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A funny thing happened to Nora Volkow, MD, the new director of the National
Institute on Drug Abuse (NIDA), when she first applied for a grant from the
agency: she was rejected.
In 1984, she was finishing her residency in psychiatry at New York University,
where she had pioneered brain imaging studies of drug users. "I started to
find out cocaine abusers had vascular pathology, sort of small vascular accidents,"
said Volkow, now 47. "NIDA came back to me and said, ‘there's no evidence
that cocaine is toxic.'"
Discouraged, the young Volkow [pronounced VOHL-kov] abandoned further
vascular pathology research. Although cocaine was gaining traction as a recreational
drug, it had been licensed as an anesthetic for decades. The idea that it
triggered tiny strokes in the brain was radical, and it took three years for
a journal to accept Volkow's original paper for publication.
But she was right, as other researchers went on to show.
On meeting Volkow, her devotion to understanding addiction is immediately
evident. During a recent sit-down interview, words spill out so quickly that
a journalist abandons his notepad and keeps a close eye on his recorder. Sporting
brown leather boots and a light leather jacket instead of one of the suits
so common for those running Washington's billion-dollar agencies, the Mexico
City native with a famous Russian heritage flutters her hands and leans forward
when making a point.
Six months into Volkow's tenure, that office is a study in harried minimalism.
Walls barren of art or photos, a few chairs and a sofa flank a desk that holds
the conduit to Volkow's intellectual marrow: two huge flat-panel monitors.
As the clock leaning against the foot of the sofa sweeps through the minutes,
Volkow is reminded again of her struggle to find time to study the latest
brain scans and data tables from Brookhaven National Laboratory, Upton, New
York, where she previously headed the life sciences division and published
dozens of pioneering brain imaging studies.
Volkow carries a computer nearly everywhere, popping it open in airports,
cabs, and, this morning, at the Department of Motor Vehicles. She was supposed
to fly to New York for her once-a-month visit to Brookhaven, but she was held
back by her director's duties and a more quotidian chore—beating a 6-month
deadline to get her Maryland driver's license.
While snaking through the notoriously long queues, Volkow absorbed Brookhaven
data that show a brain region important for motivation "clearly activates
in a person that is addicted but not in a non-addicted person." The data help
cement a finding that has prompted addiction researchers to focus on not just
the brain's pleasure centers, but its motivation zones too.
"When you are not addicted, a drug can feel good," said Volkow. "But
what you don't feel is the drive, the need for more. And now we have the data
to document that [this drive] is clearly associated" with the orbital frontal
Volkow said that discoveries like these make her "high." So much so
that she made it known that giving up her Brookhaven laboratory would be a
deal breaker when approached by NIH Director Elias Zerhouni, MD. Zerhouni
acceded, confident that Volkow would sort out her schedule.
But still, Volkow feels constrained. More than anything, she wants to
think. She runs 6 miles every morning, indoor on a treadmill if need be, to
give her a "protected" hour to do so.
Some of her best ideas come during runs. She also uses the time to mentally
prepare for speeches, something she's been doing a lot. Since joining NIDA
in May, Volkow has been in high demand. She's given, by her estimation, 65
"major speeches" and countless minor ones. The week after meeting with JAMA,
she was scheduled to deliver seven talks, including a headliner at the Institute
of Medicine's annual meeting. A month earlier, she had jetted between Russia,
Washington, and Los Angeles in the span of 6 days.
Volkow's rapid-fire and playful speeches typically draw rave reviews.
At an October meeting in San Francisco, she brought 300 addiction specialists
to their feet, a standing ovation that played in sharp contrast to the tepid
applause given to a representative of the White House's Office of National
Drug Control Policy at the same meeting.
As Volkow laid out her vision for NIDA, she was forced to pause after
saying, "Look, I will be candid." When the applause quieted, she continued:
"Because there's no point not to be. The fact is, there is not much interest
from drug companies in addiction medicine . . . . We have to incentivize them
to try [new medications] for addiction."
At that California Society for Addiction Medicine meeting and at the
larger June gathering of the College on the Problems of Drug Dependency, attendees
expressed surprise that such a straight shooter could win the top job at NIDA,
a position fraught with political pressure. For example, some addiction specialists
took issue with use in an antidrug campaign a couple of years ago of an image
of a "plain brain" and a "brain on ecstasy" that showed what looked like a
hole in the head of the drug user (JAMA. 2001;86:777-778). The methods behind
the study that spawned that image (Lancet. 1998;
352:1433-1437) was repeatedly questioned and a larger, better controlled study
reported conflicting findings (Arch Gen Psychiatry.
