- Email: [email protected]
NIDA in the 90's: (1994-2001)
Drug and Alcohol Dependence 107 (2010) 99–101
Contents lists available at ScienceDirect
Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
CPDD News and Views
NIDA in the 90s: (1994–2001)夽 Alan I. Leshner I was fortunate to be the Director of NIDA during a period that I often characterize as benefiting from the “alignment of the stars.” NIDA, along with the National Institute of Mental Health (NIMH) and the National Institute of Alcohol Abuse and Alcoholism (NIAAA), had returned two years before to a quitewelcoming National Institutes of Health (NIH). I was Harold Varmus’s first appointment, and he was extremely supportive of the goals I brought to the job. These included: • ensuring that NIDA would be a quintessential public health institute, one with both outstanding science and effective programs to bring that science to practitioners and the broader public; • making NIDA one of the pre-eminent neuroscience institutes at NIH; • making NIDA’s Intramural Program one of the premier centers of addiction neuroscience in the world; • making addiction as much a health issue as a criminal justice issue for American society; • moving the Institute out of the very uncomfortable Parklawn Building and into an NIH building. The notion that NIDA should become a true public health institute reflected many of the attitudes prevailing at the now former Alcohol, Drug Abuse and Mental Health Administration (ADAMHA), which itself included both scientific and commu-
夽 This material is not peer-reviewed by the Journal, but is reviewed prior to publication by the members of the CPDD Publications Committee and invited members of the College. News and Views is edited by the Chair of the CPDD Publications Committee: Richard De La Garza, II, Baylor College of Medicine, Menninger Department of Psychiatry & Behavioral Sciences, Houston, TX. E-mail address: [email protected]. 0376-8716/$ – see front matter doi:10.1016/j.drugalcdep.2009.05.005
nity service activities. Robert Trachtenberg, the long-time ADAMHA and then SAMSHA Deputy Administrator was an important mentor and ally in getting these goals accomplished. Although NIDA no longer had direct service programs in its own purview, I felt it was important that it do what it could to ensure that the science it supported was used in real-life settings and in public policy. After all, the fact that NIDA supports over 85% of the world’s research on the health aspects of drug abuse and addiction gives it a special responsibility to make sure that its science is both useful and used. Although SAMHSA shared responsibility for disseminating the results of NIDA-supported research, the power of a scientific institute doing that directly could not be matched. I inherited an institute in excellent shape from my predecessor directors and, more recently, from Richard Milstein’s excellent tenure as Acting Director. In addition to his earlier role as Acting Director, Dick was a fine Deputy Director throughout my years at NIDA. We also all benefited from the great leadership provided by NIDA’s two Associate Directors, Tim Condon and Laura Rosenthal, and the excellent senior staff. Barry Hoffer exceeded the high expectations I had when I appointed him as Scientific Director of NIDA, and he recruited to and retained at the NIDA Intramural Program an array of top scientists, including particularly Roy Wise, who continues as Barry’s very effective Deputy Scientific Director. Under Barry’s leadership, the NIDA IRP has achieved the goal I set when I came to NIDA and is unquestionably one of the finest neuroscience of addiction centers in the world. Another important aspect of these goals being implemented is that my superb successor, Nora Volkow, has shared many of them. She has done a splendid job of moving NIDA to the next level of excellence.
When she was appointed, many people accused me of having selected my own successor, but it was not true. In fact, none of the deciders had asked me until they were about to appoint her. But reader, be assured: had I the choice, I would have chosen her. She is outstanding. The alignment of the stars also included great support from both “above” and “the side.” Harold Varmus remained extremely supportive and frequently helped me think through tough issues. Donna Shalala, Secretary of Health and Human Services, understood our issues and found ways to make it easier for us to succeed. Barry McCaffrey, the Director of the White House Office of National Drug Control Policy (ONDCP), known generally as the Drug Czar, figured out very early on how important the science of addiction could be, both to public understanding and public policy, and he did what he could, within the constraints of politics and public policy making, to help us work to replace ideology with science as the foundation of American drug policy. Other excellent partners in that effort included the leadership group at the Department of Justice’s Office of Justice Programs, including Laurie Robinson, Jeremy Travis and Shay Bilchik. In addition, David Mactas, as the Director of SAMHSA’s Center for Substance Abuse Treatment (CSAT), was a particularly strong partner early on in trying to bring science to drug treatment throughout the United States. The point of listing all these partners is not just to acknowledge their efforts and colleagueship, but also to emphasize that having so many partners with shared goals can mean so much to getting things done. I was NIDA Director during a time un-matched in its history for having both bosses and so many colleagues in other agencies who shared our vision and goals. And, of course, having partners alone could not do it. We also benefited greatly
100
from the largess that came with the decision to double the NIH budget over five years. This was a bi-partisan initiative mounted by John Porter (R-IL) in the U.S. House of Representatives and Arlen Spector (R-PA) and Tom Harkin (D-IA) in the U.S. Senate. Having the rapid budget growth this initiative delivered meant we could start an array of new initiatives and, at the same time, expand our grant portfolio in virtually every field.
