Prevention Profiles: Take Five - Dr. Nora Volkow (NIDA)


Dr. Volkow

Audio file

Dr. Nora Volkow, director of the National Institute on Drug Abuse (NIDA), recently sat down with Rich Lucey, a prevention program manager at the Drug Enforcement Administration, to talk about the upcoming National Drug and Alcohol Facts week, drug use among college students, her advice to prevention professionals, and more.

Rich Lucey:
Hi. This is Rich Lucey with the Drug Enforcement Administration's community outreach and prevention support section and welcome to this edition of our new feature on our website, called “Prevention Profiles: Take Five.”

This is a new feature that we've launched, where I will be interviewing individuals at the federal, the national, state, and local levels about current and emerging issues … drug abuse issues …  among college students.

I'm very pleased today to have as our guest Dr. Nora Volkow.

So Dr. Volkow, welcome.

Dr. Nora Volkow:
Good morning, thanks for having me here.

Dr. Volkow, I’m sure many listeners know, is director of the National Institute on Drug Abuse.

She became the director in May of 2003. DEA works very closely with NIDA and looks to NIDA as our experts on the world’s research on the health aspects of drug abuse and addiction.

Dr. Volkow’s work has been instrumental in demonstrating that drug addiction is a disease of the human brain. She's also made important contributions to the neurobiology of obesity, ADHD, and aging.

So, we're going to jump right in.

Again, the whole basis of this new feature that we have called “Prevention Profiles: Take Five” is to center the interview around five foundational interview questions.

So, I'm going to just jump right in with our first question:

Dr. Volkow, over the course of the 25 years that I've worked in the drug abuse prevention field at the state and the federal levels, one of the things that I continue to hear is that prevention is too late for college students. They've made up their mind to use drugs, you can't change that. What's your reaction to that type of thinking, and why is it important to focus on college students in drug abuse prevention efforts?

Dr. Volkow:
I'd say that prevention is never too late, regardless of age. And that pertains actually if someone who started to take drugs or in alcohol, for example, in their 60s – you still can do prevention and change the behavior of that person.

So, I would start by stating that “it's too late” is actually wrong.  And, indeed, that college is a period of time when and you see young people taking more drugs.

So the highest prevalence rates of drug use of occurs in individuals that are 18 to 24 years of age and, interestingly, we're seeing that for some of the drugs the rates are even higher among those that are in college than those that are not. [This], in fact in a way, reflects also group dynamics that facilitate drug utilization and normative attitudes towards drug taking and expectation. So that increases the likelihood that your person in college would take drugs.

So, it is a very important age and circumstance at which there should be very strong prevention efforts to inform young people about what are the consequences of drugs and why it doesn't necessarily make sense at all to take drugs. But in a way that is relevant to them.


And I know the data support that because with this age group – both with the Monitoring the Future study results that have just come out, the National survey on Drug Use and Health – by and large we're seeing really nice declines among 12 to 17 year olds and the other age groups.
But for 18 to 25 it seems to be going up.

Dr. Volkow:

Yeah we're seeing it going up. For example, it’s very notable for marijuana that is an area. We also see that this age group is also at higher risk for abuse of prescription drugs, and that includes prescription opioids or prescription stimulant drugs. Those are the ones that are most favored.

But also prescriptions sedatives … like benzodiazepines. And we of course know that college is basically associated with very high rates of alcohol drinking. And not just alcohol drinking, per se, for binge episodes with very very high consumption of very large doses of alcohol.

And all of those are in turn basically leading to negative outcomes.


So my second question does focus on prescription drug misuse, which is a concern among college students just like it is elsewhere.

But among college students, it seems that the bigger concern is around the non-medical use of prescription stimulants because students think it's going to help them get better grades.

What's the important messaging we need to get out to college students about that issue?

Dr. Volkow:

Indeed, prescription stimulants are abused more by college students.  I think it is one of the highest risk groups than others. And part of it relates exactly to the belief that if you take a stimulant, you will be able to perform better in a sense and in your courses.

Now, what [does] the data shows us about it? If you're going to be studying the night before and you don't want to sleep, a stimulant will keep you awake. And that is correct.

Now what the studies have shown is that, on the other hand, the outcome and the grades themselves do not differ very much.

And it was a very interesting study that was done on medical students that were actually given stimulants versus those that were not. And then they were evaluated on their outcomes and they showed no differences in those that have been given that stimulants in order for them to study for the exam, versus those that were not given them.

