Editor’s Note: This is the third installment in “The Way Back Machine,” a series of interviews with key theorists and practitioners of alcohol and drugs research, treatment, and recovery among women and communities of color during the 1970s, ‘80s, and ‘90s. Through these interviews, Points co-founder and Managing Editor Emerita Trysh Travis works out some of the theoretical issues she articulated almost ten years ago in “Feminist Anti-Addiction Discourse: Towards A Research Agenda.”
First, a little background: in response to the heroin panic then gripping the nation, the National Institute on Drug Abuse (NIDA) was founded by executive order in 1973 within the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) housed in the Department of Health, Education, and Welfare (now the Department of Health and Human Services). In the words of its founding Director, Robert L. DuPont (2009), NIDA represented “the nation’s new commitment to demand reduction as a central element of drug abuse policy, and as the center of public health activity on drug abuse.” For about ten years, NIDA functioned as what DuPont called a “three-legged stool”: it oversaw research (human and animal studies of the “basic biology of addiction” as well as drug epidemiology and drug effects); training (of clinical personnel); and service (in the areas of drug abuse prevention and treatment). But in the 1980s, things got complicated.
Beginning in 1982, the Reagan administration’s shift from categorical to block grants gave states new discretion in spending on alcohol, drug, and mental health issues. Subsequent legislation throughout the ‘80s—influenced in part by a new panic over cocaine—pushed for more prevention and treatment services for “special populations,” including youth, pregnant women, the chronically mentally ill and un-housed, minorities, and people with HIV.
The 1992 ADAMHA Reorganization Act broke NIDA’s three-legged stool approach to drug problems. Along with its coequals, the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Mental Health, NIDA’s research leg moved into the National Institute of Health. The legs devoted to training and services were parceled out to two new Centers, one for Substance Abuse Prevention and one for Substance Abuse Treatment. These entities were housed in ADAMHA’s replacement, the Substance Abuse and Mental Health Services Administration. If you’ve followed me this far, you can probably tell: the 1980s and 1990s were a helluva time.
As Laura Schmidt and Constance Weisner (2002) have pointed out, block grant funding threatened the survival of women’s treatment programs founded in the late 1970s. States had discretion in how they spent block grants—so, if a state didn’t care about women substance users, well, too bad. In response, activists and treatment providers worked to frame women—especially pregnant women—as a “special population” deserving of their own stream of research funding.
One of the staunchest advocates for research on women was Cora Lee Wetherington, who came to NIDA as a program officer in 1987 and served as Women and Gender/Sex Differences Research Coordinator from 1995 until her retirement in 2019. As a friendly co-conspirator on countless research proposals and a tireless promoter of the (crazy!) notion that research protocols needed to enroll female subjects if they hoped to produce real-world outcomes, Wetherington helped shape a generation (maybe two!) of federally-funded feminist research. She sat down with Points Managing Editor Emerita Trysh Travis to reflect on what a long, strange trip it’s been.
Cora Lee Wetherington (left) moderating a panel at the 2018 “Opioid and Nicotine Use, Dependence, and Recovery: Influences of Sex and Gender” conference hosted by the Food and Drug Administration. Image Courtesy of FDAWomen on Twitter.
Trysh Travis: Can you tell us how you got to NIDA?
Cora Lee Wetherington: I arrived at NIDA in 1987 from UNC-Charlotte, where for twelve years I was a professor of psychology. It was a stimulating time at NIDA with lots of different research supported. I was a program officer in what was then the Clinical and Behavioral Pharmacology Branch, which supported laboratory studies with human and animals.
Program officers have many roles. Foremost, they develop and promote programs of research to stimulate the scientific field in new directions. They make grant funding recommendations, monitor grants in their portfolio, and provide advice to prospective grant applicants—offering feedback on their proposals including tweaks to the research aims and methodology, suggesting areas of related research to incorporate, and advising on choice of study section to review the application. After a grant has undergone study section review, a program officer will go over the reviewers’ feedback with the applicant and offer suggestions on how to respond. In short, a program officer engages with prospective grant applicants to think about the science and logic behind a proposal, its methodology, and its scientific importance to the field. So, you can see, the job of a program officer is perfect for someone with a lot of scientific curiosity and a desire to move the field forward.
TT: And where was research on women at NIDA at this time?
CLW: Although NIDA had a Program on Women’s Concerns [described at pp 530–32] beginning in 1974, we were still in a pretty basic place when I arrived. Most animal and human studies were conducted with males. The fact that scientific research was being conducted this way really got me curious. Why was it being assumed—perhaps unconsciously—that research outcomes applied to both males and females if the data weren’t analyzed to detect whether that was true? Trying to change this practice emerged as my major area for emphasis—along with increasing female-based research.
Clinicians were clear that men and women faced different issues in treatment. In the ‘90s, the Clinical Director at the Betty Ford Center told me that she would routinely drop in on men’s groups, women’s groups, and mixed gender groups at the Center just to listen to the conversation about use and recovery. She said the differences were phenomenal. Yes, the groups all had a shared problem, but, in the mixed gender groups, the men had the same power position in the treatment space as they did outside, and women were marginalized. Discussion and disclosure by women was far greater in women-only groups than in mixed-gender groups. But this structuring framework was not always at the forefront of clinicians’ or researchers’ minds.