1. Addiction is a brain disease This became known as the NIDA mantra during my tenure as NIDA Director. Being a psychologist by training, I always added “Expressed in Behavioral Ways – Both Developing and Recovering from It Depend on Behavior and Social Context.” However, all anyone ever heard was “Addiction is a Brain Disease.” In truth, I did not invent the concept. I learned it from Charles O’Brien, one of the true leaders in drug addiction research, who had been using the phrase for many years before we met. But it did resonate with me, and I saw its powerful potential to change the way the public sees addiction and, perhaps, to help reduce the stigma associated with it. A similar understanding had, after all, been extremely effective in reducing the misunderstanding and stigma attached to other brain disorders, like schizophrenia and depression. I had learned that lesson during my tenure as Deputy Director and Acting Director of NIMH. In trying to translate the concept for the public, I started using a metaphor of a “switch” in the brain, a set of brain changes through which voluntary drug use gets converted into compulsive, often uncontrollable drug craving, seeking and use—the condition we mean by the term addiction. This upset some of my scientific colleagues, both because they knew there was not really a literal switch mechanism that flipped precipitously – addiction comes on more gradually – and because, I believe, it conflicted with the metaphors they used when thinking about the process (I called this “metaphor envy”). The concept of addiction as a brain disease was fairly slow to gain acceptance in the addiction field, but over time I do believe most scientists and practitioners came to understand both its science base and its usefulness in public, practice and policy settings. Some policymakers, like Drug Czar Barry McCaffrey, for some reason had trouble saying “addiction is a brain disease,” although they did understand the core concept. McCaffrey liked to describe the fact that addiction comes about because of the effects of prolonged
A.I. Leshner / Drug and Alcohol Dependence 107 (2010) 99–101
drug use on brain structure and function, using phrases like “addiction happens because your brain is rewired by repeated drug use.” This sounded fine to me, so long as someone in the White House understood the science in a fundamental way and was supportive of conceptualizing the issue as basically as health related—one that comes about because of brain changes. Perhaps the most important consequence of conceptualizing addiction as a brain disease was that it explained why one cannot just quit by force of will alone—why treatment is essential. We do not ask schizophrenic individuals to manage their hallucinations and delusions without treatment. We do not expect depressed patients to simply “pull themselves up by their bootstraps” any more. So, why is it the norm to expect addicts to simply quit without treatment if they too have a brain disease?
2. Science to practice One day CSAT’s David Mactas came to see me and said he had a great idea for a study by the Institute of Medicine (IOM) of the National Academy of Sciences. Mactas was interested in improving drug addiction treatment on a grand scale and believed that a study by the IOM focused on moving science into practice in real-life settings would be extremely useful. I agreed to cosponsor the study. Mactas had left CSAT by the time we could implement the IOM study’s recommendations, so, with the agreement of the NIDA Advisory Council, I adopted for the Institute the goal of “Improving Drug Abuse Treatment Throughout the Nation Using Science as the Vehicle.” The vehicle for this initiative would be based on one of the IOM’s recommendations: building a clinical trial network throughout the United States for drug abuse treatment research and its testing in practice settings. Many NIH institutes have clinical trial networks that typically include research universities and the hospitals associated with them. Some include physicians working in other, even private practice, settings. What was unique about the NIDA Clinical Trial Network notion was that it included both clinical researchers and practitioners working in real-life community-based settings, most of whom were not themselves scientists or scientifically trained. One of my best hiring decisions was to select Betty Tai to implement and oversee the NIDA National Drug Abuse Treatment Clinical Trials Network. Over the years, working with a very effective Steering Committee of superb clinical researchers and community-based treatment providers, she and her NIDA
colleagues have built and implemented a network of almost two dozen universitybased “nodes” that include well over 100 community-based treatment programs. The Network has completed more than a dozen formal protocols and published tens of studies in well-respected journals. It is too soon to know whether this network will in fact accomplish its goal of revolutionizing drug addiction treatment throughout the nation and making it science based, but they are well on their way and I believe drug treatment as practiced in the community is getting better and better. As I was leaving NIDA, we had also decided to establish a similar network for prevention research and one for treatment in criminal justice settings. Budget constraints have made it difficult to implement those ideas fully, although Nora Volkow has made substantial progress in getting them into place and functioning effectively. One more mechanism of moving science into practice deserves mention. This idea was to distill underlying principles derived from research and lay them out in simple form for widespread dissemination to practitioners and the public. The first of these was “Preventing Drug Use Among Children and Adolescents, a Research-Based Guide.” The second was “Principles of Drug Addiction Treatment.” Drs. Volkow, Condon, and their colleagues have updated these and added other titles to the series. They have received very wide circulation, and I believe they have been very influential in shaping prevention and treatment practices.
