When Congress adopted the NIH (National Institutes of Health) Reform Act of 2006, it created a Scientific Management Review Board (SMRB) charged with making recommendations about establishing or abolishing institutes under NIH. Two institutes of great importance to the addiction treatment community--the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA)--are presently under close scrutiny.
During four meetings held last year, and another meeting with the NIAAA council that took place Feb. 3, the Substance Use, Abuse, and Addiction Working Group of the SMRB heard presentations from stakeholders on a possible merger of NIDA and NIAAA. The working group was to present a full range of options to the SMRB on March 10, and in May there will be a recommendation for a final decision, which ultimately will be made by NIH director Francis S. Collins, MD, PhD.
Not far beneath that landscape of facts lies a wellspring of emotion and fear. Alcohol researchers and the NIAAA community are deeply worried that in any merger, NIAAA would be the loser and NIDA would be the winner. As one observer put it: "To NIAAA, it's a merger. To NIDA, it's an acquisition."
Not only are alcohol researchers worried about losing money, but they also are troubled by the possible loss of alcohol's unique identity as the primary drug of abuse, and a pervasive sense that the value of their work is not being recognized. Basically, those in favor of the merger ask, "Why not?" and say "The science is the same," and those opposed ask, with anguish, "Why?" and say "The science is not the same!"
The discussion has led to divisiveness, putting long-time colleagues and friends on opposite sides of the issue. And while current employees of NIDA and NIAAA will not discuss this sensitive topic publicly, former ones do--none more eloquently than Enoch Gordis, MD.
"This is clearly not a time to bury the NIAAA," wrote Gordis, former NIAAA director for 15 years, in written closed testimony to the Substance Use, Abuse, and Addiction Working Group last December. "That would be a terrible message to the American public and to the global community," he wrote, adding that the World Health Organization has found that alcohol is the fifth leading cause of premature death and disability worldwide. "I ask this committee and the NIH: please don't take the sign off the door."
Alcohol is unique in its actions and in the scale of the problems it causes, wrote Gordis. "The statement regarding both institutes that 'the science is the same,' which comes so trippingly off the tongue, is a serious misrepresentation of the scientific reality, and results from a very narrow perspective of the universe in which alcohol issues, problems and science play out."
Most alcohol abusers and alcoholics are not drug abusers, Gordis points out--of the 18 million adults with an alcohol use disorder, only 13 percent also have a drug abuse disorder.
Another key participant in the discussion is the recovering community, which traditionally has had a close connection with NIAAA. The late U.S. Sen. Harold E. Hughes, a recovering alcoholic, helped created the Comprehensive Alcohol Abuseand Alcoholism Prevention, Treatment and Rehabilitation Act of 1970, legislation that established NIAAA. Hughes believed that alcohol research needed its own "highly visible agency," recalled Gordis. And Bill Wilson, the founder of Alcoholics Anonymous (AA), broke his anonymity to testify before Congress on behalf of establishing NIAAA.
Invoking the name of Bill Wilson is a sign of some of the unspoken differences between NIDA and NIAAA--many people who want NIAAA to remain aseparate institute are recovering alcoholics, with all of the personal investment that entails.
Gordis's letter, along with one from Ting-Kai Li, MD, NIAAA director from 2002 to 2008, was made public by the Research Society on Alcoholism on Jan. 28. Yet it's not only researchers who are concerned about a merger.
The National Association of Addiction Treatment Providers (NAATP) officially opposed the merger around the time of the SMRB working group's first meeting last April. According to NAATP president and CEO Ronald J. Hunsicker, it is only the existence of NIAAA that has prevented alcohol, the most commonly abused substance, from being ignored amid a growing focus on drug abuse issues and treatments.
With a focus on pharmaceutical cures for addiction, there will not be as much "personal transformation," says Hunsicker. "We would have people who are perhaps not using, but they would not be having any major changes taking place," he said. "Do we work to get people to make lifestyle changes, or is it just chemistry development?"
Hunsicker would like to see more of a focus on addiction as a primary disease, with recovery measured not by "fewer drinking days" but by "long-term recovery." He would like to see both NIDA and NIAAA have a focus on recovery that goes beyond biochemical concerns, even taking into consideration the spiritual.
