Nora D. Volkow, MD: The Pain Crisis, and Optimizing Addiction Care Delivery


The director of NIDA discusses the interplay of substance use disorder and pain in patients, as well as means to assure patients are receiving evidenced-based treatment.

As highlighted in previous segments of her interview with HCPLive, National Institute on Drug Abuse (NIDA) director Nora D. Volkow, MD, foresees an uphill climb in combating the exacerbation of US substance use disorder and overdose rates spurred by the COVID-19 pandemic.

Key to addressing historic rates of addiction and overdose are remaining dedicated to treating the whole patient, and continuing to seek optimal definitions of care.

In the final segment of an interview with HCPLive during the American Psychiatric Association (APA) 2022 Annual Meeting in New Orleans this week, Volkow discussed the twin epidemic status of substance use disorders and chronic pain conditions in the US, the means to pursue value-based care options, and the value of APA’s headline theme of “Social Determinants of Mental Health.”

On the pain crisis’ impact on addiction, Volkow stressed the “highly comorbid” presence of pain in individuals with both substance use disorder and other mental illnesses.

“When we speak about pain, we make these distinctions between physical and psychological pain, but it’s a little bit arbitrary because one of the issues that hardest for patients to deal with pain is the emotional aspect of that pain, the fear that they have,” Volkow said. “And to the extent that we can mitigate that emotional component of pain, they are able to tolerate much more physical pain.”

Between overlapping neurocircuits influencing treatment response, and the exacerbation of pain sensation and stress related to it among patients undergoing withdrawal, Volkow sees an issue constant interplay between pain and addiction. Even in the simplest terms, pain increases risk of stressors, which increases anxiety, which leads to risk of mental illness. “So you start to accumulate them, and there is a level where you love the capacity to actually buffer it,” she said.

On the subject of defining and promoting optimal care for substance use disorder, Volkow highlighted NIDA’s emphasis on setting evidence-based precedent.

“What we do as an agency is provide evidence about what are our interventions and what are their positive outcomes,” she said. “Based on that, we fund researchers…to take that evidence and construct a scoring card that gives you an idea of whether a treatment program has elements the research has shown to be effective. This is the first step toward improving the quality.”

Volkow also noted collaborations such as that between the non-profit organization Shatterproof and private insurers to reimburse treatment costs based on NIDA’s effective treatment scoring—a buck in the standard of US health care coverage that does not carry a similar demand for quality-based patient care.

“We are bringing in science that can be used to create ways of identifying quality care, and promoting researchers to come up with models that can facilitate that translation,” she said.

Lastly, on reviewing the thematic headline of APA 2022, Volkow highlighted the significance of non-clinical patient factors on her field of care.

“While they are not the only factor, they are crucial factors in enabling presentations, in determining the severity, in modulating the success of treatment and recovery, and inequity,” Volkow said. “I think is one of the biggest lessons from the COVID-19 pandemic.”

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