3. Science and the public For NIDA to be a quintessential public health institute it needed to expand greatly its activities educating the public, based on the science it supports. My most effective partner in these efforts was Tim Condon, then Associate Director of NIDA, who was responsible for science policy, public communications and an array of other areas. Dr. Condon’s creativity and willingness to try unorthodox ideas was critical to all our efforts. Many of our activities seemed unconventional at first, but we needed to get people’s attention. We needed to convince them that there was a science base for understanding and dealing with addiction; and, more importantly, that they should turn to that science, rather than to their own individual impressions or, worse, their ideologies. And that was not easy. I have frequently said that I was the only NIH institute Director who would go to cocktail parties and
A.I. Leshner / Drug and Alcohol Dependence 107 (2010) 99–101
have people tell him how to do his job. No one told the Director of the heart institute how to deal with cardiac catheterization or the diabetes institute how best to treat that disease. But everyone is an expert on marijuana; just ask them. One of my favorite public education projects was a series of “go-cards.” These were post-cards with wonderful sciencerelated graphics that we placed in bars, restaurants and other public gathering spots. They drew the reader to special web sites containing science-based information about either individual drugs of abuse or addiction more generally. Thousands of these were distributed around the United States. Another great project was “NIDA Goes to School.” We sent boxes of materials to every school district in the United States. The material was specially suited to middle school students, and over 20,000 copies were disseminated. NIDA has updated these materials many times since I left the Institute and has an excellent collection of materials for all sectors of the public and for citizens of all ages. We also started a series of TV and print ad public service announcements called “Keep Your Brain Healthy: Don’t Use Drugs.”
Perhaps the strangest thing we did as an NIH institute was the Prism Awards. Done as a partnership with the Entertainment Industries Council, we gave out awards to writers, directors and actors in Hollywood for accurate depiction of drug abuse and addiction. The first year, about 50 people came. The last year I attended, we had about 400 people in tuxedos and long gowns at a very fancy event on a movie lot. The ceremony was broadcast on a major cable TV network. Did any of these public education activities have real impact? Have we changed the climate for drug abuse and addiction? When I left NIDA in December 2001, I felt that we had made some real progress. As evidence, when I first came to NIDA, people would ask me what the National Institute of Drug Abuse was; now people know it. And the idea that addiction is a health issue with a science base is no longer totally foreign to the general public, although I am not so sure many current policy leaders understand the point. In addition, I do believe that more and more people believe that drug treatment can work when done properly and comprehensively. However, it is still very hard to get people to go for treatment and to stay
101
in it long enough for it to have an effect. And people still persist in making up prevention programs as they go along, rather than relying on the array of prevention programs developed and tested through scientific research. As to policymakers, we have made some progress—there are many more drug courts, and treatment is an integrated component of many criminal justice systems. The widely accepted notion that treatment should be offered, or required, for addicts under criminal justice control is based on understanding the science that has shown it reduces recidivism. However, it is a continuing struggle that requires great persistence to get policymakers to stick to the science and not play to the ideologies that drive so many of the common misconceptions about drug abuse and addiction. I do believe that because of NIDA’s work, the United States now does have the science base to develop much more rational and effective national drug policies, and that this science base is getting stronger all the time. What we need is the political will and fortitude to stick to the science, reject counterproductive ideologies and at last get the job done.