But what was very interesting was that those that had been given that stimulant medication felt that that they had performed better than they actually had. And this is something that is recognized about similar medications. That they gave you the perception that actually you are doing better than you actually objectively are doing.

Now this this actually promotes the sense and the belief that stimulants help you perform better, when in fact they may not necessarily do that.

The other very interesting aspect about what stimulants do is that if you are performing poorly – for example, if you have problem with attention – the stimulant medication may help you to some extent.

But, if you're already performing very well then the stimulant medication will deteriorate your performance.

And so it has been shown, for example, that stimulants make you much more perseverative on your on your behaviors, including your thinking processes. So if you are solving a particular puzzle, for example, and then the rule for solving the puzzle change and you're on a stimulant medication, you have a much harder time to shift to the new way of solving it.

So that that's exactly where the perseverative thinking comes along and where you may in fact see deterioration on cognitive performance for certain tasks.

On the other hand, if you put someone on a very boring task that is just repetitive, repetitive, repetitive, then the stimulant medication may actually make you perform better because you will perseverate and it will appear like the particular task is more interesting.

There are two other important effects of stimulants that I think it's important for college students to know before they actually take or decide to take a medication (unless of course they have proper diagnosis of attention deficit disorder) is that number one, stimulant medications can be addictive and when they produce addictions these are actually quite difficult to treat, that’s one.

The second one is that stimulant medication also can produce psychosis and acute psychosis and that can be quite a terrifying experience. It's not long-lasting, which means it is not like you're going to have this psychosis for five or six months but it will produce and it could produce a short psychosis that again can be that can be handicapping and erode the confidence of that individual.

So there are these two very negative side effects of stimulant addiction and then psychosis. And then apart from all of this, when you are taking stimulant medications regularly, you do become tolerant to them, which means you need higher and higher doses. And the higher doses that you need, the higher the likelihood that you may become addicted to them and the higher the likelihood that you may have a psychotic episode.


So it’s interesting, the study you mentioned is the first time I've heard about that one. So we know students go into a test … or pretest… thinking that if I take this prescription stimulant it’s going to help me. But this study is showing that even post test, they felt that it helped them until the actual grade was in front of them.

Dr. Volkow:

Yeah, and this is an interesting aspect of stimulants. And actually it's quite well recognized because, for example, in the air pilots. Pilots are given stimulants in order for them to be able to stay awake when they have to operate for 48 or 72 hours. So you want them to be basically on top. And it has been already recognized that there was a discrepancy between how they were performing and [how] they thought they were performing.

But in a war-type situation it may be actually be beneficial to give you a sense of overconfidence.

So in those circumstances, these effects of stimulants by itself may not be negative. And, again, this is recognized under very special circumstances. But one needs to understand also what those circumstances are because you don't want to actually make mistakes; in the sense that you think you are performing very well when in fact you are not when things may be very vulnerable.

So that’s whereupon one has to be mindful of ultimately what these drugs do and what they do not.


So I'm gonna switch over to… let's talk about marijuana.

We know that daily marijuana use is at its highest rate among 19 to 22 year olds since the 1980s. And the Monitoring the Future Study tells us that almost 5 percent of college students use marijuana on a daily or a near daily basis.

So what does the prevention field need to be doing to help turn the tide and decrease that rate?

Dr. Volkow:

Well, one of the things that the prevention field needs to do is to actually provide information about what may be the adverse effects of marijuana in a way that is subjective and not exaggerated.

I think that in general there has been the sense marijuana is not a harmful drug. And many of the arguments are given [because of the] changes in policy towards approval of medical marijuana.

This actually is something that we're trying. If it's a medicine it cannot be harmful.

And that is in fact, for example, why we are seeing people favoring the use of opiate medications to get high because they have a sense that if it's a medicine it is not so harmful.

So the same logic applies to medical marijuana when in fact it is not the case.

The other aspect that has changed normative attitude is that many people have been exposed to marijuana when they were younger and they didn't see any adverse consequences.

Without actually … so they portray that and say, “Look I used to take marijuana when I was a young person so and I'm basically very successful.”

Now what has happened is the content of THC, the active ingredient of marijuana, is significantly higher than what it was when those parents were taking it as youths.

So, the higher the content of 9-THC, the higher the likelihood that you can actually become addicted to it. And also, interestingly, high content 9-THC also has an associated risk of psychosis.

And here the associated risk of psychosis tends to actually show to be longer lasting than the ones that we were discussing for the stimulant drugs.

