RESEARCH CENTRES SERIES
Addiction Research Centres and the Nurturing of Creativity
The Kurihama Medical and Addiction Centre—a profile
The Kurihama Medical and Addiction Center began to conduct research and to provide medical care for alcohol-related problems in 1963, when special alcoholism treatment wards were established in Japan for the first time. At first, the provision of medical care to patients was prioritized. However, training courses for specialists were initiated in 1975, and the Department of Clinical Research was established in 1984, which led to the formation of the present management structure in which the centre's staff are shared by three departments: Medical Care, Clinical Research and Education and Information. The Department of Medical Care provides specialized treatment for alcohol use disorders and medical services for other conditions, including behavioural addictions such as internet addiction and gambling disorder, as well as dementia and other psychiatric disorders. The Departments of Clinical Research and Education and Information are engaged mainly in specialized activities related to alcohol. The Department of Clinical Research conducts research on the epidemiology of alcohol use, the effects of alcohol on health and the treatment of alcohol use disorders in Japan, in cooperation with universities and other research institutions. The Department of Education and Information fosters the human capacity to achieve the primary, secondary and tertiary prevention of alcohol-related problems and the dissemination of information on alcohol. The centre also performs alcohol-related problem prevention activities, government consultations and international collaborative research and personal exchanges, thereby functioning as a central institution for alcohol policy-based medical services and research in Japan.
Evolution and Circumstances
The Kurihama Medical and Addiction Centre began as the Nobi branch of the Imperial Naval Hospital in 1941 during the Second World War. The hospital was taken over by the Ministry of Welfare, and at the end of the war in 1945 was renamed the National Kurihama Hospital. In those days, the hospital was a general hospital that provided treatment for veterans. In 1947 the hospital became a sanatorium for the treatment of pulmonary tuberculosis, and was renamed the National Sanatorium Kurihama Hospital. Over time, the number of tuberculosis patients decreased, and the main services of the hospital shifted to the provision of psychiatric care.
In 1964, the Olympics were held in Tokyo. In 1963, a ‘Law to Prevent Acts of Public Nuisance Due to Alcohol Consumption’ was enacted, mainly to control inebriated individuals who threatened to obstruct the success of the Olympics. Because of this law, a special alcoholism treatment ward was established at our centre that same year, becoming the first of its kind in Japan. Specialized treatment for alcoholism began in one ward and gradually expanded into more specialized wards, such as a detoxification ward, a young and middle-aged alcoholics ward, a special elderly alcoholics ward and a women's special care unit. In addition, treatment was performed in open wards, mainly as group therapy, with respect given to the independence of the patients. This treatment style has spread throughout Japan and is known as ‘the Kurihama method’.
In 1989 the hospital was designated a World Health Organization (WHO) Collaborating Centre on Research and Training for alcohol-related problems, and since 2004 the hospital has been an affiliate of the National Hospital Organization (NHO), which is a specially incorporated administrative agency under the jurisdiction of the Ministry of Health, Labour and Welfare (MHLW).
Outline of the Centre
The Kurihama Medical and Addiction Centre is basically a hospital consisting of three departments: Medical Care, Clinical Research and Education and Information. Of these, the Department of Medical Care has the largest number of staff members and the largest budget. This department provides out-patient and hospital care services for psychiatric disorders, such as depression and schizophrenia, in addition to behavioural addictions, specialized dementia care focusing on early detection and treatment and world-leading medical care in the fields of upper and lower gastrointestinal tract endoscopy. The centre also emphasizes forensic psychiatry. In Japan, forensic psychiatric treatment systems were established after the enactment of the Medical Treatment and Supervision Act in 2005. At our centre, two forensic psychiatric wards, with the second largest number of beds in Japan, were opened in 2006. Alcohol-specific forensic psychiatric treatment and research are undertaken in one of these wards.
In contrast, the Department of Clinical Research and the Department of Education and Information are engaged mainly in specialized activities related to alcohol use. In cooperation with the Department of Medical Care, these departments undertake comprehensive activities associated with alcohol use, such as medical care for alcohol-use disorders, research, staff development, alcohol-related problem prevention activities, the transmission of information on alcohol and government consultations.
The total number of beds at the centre is 290; of these, approximately 150 are used for the treatment of alcohol-use disorders. The total number of staff is approximately 300, including 30 medical doctors, 180 nurses and 90 other staff. Several dedicated staff members, excluding research assistants, work in the Department of Clinical Research and in the Department of Education and Information. Doctors and co-medical staff engaged in medical care are required to contribute to all the departments.