Contents lists available at ScienceDirect
Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep
CPDD News and Views
NIDA in the 90s: (1994–2001)夽 Alan I. Leshner I was fortunate to be the Director of NIDA during a period that I often characterize as benefiting from the “alignment of the stars.” NIDA, along with the National Institute of Mental Health (NIMH) and the National Institute of Alcohol Abuse and Alcoholism (NIAAA), had returned two years before to a quitewelcoming National Institutes of Health (NIH). I was Harold Varmus’s first appointment, and he was extremely supportive of the goals I brought to the job. These included: • ensuring that NIDA would be a quintessential public health institute, one with both outstanding science and effective programs to bring that science to practitioners and the broader public; • making NIDA one of the pre-eminent neuroscience institutes at NIH; • making NIDA’s Intramural Program one of the premier centers of addiction neuroscience in the world; • making addiction as much a health issue as a criminal justice issue for American society; • moving the Institute out of the very uncomfortable Parklawn Building and into an NIH building. The notion that NIDA should become a true public health institute reflected many of the attitudes prevailing at the now former Alcohol, Drug Abuse and Mental Health Administration (ADAMHA), which itself included both scientific and commu-
夽 This material is not peer-reviewed by the Journal, but is reviewed prior to publication by the members of the CPDD Publications Committee and invited members of the College. News and Views is edited by the Chair of the CPDD Publications Committee: Richard De La Garza, II, Baylor College of Medicine, Menninger Department of Psychiatry & Behavioral Sciences, Houston, TX. E-mail address: [email protected]. 0376-8716/$ – see front matter doi:10.1016/j.drugalcdep.2009.05.005
nity service activities. Robert Trachtenberg, the long-time ADAMHA and then SAMSHA Deputy Administrator was an important mentor and ally in getting these goals accomplished. Although NIDA no longer had direct service programs in its own purview, I felt it was important that it do what it could to ensure that the science it supported was used in real-life settings and in public policy. After all, the fact that NIDA supports over 85% of the world’s research on the health aspects of drug abuse and addiction gives it a special responsibility to make sure that its science is both useful and used. Although SAMHSA shared responsibility for disseminating the results of NIDA-supported research, the power of a scientific institute doing that directly could not be matched. I inherited an institute in excellent shape from my predecessor directors and, more recently, from Richard Milstein’s excellent tenure as Acting Director. In addition to his earlier role as Acting Director, Dick was a fine Deputy Director throughout my years at NIDA. We also all benefited from the great leadership provided by NIDA’s two Associate Directors, Tim Condon and Laura Rosenthal, and the excellent senior staff. Barry Hoffer exceeded the high expectations I had when I appointed him as Scientific Director of NIDA, and he recruited to and retained at the NIDA Intramural Program an array of top scientists, including particularly Roy Wise, who continues as Barry’s very effective Deputy Scientific Director. Under Barry’s leadership, the NIDA IRP has achieved the goal I set when I came to NIDA and is unquestionably one of the finest neuroscience of addiction centers in the world. Another important aspect of these goals being implemented is that my superb successor, Nora Volkow, has shared many of them. She has done a splendid job of moving NIDA to the next level of excellence.
When she was appointed, many people accused me of having selected my own successor, but it was not true. In fact, none of the deciders had asked me until they were about to appoint her. But reader, be assured: had I the choice, I would have chosen her. She is outstanding. The alignment of the stars also included great support from both “above” and “the side.” Harold Varmus remained extremely supportive and frequently helped me think through tough issues. Donna Shalala, Secretary of Health and Human Services, understood our issues and found ways to make it easier for us to succeed. Barry McCaffrey, the Director of the White House Office of National Drug Control Policy (ONDCP), known generally as the Drug Czar, figured out very early on how important the science of addiction could be, both to public understanding and public policy, and he did what he could, within the constraints of politics and public policy making, to help us work to replace ideology with science as the foundation of American drug policy. Other excellent partners in that effort included the leadership group at the Department of Justice’s Office of Justice Programs, including Laurie Robinson, Jeremy Travis and Shay Bilchik. In addition, David Mactas, as the Director of SAMHSA’s Center for Substance Abuse Treatment (CSAT), was a particularly strong partner early on in trying to bring science to drug treatment throughout the United States. The point of listing all these partners is not just to acknowledge their efforts and colleagueship, but also to emphasize that having so many partners with shared goals can mean so much to getting things done. I was NIDA Director during a time un-matched in its history for having both bosses and so many colleagues in other agencies who shared our vision and goals. And, of course, having partners alone could not do it. We also benefited greatly
100
from the largess that came with the decision to double the NIH budget over five years. This was a bi-partisan initiative mounted by John Porter (R-IL) in the U.S. House of Representatives and Arlen Spector (R-PA) and Tom Harkin (D-IA) in the U.S. Senate. Having the rapid budget growth this initiative delivered meant we could start an array of new initiatives and, at the same time, expand our grant portfolio in virtually every field.