2001;58:901-906). So NIDA abandoned the $42 million "club drugs" campaign
featuring the misleading brain image and replaced it with subtler materials,
including, most recently, a Web site featuring straight-talking teens (http://www.teens.drugabuse.gov). Among the stories of pain and suffering,
the site acknowledges that drugs can feel good.
"If you present [addiction] in a way that people can comprehend and
see it not as just a black-and-white situation but in all its complexity,
they're very receptive," said Volkow. "We assume people want very simple [information],
that NIDA should say it's just black-and-white. But . . . it's not." As an
example, Volkow said that while exposure to drugs obviously plays in a role
in whether an adolescent becomes addicted, so do the less-publicized influences
of family, community, and culture.
Those factors profoundly steered the intellectual career of Volkow,
who came of age in Mexico City as one of four precocious great-granddaughters
of Russian revolutionary Leon Trotsky. In 1940, her young father had seen
Trotsky die at the end of an ice ax wielded by a Soviet agent. But the family
stayed, maintaining the house in Mexico City as a museum of sorts.
Famous people visited often, and it was the job of Volkow and her sisters
to lead impromptu tours. "We got to see people from all over the world, presidents,
actors," said Volkow, a star student who became interested in science at age
"I was so excited, I was always learning," she said. "Here you have
four girls playing together in this extraordinary house with all sorts of
books and things that are fascinating and very old." A high point came during
one of her "novelist obsessions." She routinely devours oeuvre after oeuvre
and was in the middle of her Gabriel García Márquez obsession
when he visited.
The surfeit of intellectual stimulation rendered drugs of abuse a nonissue
for the young Volkow. "I was extremely lucky," she said, her Spanish-Russian
accent lengthening the "u".
Volkow swigs her drug of choice—Coke, the kind in a can—and
muses about why coffee, with twice the caffeine, is unpleasant to her.
"It's an individual sensitivity," she says.
So it goes with all drugs that affect the brain—each person responds
differently. It's one of the principles that ignited Volkow's curiosity in
addiction science when she reached medical school at age 18.
Loss of control
But it was a second principle, loss of control, that provided Volkow
with an emotional stake in addiction. As she grew up, she watched a favorite
relative succumb to alcoholism. "I loved him dearly," said Volkow. "He was
very devoted to his family and yet he knew that he was destroying them [with]
this behavior. And that's a classical process of addiction. It's not that
they don't care but something has changed their ability to control."
Volkow is now in a position to focus NIDA's billion-dollar budget on
why that is so, and how to prevent and treat it. In particular, she wants
to learn how drugs of abuse affect children and adolescents.
"Addiction is a developmental disease," Volkow says, and ample statistics
bear her out. "I don't think we've officially stated it in any way like that.
We do know that [addiction] begins in childhood and adolescence. And yet we
know so little about the adolescent brain." It's "shocking," for instance,
that no one knows whether adults or adolescents will self-administer drugs
at a more rapid rate.
However, researchers do know that the anterior cingulate gyrus, a region
responsible for inhibition, continues growing in humans through about age
21. "That's why when you mature, your ability to say ‘no' is increased."
She wants to use imaging to test strategies for enlarging and strengthening
this region of the brain.
The concept may sound radical, Volkow readily admits, but she quickly
points to an imaging study of London taxicab drivers. The cabbies' spatial
memory centers in the hippocampus are significantly larger than those of noncabbies.
"It's because they are constantly exposed to spatial information . .
. and that has led to synaptogenesis and enlargement," she explains. "Look,
we can strengthen the reading abilities of kids who can't read [well]. So
why don't we think of inhibitory control as a function like reading?"
It's a strategy as sophisticated as "just say no" was facile. And in
fact, Volkow would love to turn her scanners on that campaign.
"In the first series of meetings we had [at NIDA], I said, ‘How
do we optimize sending a message to adolescents about the deleterious effects
One answer, she said, is using imaging to study the adolescent brain's
response to effective and ineffective educational messages. "If we know from
epidemiology that there is a particular ad that is protective in adolescents,
we can look at how it activates the brain differently from an ad that we know
has been a failure," she explains. "If you get a signal, say, for example,
in the amygdala [a center for emotional memory], it's more likely to have
an impact than an ad that stimulates the hippocampus [a center for spatial
The rest of Volkow's agenda is equally ambitious. She is determined
to offer more support to young researchers. She also wants hard data on the
deleterious effects of smoking during pregnancy, a deeper understanding of
the brain's development, and a flowchart of how environmental stress affects
different neurotransmitter systems, especially those that are crucial to mood
But most of all, Volkow wants to think. "This is one of the things I
say to people: ‘you have to protect me and allow me to think.' I say,
‘You don't want a director who doesn't think.'"
Vastag B. Nora Volkow, MD. JAMA. 2003;290(20):2647–2652. doi:10.1001/jama.290.20.2647
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