Combining Addiction Agencies.
For nearly a decade, the idea of combining the federal government’s two primary addiction research institutes has made good sense. Recently, an independent panel officially recommended a merger—but alcohol researchers opposed the notion, as they have in the past.
The National Institutes of Health, the nation’s premier biological research institution, is composed of 27 separate medical institutes, each fighting for its share of funding and recognition under the larger umbrella of the parent organization. If this seems like an unwieldy arrangement, that’s because it is. Duplication and overlap is inevitable in as vast an enterprise as the NIH. Yet the arrangement has produced some of the best medical and biological research in the world.
Former NIH director Harold Varmus complained, according to ScienceInsider (Sub req) “that the sprawl hobbles NIH’s ability to respond to new science.” The most obvious case for streamlining and cost-savings has always been the National Institute on Drug Abuse (NIDA) on the one hand, and the clumsily named National Institute on Alcohol Abuse and Alcoholism (NIAAA) on the other.
In 2006, Congress told the NIH to create the Scientific Management Review Board to recommend ways of overhauling the NIH structure. The obvious place to start was with the two overlapping addiction institutes.
It was not a new idea. In 2003, the National Academy of Sciences (NAS) recommended merging the agencies due to “overlapping missions.” Enoch Gordis, then director of the NIAAA, was adamantly opposed to the idea, and the undertaking fell away.
Recently, the Scientific Management Review Board of the NIH voted 12-3 in favor of the merger, and sent the proposal to the desk of NIH director Francis Collins. However, the board also recommended an outside search for a director, thereby eliminating current NIDA director Norah Volkow from consideration. Dr. Volkow has been an active and public advocate for addiction awareness. An obvious choice to head the combined institute, provisionally known as the National Institute on Addiction, she would be a significant loss to the NIH. A spokesperson for Dr. Volkow would only offer NIDA’s official stance on the matter: “NIDA’s position has always been that we should create an organizational structure that best serves the science of addiction. We appreciate the thoughtful process that preceded the Board’s recommendation, and we look forward to hearing about a final decision soon.”
For years, NIAAA supporters had a ready answer when asked what made their agency different from NIDA: the liver. NIAAA did research on the liver and other organs and metabolic processes involved in metabolizing alcohol. But over the past two decades, the meaningful research coming out of NIDA has been the primary focus for most addiction researchers. NIDA’s forceful and forward-thinking director, Norah Volkow, followed an equally outspoken director, Alan Leshner. At NIAAA, the most recent director, Dr. T.K. Li, came to the institute after a distinguished career as an alcohol researcher at the University of Indiana. Dr. Li recently retired and the position is being filled on an interim basis by acting director Kenneth Warren.
NIAAA has always been the weaker sister in the addiction research family. With only half of NIDA’s billion-dollar budget, NIAAA deals strictly with alcohol research, even if the NIAAA has at times seemed unsure of what constitutes its main area of study—alcohol the addictive drug, or alcohol the healthy beverage. The merger would represent a recognition that alcohol is just another drug, albeit a legal one.
However, in a Science (sub req) interview, Francis Collins, the current director of the NIH, noted that the advisory board was “not able to come to a consensus” on the NIDA-NIAAA merger. “I guess most people would have said, ‘Well yeah, of course.’ But when you look at the details…. and you consider that alcohol is after all a legal substance and 90% of us at some point in our lives are comfortable with taking it in while the drug abuse institute is largely focused on drugs that are not legal. So there's a personality of the institute issue here that people thought might be important to preserve, others thought would be good not to preserve.”
The director’s remarks reflect the turf protection responses that this seemingly straightforward move invokes. An article by Bob Curley at Join Together notes that last year, the advisory board “voted unanimously in favor of studying the merger despite the fact that every group and individual testifying live at the hearing opposed combining the two agencies.”
Every group and individual? Curley quotes Lawrence Tabak, former acting deputy director of NIH, who minimized the likelihood of significant cost savings, and said, “there are also some issues that NIAAA deals with that are not ‘addictive’ in nature, such as binge drinking.” Representatives from the Research Society on Alcoholism and the American Association for the Study of Liver Diseases said that NIAAA’s harm reduction approach to alcohol use was “fundamentally at odds with NIDA’s focus on illegal drugs.” The National Association of Addiction Treatment Providers also opposed the merger, citing fears of a “loss of focus” on the problems unique to alcohol.
Beyond the official testimony, many prominent drug addiction experts feel differently. “The basic biology of drug abuse and addiction are highly overlapping for all drugs of abuse,” according to Eric Nestler of the department of neuroscience at the Mount Sinai School of Medicine. “There’s a huge confusion—not only among the lay public but among some treatment providers too—that alcohol is ‘not a drug,’” he said in the Join Together article. “This is absurd, yet the current separation of alcohol into a separate institute provides credence to that notion.”
According to noted addiction researcher Charles O’Brien of the University of Pennsylvania’s department of psychiatry, “There’s no scientific rationale to have a separate institute for a single drug. Ethanol activates the reward system similar to opioids and other abused drugs using different mechanisms to act on the same structures.” In addition, O’Brien notes that most addicts use more than one drug, but that NIAAA funding limit researchers to projects for “pure alcoholics, despite the reality of the clinical populations.”
The dual agencies, by their very existence, imply that addiction to alcohol and addiction to other drugs are wholly separate spheres of inquiry and investigation—a notion damaging to scientific research and public health. The primary hurdle to the merger is political, not scientific.
On the face of it, the merger makes sense, and in fact is long overdue. To keep these agencies separate means continuing to perpetuate the myth that there is something crucial that separates alcoholism from drug addiction. And there isn’t. Treating alcoholism and alcohol abuse as a syndrome somehow apart from drug abuse and addiction is outdated and unwarranted. We know too much now about both conditions to maintain the pretense.
As DrugMonkey, a pseudonymous science blogger funded by the NIH, summed it up: “If Institutes are to be merged than NIDA/NIAAA is at the very top of the list. If these cannot be merged then I do not see how any other mergers can be accomplished.”
Graphics Credit: http://www.hbcprotocols.com/nihfunds.html