1. Addiction is a brain disease This became known as the NIDA mantra during my tenure as NIDA Director. Being a psychologist by training, I always added “Expressed in Behavioral Ways – Both Developing and Recovering from It Depend on Behavior and Social Context.” However, all anyone ever heard was “Addiction is a Brain Disease.” In truth, I did not invent the concept. I learned it from Charles O’Brien, one of the true leaders in drug addiction research, who had been using the phrase for many years before we met. But it did resonate with me, and I saw its powerful potential to change the way the public sees addiction and, perhaps, to help reduce the stigma associated with it. A similar understanding had, after all, been extremely effective in reducing the misunderstanding and stigma attached to other brain disorders, like schizophrenia and depression. I had learned that lesson during my tenure as Deputy Director and Acting Director of NIMH. In trying to translate the concept for the public, I started using a metaphor of a “switch” in the brain, a set of brain changes through which voluntary drug use gets converted into compulsive, often uncontrollable drug craving, seeking and use—the condition we mean by the term addiction. This upset some of my scientific colleagues, both because they knew there was not really a literal switch mechanism that flipped precipitously – addiction comes on more gradually – and because, I believe, it conflicted with the metaphors they used when thinking about the process (I called this “metaphor envy”). The concept of addiction as a brain disease was fairly slow to gain acceptance in the addiction field, but over time I do believe most scientists and practitioners came to understand both its science base and its usefulness in public, practice and policy settings. Some policymakers, like Drug Czar Barry McCaffrey, for some reason had trouble saying “addiction is a brain disease,” although they did understand the core concept. McCaffrey liked to describe the fact that addiction comes about because of the effects of prolonged
A.I. Leshner / Drug and Alcohol Dependence 107 (2010) 99–101
drug use on brain structure and function, using phrases like “addiction happens because your brain is rewired by repeated drug use.” This sounded fine to me, so long as someone in the White House understood the science in a fundamental way and was supportive of conceptualizing the issue as basically as health related—one that comes about because of brain changes. Perhaps the most important consequence of conceptualizing addiction as a brain disease was that it explained why one cannot just quit by force of will alone—why treatment is essential. We do not ask schizophrenic individuals to manage their hallucinations and delusions without treatment. We do not expect depressed patients to simply “pull themselves up by their bootstraps” any more. So, why is it the norm to expect addicts to simply quit without treatment if they too have a brain disease?
2. Science to practice One day CSAT’s David Mactas came to see me and said he had a great idea for a study by the Institute of Medicine (IOM) of the National Academy of Sciences. Mactas was interested in improving drug addiction treatment on a grand scale and believed that a study by the IOM focused on moving science into practice in real-life settings would be extremely useful. I agreed to cosponsor the study. Mactas had left CSAT by the time we could implement the IOM study’s recommendations, so, with the agreement of the NIDA Advisory Council, I adopted for the Institute the goal of “Improving Drug Abuse Treatment Throughout the Nation Using Science as the Vehicle.” The vehicle for this initiative would be based on one of the IOM’s recommendations: building a clinical trial network throughout the United States for drug abuse treatment research and its testing in practice settings. Many NIH institutes have clinical trial networks that typically include research universities and the hospitals associated with them. Some include physicians working in other, even private practice, settings. What was unique about the NIDA Clinical Trial Network notion was that it included both clinical researchers and practitioners working in real-life community-based settings, most of whom were not themselves scientists or scientifically trained. One of my best hiring decisions was to select Betty Tai to implement and oversee the NIDA National Drug Abuse Treatment Clinical Trials Network. Over the years, working with a very effective Steering Committee of superb clinical researchers and community-based treatment providers, she and her NIDA
colleagues have built and implemented a network of almost two dozen universitybased “nodes” that include well over 100 community-based treatment programs. The Network has completed more than a dozen formal protocols and published tens of studies in well-respected journals. It is too soon to know whether this network will in fact accomplish its goal of revolutionizing drug addiction treatment throughout the nation and making it science based, but they are well on their way and I believe drug treatment as practiced in the community is getting better and better. As I was leaving NIDA, we had also decided to establish a similar network for prevention research and one for treatment in criminal justice settings. Budget constraints have made it difficult to implement those ideas fully, although Nora Volkow has made substantial progress in getting them into place and functioning effectively. One more mechanism of moving science into practice deserves mention. This idea was to distill underlying principles derived from research and lay them out in simple form for widespread dissemination to practitioners and the public. The first of these was “Preventing Drug Use Among Children and Adolescents, a Research-Based Guide.” The second was “Principles of Drug Addiction Treatment.” Drs. Volkow, Condon, and their colleagues have updated these and added other titles to the series. They have received very wide circulation, and I believe they have been very influential in shaping prevention and treatment practices.
