychedelic drugs like psilocybin and an ecstasy. And it is our responsibility to provide that knowledge.”

Earlier in 2023, Volkow also said there is emerging evidence that psychedelics carry “significant potential” as therapeutic treatments for certain mental health conditions, and it’s a topic of “great interest” for researchers.

The director told Marijuana Moment in 2021 that researchers need to prioritize psychedelics research, as more people are likely to use them as they’re exposed to studies showing the therapeutic potential of the substances.

In 2022, she argued that drug criminalization has “created a structurally racist system” in which Black people are treated “worse” than others. Volkow also talked about the relationship between racial prejudice and drug criminalization in 2021, saying the US is “currently reckoning with a long history of discriminatory and racist policies, many of which still continue today.”

In a separate essay in 2021, the health official reiterated that the current federal drug policy leads to disproportionate enforcement against communities of color and can actually increase the risk of overdose deaths. She stopped short of explicitly endorsing decriminalization, but signaled that it was time for that kind of an approach to effectively combat SUD and overdose.

Image via National Institute on Drug Abuse

The Influence Foundation, which operates Filter, previously received a restricted grant from the Drug Policy Alliance to support a Drug War Journalism Diversity Fellowship.

This story was originally published by Marijuana Moment, which tracks the politics and policy of cannabis and drugs. Follow Marijuana Moment on Twitter and Facebook, and sign up for its newsletter.

Kyle is Marijuana Moment‘s Los Angeles-based associate editor. His work has also appeared in High Times, VICE and attn.