Arguing the science
On the other side of the argument are some of the top names in addiction research. "The science on use, abuse and addiction clearly belongs together," says Mary Jeanne Kreek, MD, head of the Laboratory of the Biology of Addictive Diseases at Rockefeller University in New York City.
Kreek, who helped to discover methadone as a treatment for opioid addiction, says both NIAAA and NIDA "do a fine job of looking at various health consequences" of abuse and addiction. Put together, she says, they could do even better. "Alcohol and drugs are the two biggest public health problems out there." Kreek thinks a combined NIDA-NIAAA could be "bigger and wealthier" than the two institutes are individually.
Kreek's top concern is that the merger not be used to cut costs--a message that both NIDA and NIAAA supporters emphasize. "The total pool needs to go up," she says. Her final slide at her September 2009 presentation before the working group won fans at NIAAA and NIDA both. It reads: "NIH--and Congress--must see any merger of NIH-NIDA and NIH-NIAAA as a move to enhance science and thus, ultimately, healthcare in the very costly areas of the addictive diseases, and not as a 'cost saving' strategy."
Herbert D. Kleber, MD, professor of psychiatry and director of the division on substance abuse at Columbia University, says NIDA's clinical trials would benefit from more emphasis on alcohol, just as NIAAA's clinical trials would benefit by including polydrug abusers. Kleber is a former deputy director for demand reduction at the Office of National Drug Control Policy (ONDCP).
Another benefit of a combined institute would be a focus on relapse prevention, says Kleber, adding that "the role that alcohol and other substances play in relapse for each disorder has been inadequately studied."
So far there has been no discussion of reducing the budget for either of the institutes, and "no discussion whatsoever" of reducing the total pool of money, says Amy P. Patterson, MD, executive director of the SMRB and acting director of NIH's Office of Science Policy. But there may be more of a "cross-cutting" approach to making grant awards, instead of keeping a certain amount of money in alcohol research and a certain amount in drug research. "It may be redistributed, reflecting a more interdisciplinary approach," Patterson says.
Noting that NIH is looking at the restructuring of other institutes as well as NIDA and NIAAA, Patterson says "this isn't just about moving boxes on paper." A NIDA-NIAAA merger is one possibility, but there are other possible changes as well. "If one is to take a truly scientific approach, one needs to take a broad look at addiction--and it's not simply drugs and alcohol," says Patterson.
If a merger occurs, there would be a new mission statement, and a search for a director, says Patterson, who acknowledges that there is "a lot of anxiety about what will change and what won't change." There is currently no NIAAA director. The director of NIDA, Nora D. Volkow, MD, would not automatically be the director of the new institute.
'A lot of angst'
Whenever anyone talks about a merger, there are concerns about what will be saved and what will be lost, says Patterson. "I think this is a particularly poignant case," she says of the NIDA-NIAAA discussion.
The SMRB is "trying to be very careful and understanding of the anxieties that are swirling about," she says. "There's a lot of angst associated with the deliberation of this topic," both in the patient community and the research community. "There will be great interest at NIH to bring it to as quick a conclusion as possible."
BUT ... Major Budget Concerns!!!
NIH--and Congress--must see any merger of NIH-NIDA and NIH-N1AAA as a move to enhance science and thus, ultimately, healthcare in the very costly areas of the addictive diseases, and not as a "cost saving" strategy.
BUDGET: 1 + 1 must = 2+ (or 3), NOT 1.2 or 1.5!
Slide from Mary Jeanne Kreek, MD
Key players in merger discussions
Non-federal members of the Substance Use, Abuse, and Addiction Working Group of the SMRB are William Roper, MD (chair); Eugene Washington, MD; Deborah Powell, MD; Huda Zoghbi, MD; and Norman Augustine. Federal members are Josephine P. Briggs, MD; Richard Hodes, MD; Griffin Rodgers, MD; Lawrence Tabak, DDS, PhD; and NIH Director Francis S. Collins, MD, PhD.
For more information, including PowerPoint presentations and video-casts, visit the SMRB website at http://smrb.od.nih.gov.
Alison Knopf is a freelance writer based in New York.