3. Science and the public For NIDA to be a quintessential public health institute it needed to expand greatly its activities educating the public, based on the science it supports. My most effective partner in these efforts was Tim Condon, then Associate Director of NIDA, who was responsible for science policy, public communications and an array of other areas. Dr. Condon’s creativity and willingness to try unorthodox ideas was critical to all our efforts. Many of our activities seemed unconventional at first, but we needed to get people’s attention. We needed to convince them that there was a science base for understanding and dealing with addiction; and, more importantly, that they should turn to that science, rather than to their own individual impressions or, worse, their ideologies. And that was not easy. I have frequently said that I was the only NIH institute Director who would go to cocktail parties and
A.I. Leshner / Drug and Alcohol Dependence 107 (2010) 99–101
have people tell him how to do his job. No one told the Director of the heart institute how to deal with cardiac catheterization or the diabetes institute how best to treat that disease. But everyone is an expert on marijuana; just ask them. One of my favorite public education projects was a series of “go-cards.” These were post-cards with wonderful sciencerelated graphics that we placed in bars, restaurants and other public gathering spots. They drew the reader to special web sites containing science-based information about either individual drugs of abuse or addiction more generally. Thousands of these were distributed around the United States. Another great project was “NIDA Goes to School.” We sent boxes of materials to every school district in the United States. The material was specially suited to middle school students, and over 20,000 copies were disseminated. NIDA has updated these materials many times since I left the Institute and has an excellent collection of materials for all sectors of the public and for citizens of all ages. We also started a series of TV and print ad public service announcements called “Keep Your Brain Healthy: Don’t Use Drugs.”
Perhaps the strangest thing we did as an NIH institute was the Prism Awards. Done as a partnership with the Entertainment Industries Council, we gave out awards to writers, directors and actors in Hollywood for accurate depiction of drug abuse and addiction. The first year, about 50 people came. The last year I attended, we had about 400 people in tuxedos and long gowns at a very fancy event on a movie lot. The ceremony was broadcast on a major cable TV network. Did any of these public education activities have real impact? Have we changed the climate for drug abuse and addiction? When I left NIDA in December 2001, I felt that we had made some real progress. As evidence, when I first came to NIDA, people would ask me what the National Institute of Drug Abuse was; now people know it. And the idea that addiction is a health issue with a science base is no longer totally foreign to the general public, although I am not so sure many current policy leaders understand the point. In addition, I do believe that more and more people believe that drug treatment can work when done properly and comprehensively. However, it is still very hard to get people to go for treatment and to stay
101
in it long enough for it to have an effect. And people still persist in making up prevention programs as they go along, rather than relying on the array of prevention programs developed and tested through scientific research. As to policymakers, we have made some progress—there are many more drug courts, and treatment is an integrated component of many criminal justice systems. The widely accepted notion that treatment should be offered, or required, for addicts under criminal justice control is based on understanding the science that has shown it reduces recidivism. However, it is a continuing struggle that requires great persistence to get policymakers to stick to the science and not play to the ideologies that drive so many of the common misconceptions about drug abuse and addiction. I do believe that because of NIDA’s work, the United States now does have the science base to develop much more rational and effective national drug policies, and that this science base is getting stronger all the time. What we need is the political will and fortitude to stick to the science, reject counterproductive ideologies and at last get the job done.