TT: It does seem like there was a concerted effort to change that in the late ‘80s and early ‘90s.
CLW: After I arrived, Loretta Finnegan came to the government in 1992 as associate director of the Office of Treatment Improvement within the Alcohol, Drug, and Mental Health Administration (ADAMHA). She was a neonatologist and had made a huge impact studying perinatal heroin exposure and maternal health at Philadelphia General Hospital during the 1970s. NIDA had funded The Family Center she started there, one of the first holistic clinics to provide comprehensive services to pregnant women who abused drugs.
When ADAMHA became the Substance Abuse and Mental Health Services Administration (SAMHSA) in 1992, Finnegan moved over to become Senior Advisor on Women’s Issues at NIDA. She was a powerful voice advocating for treatment for drug-dependent pregnant women during the crack cocaine crisis when the standard policy in some states was criminalization and incarceration— “We must throw these women in jail and take away their babies.”
This was the climate in 1994 which a group of us at NIDA, under Dr. Finnegan’s leadership, put on the conference, “Drug Addiction Research and the Health of Women.” It was an effort to assess the state of the science and identify research gaps. Topics included epidemiology, risk factors, biological factors, health effects, co-occurring mental health conditions, intimate partner violence, prevention and treatment, and legal issues.
TT: You arrived at NIDA right before President Bush declared that the ‘90s would be a “decade of the brain” in terms of drug research. How did that commitment to brain science shape work on women and gender differences?
CLW: NIDA does fund research that seeks to identify and address social determinants of women’s drug use as well as the role of biological factors and their implications for etiology and for treatment development. These projects combine rigorous science with attention to social factors like gender, race, poverty, and exposure to stress, trauma, and violence. They look at these determinants along with biological factors and extend or translate the research to treatment and prevention. I think of the work of addiction psychiatrist Kathleen Brady at the Medical University of South Carolina, whom we began funding in 1996.
She conducts basic laboratory research on sex differences in the biology of stress. But that’s not where she stops. She looks at how those biological differences play out in the etiology of drug use and at the application of that knowledge to treatment development— both behavioral and pharmacologic. Hendrée Jones at UNC-Chapel Hill is another example. She led the landmark multi-site study on opiate-dependent pregnant women that compared the effects of medication-assisted treatment (with either methadone or buprenorphine) on outcomes in newborns. At Horizons, a treatment program at UNC-Chapel Hill for drug-using women and their children, she brings behavioral psychology and pharmacology together to make medication-assisted treatment part of comprehensive trauma-informed care.
Or think of someone like Nabila El-Bassel at Columbia’s School of Social Work. She founded the Social Intervention Group in 1990 to develop evidence-based prevention and intervention approaches to HIV in women—for whom infection is almost always coincident with injection drug use and often co-occurrs with gendered violence. Most recently she is the principal investigator in the New York site of the HEALing (Helping End Addiction Longterm) Communities Study, which looks to reduce opioid overdose and death in New York State by 40 percent in four years. She brings to that project the need for and the expertise in addressing women-specific factors. These are just a few of the stand-out examples of NIDA-funded researchers who are directly translating the results of their research to treatment and prevention programs that speak specifically to women’s needs.
TT: To wrap up, I’m going to ask you to make a gross generalization. It’s been almost thirty-five years since you started work at NIDA. When it comes to women on drugs, has there been more continuity or more change in the field?
CLW: It has been immensely gratifying to see the progress that has been made in the field since I became NIDA’s Women & Sex/Gender Coordinator in 1995. As you can imagine, in that role, I prepared many reports. There was a period of time early on when I knew about virtually every relevant grant we funded in this area and drew on them all for reports and for presentations I made to the scientific community. I’m proud to say those days did not last long: the number of women/female-focused grants steadily rose as we promoted that research area as well as the importance not only of including both sexes/genders in animal and human research but also analyzing the data to see if outcomes were the same or different by gender.
There were a few NIDA-funded researchers who had already been doing this as early as the ‘80s. (Animal model work by Jill Becker at the University of Michigan immediately comes to mind.) This very simple approach of including both sexes/genders in research designs—and analyzing data to detect any differences in results—is a powerful generator of new knowledge. When followed, it automatically generates research outcomes about both females and males, doubling the research outcomes of a study! Importantly, it prevents an automatic assumption that a research outcome applies to both females and males, when in fact that could be a false conclusion.
Along with promoting research specific to women/females, advocating for this approach became a central part of my mission at NIDA early-on. In 2015, it received a very important boost: NIH implemented the Sex as a Biological Variable (SABV) policy, stating “NIH expects that sex as a biological variable will be factored into research designs, analyses, and reporting in vertebrate animal and human studies.” This policy was developed by the NIH Office of Research on Women’s Health, and it was very gratifying to have played a role in its development. Full implementation of this SABV research approach will be transformational for the advancement of treatment and prevention of disease—and for the promotion of health and well-being for both women and men.