BETHESDA, MD — Nora Volkow, the federal government’s top drug addiction researcher, laughed when asked how a spate of recent policy changes at the National Institutes of Health had affected her day-to-day work.
“They have increased my blood pressure and heart rate,” Volkow said before declining to answer specific questions about Trump administration policy changes, instead referring them to the Department of Health and Human Services, the NIH’s parent agency.
But in an interview on the research agency’s campus here last week, Volkow delivered an impassioned defense of the NIH and the National Institute on Drug Abuse, the roughly $1.6 billion sub-agency that she has led since 2003.
Volkow, who is originally from Mexico, said that the NIH is a significant source of pride and admiration everywhere she travels. And while she said it’s sometimes good to “shake the system” for the purpose of rooting out inefficiencies, she cautioned that doing so is only productive if the end goal is truly to strengthen the organization.
In a wide-ranging interview, Volkow also discussed Robert F. Kennedy Jr., the Trump administration’s new health secretary, who has instituted major shake-ups at NIH in his first weeks on the job, including a pause on many grant reviews, proposing a significant cut in “indirect cost” rates, and cancelling numerous funding awards outright.
Kennedy is in long-term recovery from alcohol and heroin addiction and has spoken frequently about his experience with 12-step recovery and his vision for a nationwide system of wellness farms used to treat addiction.
“It’s wonderful that it worked for him, but I do know a lot of people where 12 steps did not work for them,” Volkow said, cautioning that Kennedy’s own experience recovering from addiction may not be generalizable to the millions of Americans with substance use disorders.
And in a rare opportunity for optimism in the addiction world, Volkow shared her theory as to why overdose deaths in the U.S. are suddenly plummeting after sharply increasing in the wake of the Covid-19 pandemic. Her multi-faceted explanation included improvements in access to naloxone and medications for opioid use disorder, like methadone and buprenorphine, as well as law enforcement’s success preventing fentanyl from crossing the border, the pandemic’s end, and the grim reality that many of the most vulnerable American drug users are already dead.
The following conversation has been edited for length and clarity.
STAT: The new health secretary, Robert F. Kennedy Jr., is very public about being in long-term recovery from addiction to alcohol and opioids. Are there benefits to having someone in long-term recovery serving as the country’s top health official?
Volkow: I don’t know what his specific views are on this, because I haven’t spoken with him. But I do resonate with the importance of these other elements that will determine whether someone is successful or not.
We need to develop the research pertinent to recovery, because it’s the only way we can document the evidence that can then hopefully be reimbursed, just like you have interventions for recovery from cancer that can support better long-term outcomes, or for diabetes. You need support systems, and those are paid by insurance or other mechanisms, so that is the element where it’s important to understand: What is the support that’s necessary to help people achieve recovery?
I don’t know if you watched Kennedy’s confirmation hearing, but he was asked whether he supports the use of effective medications for opioid use disorder like methadone and buprenorphine. He gave an interesting answer in which he basically said: I support the medications’ use, but the “gold standard” is 12-step recovery.
His own experience basically leads him to say: “It worked for me.” And we have this tendency, it is the way that our brain is hardwired, to internalize. We predict the world on the basis of our own experiences. And so you are projecting that into the overall, and it’s wonderful that it worked for him, but I do know a lot of people where 12 steps did not work for them. The way I would put it — and again, I haven’t spoken with him — is that there are certain antidepressants, SSRIs, that may work well for one person, others it doesn’t work, so you do something else. Behavioral interventions may not work. Not everybody responds the same way. And I met many patients, I have interacted with many patients that do not like the philosophy of the 12-step program — it doesn’t speak to them.
Do you think that stems largely from the historic hostility of Narcotics Anonymous, in particular, to medications for opioid addiction?
I’ve had patients saying, “I respond very, very well to buprenorphine, but I also want to be able to take advantage of the 12-step programs. But my 12-step programs are very categorical. They want me to stop buprenorphine, and I am afraid that if I stop buprenorphine, I’m going to overdose. So this is a situation we shouldn’t have.
But I do think that there are other elements that play into it. Let me give you an example: What we’re trying to achieve with addiction recovery, you want to empower the person so that they are in control. And 12-step programs require that you basically render control to another god. So that argument, I’ve also heard. So in my view, there’s not one solution for every person. We all find ourselves in situations that are stressful and unique, and we respond differently.
Obviously, it’s been an extraordinary six weeks politically, and there’s a lot happening. How have the recent policy changes at NIH impacted you, and your work?
Well, I’ve been told I cannot say anything. [Spokeswoman, from other side of the room: We can refer you over to HHS for anything related to specifics.]
They have increased my blood pressure and heart rate. That’s the only thing I can say. They have actually created insomnia.
Well then, more broadly speaking, what would you want to tell the public about the value of NIDA and the NIH’s work, in general? What do you want people to know as these conversations are happening?
I think we need to hear from every perspective. I’m being very honest, and I shouldn’t be taken out of context. I do think that it’s good to shake the system in a way that leads to reassessment of processes and ways of doing things. I do think that’s very valuable, and being self-critical. The issue is: that is valuable if there is a goal to truly strengthen an organization that has no parallel in the world in terms of its contribution to knowledge, to science, to solutions, to health care, and to economics.
I mean, it’s extraordinary. Me, coming from Mexico, and I travel a lot — you see how people admire the NIH. Having said that, the question is, can we do things better? Can we accelerate the development of all of this knowledge into translation? I think absolutely yes. Are there models that we also could rebalance, in setting priorities?
And I resonate totally, 100%, because it’s very frustrating for me as a scientist when I encounter situations where there is inflexibility on understanding alternatives. I think that dialogue and openness is fundamental for science. You can create a model, let new data come in, and if the new data doesn’t support the model, destroy the model but use the data. That’s what we are aiming for there. So I don’t want this to be taken in any way out of context … but if we don’t learn from this experience what went wrong on the way that we acted, then we’re going to repeat it. And we’re not [going] to improve our processes and our ways to tackle the situation into the future.
It’s nice to be speaking to you during a moment of optimism when it comes to the addiction crisis. Death rates are plummeting: Do you have a theory as to why?
It’s a single theory that contains multiple factors.
There’s been a significant increase in people that actually have been screened and treated with medications for opioid use disorder.
Second, we have expanded access to naloxone, actually, in ways that maximize the likelihood that it is going to be ending up in the hands of people that are in the highest-risk situations and their friends network. So access to overdose treatment, access to medications for opioid use disorder, education of the public.
It is crazy, but five or six years ago, in some of the highest-hit areas, they didn’t know what fentanyl was. So there’s been a tremendous amount of education of the public, and the media gets a lot of credit for that, in making people recognize how dangerous these drugs are and where they can find them, because they appear basically in places unexpectedly.
A fourth one is that it has become harder for fentanyl to get into the United States in greater purity. So if you think about it, this has led to fentanyl, which people seek as heroin or cocaine or as methamphetamine, but now it has a lower purity, and there is less in sort of incentive for the drug dealers to use fentanyl to lace other drugs, because if it’s harder to bring, it’s harder to actually make profit. So there’s no two ways around it, I do think a fourth element may be that it’s harder to get fentanyl into people’s hands.
A fifth one that I think may be contributing — we don’t completely know what the dynamics are, but I do think it is relevant, we cannot dismiss it — is the notion that the most vulnerable people have died.
There’s been a very steep rise that happened during the Covid pandemic, close to a 50% increase in mortality. Now, the Covid pandemic is gone, and all of those factors that contributed to the sharp rise are gone. So if you normalize it back, could that have by itself, with nothing more, brought everything down? That is absolutely a contributor.
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