And this has generated an enormous amount of interest particularly among the European scientists as it relates, for example, what may be the potential risk of smoking marijuana with respect to the emergence of schizophrenia.

Now, schizophrenia is a disease characterized by psychosis. But different from just acute psychosis, it's long lasting. So you have this period of paranoia that lasts for months or years, or with hallucination.

It is not clear that marijuana will trigger a schizophrenia disease but it is a producer. It is… what the data is showing that if you do have vulnerability – which could be genetic or it could be developmental – toward schizophrenia, if you smoke marijuana it may trigger it. It may actually make it emerge earlier than it would have happened otherwise, and/or it may make it emerge in circumstances that otherwise may not have happened.

And that's where we are right now. So there is this potentially rare but very serious side effect.

And communicating this to college students, in terms of these are the most extreme, of course, of the negative effects of marijuana. But there are intermediate effects that actually are quite common and could have deleterious effects on their own. 

For example, on their ability to perform well in college. One of them is that when you're stoned you cannot learn properly. You actually cannot memorize things because one of the areas that have the highest concentration of cannabinoid receptors – which are the ones that are stimulated by marijuana – is in the hippocampus.

And you need your hippocampus to memorize things.

Now this deterioration of memory basically only lasts while you’re intoxicated with marijuana and while you have marijuana on board. So it's not that long lasting. Like is basically some studies have shown that. But it is really unclear. We don't know if marijuana produces long-lasting impairment in your capacity to learn. But we do know that when you are intoxicated it does. That is factual.

The issue is that marijuana is a lipid-soluble substance, so it stays in your body very long. So you may say, well, alcohol also interferes with your cognitive capacity but alcohol has very fast pharmacokinetic; that means it goes in and out of your body very rapidly.

Not for marijuana.

So if you're studying and you're in college and you're actually going on in the weekend and getting high on marijuana, then the effects may still be lasting during the weekday and will interfere with your performance.

And that is different from alcohol, where if you were drinking over in a Saturday or Sunday night by Monday you may be a hungover but you will basically be recovered.

So this actually can interfere with a capacity to pass grades and may lead them to flunk and do much worse than otherwise. That is an aspect that they need to know.

And another aspect that has been described now for many years in the clinical literature is that – and I don't know that this.. I only I cannot say that this is specific for marijuana I mean it may also occur with all the drugs, but it has been recognized clearly for marijuana – is that the repeated regular use of marijuana decreases your motivation for things.

And that has been described as amotivational syndrome. Apathy. Lack of interest. Lack of excitement for things.

So, if you are in college and you lose your interest on your classes that could be very very deleterious. And that can lead you to skip your classes that can lead you to skip exams, and can actually sometimes lead you to just actually get out of college. And that could be very very deleterious.

So we say that those are things that college students should know about the potential negative effects of consuming marijuana.


You started off by saying … I know that many of my colleagues around the country that work on campuses, that the messaging they give the students is the of marijuana today is not like the marijuana of yesteryear.

I mean because of the THC content, like you said, and you know with the advent of edibles … people are ingesting edibles at a higher rate because they're not getting the effects like smoking a joint. And so you know they're eating or taking the edibles and next thing you know they're in a significant situation because they've not necessarily overdosed per se but they have a lot of intake.

Dr. Volkow:

Yeah, no they actually … they’re taking a very large dose and this is what happens when you consume a drug orally. It takes much longer to get into your body, into your brain. And, as a result of that they take this cookie and they don't feel anything. So they take another cookie and another cookie and when it does hit them … that actually is where we're seeing a significant increase in psychosis.

It’s associated with consumption of these very high doses of edibles and it’s very very, again, a frightening experience for that individual.

You also see it when individuals consume very high content of 9-THC like where they may smoke it – and, for example, Skunk which can have more than 20 percent THC, sometimes 30 percent or higher. That can trigger a psychotic episode and a very very frightening experience for the individual that is consuming it.

So, yes indeed, the content of 9-THC does make a big difference in terms of its adverse effect.  And, for example, in 2000 the content of THC in marijuana may have been between 4 percent, 5 percent.

Now the content of marijuana is 12% regularly and that does not include the very high content cannabis products like Skunk … or the vaping of THC which can lead to actually a liquid that have almost 100% content of 9-THC.

So these are the routes that are now becoming available in states that have legalized marijuana, particularly for recreational purposes, where you really can see a wide diversity of products available.


So, just a couple more questions. I know next week is a big week for NIDA. It has its National Health observance which is National Drug and Alcohol Facts Week which we help to promote as well as some of our other federal partners. So it's coming up January 22nd through the 28th.

Can you tell us a little bit about what National Drug and Alcohol Facts Week is and how NIDA would like to see college campuses get more involved?

Dr. Volkow:

Well, the National Drugs Week basically was initiated as a one-day event where we have scientists from NIDA come together on one day … to answer questions from students, high school students, all over the United States that connect via computers on what they want to know about drugs.

And this has been an incredibly successful event. It's actually overpowering. There are so many questions that we have had to limit, sort of, over the past four, five years, the number of schools that can go in. So we have to pre-select them beforehand, otherwise there is just a barrage like a tsunami of questions!

And it's important because, first of all, we can provide objective information to these high school students. But it's also relevant because it gives us an idea what are the beliefs and concerns of high school students, which we then can fit into how to best optimize and tailor prevention towards this age group.

With respect to college students and other age groups, we’re encouraging –across the whole United States –that they hold events to bring in the community that relates, again, to the use of science in order to inform them about what do drugs do and what may be the negative consequences.

So, to objectively use information that has been derived from research performed either in the laboratory, or through epidemiological studies, or through the clinic that can help answer questions overall in the community and provide information that may relate to resources that can help someone that may be suffering from an addiction or they want to actually themselves become more active in engaging in prevention in that community.

So, we're using it as a way to get citizens engaged in the problem of substance use so that they can be better participants in its prevention and they can intervene when they know someone that they care for has a problem so they can send them to treatment.


And DEA is very happy to help promote this health observance. We have it on all three of our web sites –on Just Think Twice for the teens, Get Smart About Drugs for the parents and educators, as well as now for the college campuses. So we’re really trying to get the word out.

Dr. Volkow:

…This is an event that we're also working now in partnership with the Alcohol Institute and our Natural Institutes of Mental Health because as we know and I mentioned it earlier, one of the major challenges that college campuses have is the very, very high consumption of alcohol which has many very negative effects including behavioral … group behaviors that are very detrimental and that are negative for the individual and those that are nearby. So we’re trying to change that attitude.
And also college is a period where the use of drugs may be actually higher among those kids that may have a mental illness because it may be a way for them to actually auto-medicate. It's an opportunity to actually do prevention interventions that can help these kids that are much more vulnerable.


Absolutely. Well as I wrap up, I'll close with this question: what would you say to encourage the professionals who are working to prevent drug abuse among college students as well as the students themselves who are listening to the podcast?

Dr. Volkow:

Well … the notion is, when you're in college, you want to explore the world. And there is that young person actually taking risks and actually discovery is part of the excitement of growing up.

I think it's important to recognize that the use of drugs is a very easy way out that for which ultimately you are paying a price because what drugs are going to be doing is they're going to be resetting the brain systems that actually are making you want to do things and feel excitement.

So you're feeling good right now but once that drug is out of your system you feel much worse. So it's almost like mortgaging your sensations. And our brain has evolved over, really, millions of years of evolution to maximize its function and to maximize our sense of well-being and our ability to engage with others.

So the use of drugs may temporarily feel good but you're paying a price.

The price that actually is going to make you, well after you no longer have the drug, much less sensitive to the pleasures that everyday life gives you, including the enjoyment that you feel when spending time with your friends. Or playing sports, or actually viewing a movie, or something that you like very much.

So, it's actually a very easy way out that comes at a very high price. And I think that … it’s so important to send us a message that many times kids that are actually, as we were discussing, dealing and struggling with personal issues that may relate to stress at home, or with relationships or their own inner emotional turmoil may take these drugs because they make – temporarily, again –make them feel better or perform better.

And I think that the message there is if you feel yourself in those circumstances seek help. That's why we have experts that can actually help you provide an intervention that will help you feel more comfortable with yourself and not have to resort to the use of drugs to actually get that sensation of at least performing normally.

Now, that's why we have treatment interventions; whether it is behavioral intervention, psychological intervention or, in some instances, with medications that can help you actually feel back to where you were feeling before.


Yeah. Well as I wrap up --

DEA thanks you very much for your perspective [and] for NIDA’s work. We look very highly on that research and in partnering with them and so we really appreciate the time that you've given us on this podcast.

Dr. Volkow:

Well, thanks very much for your interest! Thanks very much for your collaboration!


Absolutely. And to our listeners, thank you for joining us on this edition of “Prevention Profiles: Take Five.” Take care and have a good day.