Clinical Services and Prevention of Addictive Disorders
One of the most important roles of this centre is to provide high-quality medical services for addiction disorders. The centre has taken the lead in the treatment of alcohol use disorders and has the largest out-patient and in-patient treatment capacities in Japan, with 1300 new alcoholic patients annually. In addition to detoxification treatment services, programmes such as education on alcohol-related problems, small-group psychotherapy sessions based on cognitive–behavioural therapy, personal consultation, family therapy and connection with self-help groups are provided [1, 2].
Although the centre has long focused only on alcohol in the field of addiction, it recently changed its policy to expand its clinical services and to include research on behavioural addiction. Based on this policy change, the centre launched specialized treatment services for patients with internet addiction in 2011, which was the first endeavour of this kind in Japan. Subsequently, specialized treatment services for pathological gambling have been initiated as a second behavioural addiction. Substance-use disorders other than alcohol are not dealt with at our centre because there is a well-known treatment hospital for these disorders located close to our centre, and because of our limited capacity.
The centre also plays an important role in the prevention of addictive disorders. We established the Centre for the Prevention of Alcohol-related Problems in 1992, which focuses mainly on primary and secondary prevention. This prevention centre has been engaged consistently in public awareness activities, surveys/research and information transmission to prevent underage drinking problems. It also provides technical support for the early detection and intervention of alcohol-related problems.
The Kurihama Medical and Addiction Centre places great emphasis on research related mainly to alcohol; for example, the elucidation of the pathogenesis of alcohol-related diseases and the prevention and treatment of the harmful use of alcohol. In recent years, however, our research interests have expanded to include behavioural addiction, such as internet addiction and pathological gambling, and other medical areas, including dementia and endoscopic examinations.
The Department of Clinical Research provides research facilities for epidemiological and behavioural studies and animal and molecular biological experiments. Research funds for the administration of the department and research activities are provided by the headquarters of the National Hospital Organization (NHO), with the grant amount being based on the research achievements of the centre. However, additional funding is obtained through competitive grants provided by the Ministry of Health, Labour and Welfare and other governmental funding bodies. Some researchers have collaborations and receive research funding from private entities. Altogether, the core funding from the NHO accounts for approximately 30% of the total research funds, 50% of the funds are from government grants and the remaining 20% are from the private sector.
There is no official body at the centre for determining research priorities. Conventionally, the Director of the Department of Clinical Research (Dr Yokoyama) plays a role in controlling research activities. The centre encourages researchers to apply for competitive research grants in consultation with senior researchers, and the maximum research priority is given to those studies once the funds are granted successfully. Many studies have been conducted in collaboration with universities and other institutions, but there are no formal research links with local universities.
The centre has led research into the epidemiology of alcohol use, the effects of alcohol on health and the treatment of alcohol-use disorders in Japan. In particular, the following studies have made great scientific and social contributions.
Epidemiological surveys on alcohol use
Surveys of drinking behaviour, alcohol-related problems and other addictions have been conducted in samples representative of Japanese adults [3-5]. In addition, contributions have been made to large-scale nation-wide surveys of drinking and smoking behaviour in junior and high school students, which have been conducted every 4 years since 1996. According to this survey, underage alcohol consumption has decreased clearly and consistently in recent years in Japan [6, 7].
Clinical genetic studies of alcohol-use disorders
The physiological significance of genetic polymorphisms in alcohol-metabolizing enzymes, such as alcohol dehydrogenase (ADH) and aldehyde dehydrogenase-2 (ALDH2), and their relationships with the characteristics of alcohol use disorders have been the main topics of investigation [8-11]. In addition, individuals with inactive ALDH2 who have developed alcohol dependence are speculated to have genetic and environmental risk factors. Using this hypothesis, efforts have been made to replicate existing factors and to identify new factors for alcohol-use disorders using these alcoholic models [12, 13].
Study of alcohol-related carcinogenesis
Cancers of the oral cavity, throat and upper gastrointestinal tract occur at a remarkably high frequency in patients with alcohol-use disorders, and we have reported the importance of endoscopic cancer screening using oesophageal iodine staining or other methods. In particular, we reported for the first time that oesophageal cancer tends to occur after exposure to acetaldehyde in drinkers with inactive ALDH2 [14-16]. In addition, we have reported the relationship between the risk of oesophageal cancer and factors other than drinking , the use of macrocytosis as a predictive factor for the development of esophageal cancer  and the relationship between the risk of oesophageal cancer and ADH1B gene polymorphisms and the underlying mechanism .
Prospective study to identify risk factors for alcohol-related problems
The study involves young people aged 20–23 years who have reached the legal drinking age. An investigation of the genetic background of these subjects, and an evaluation of the rate of alcohol metabolism and alcohol sensitivity  using the alcohol clamp method , psychological and psychiatric assessments and physiological and imaging examinations of the brain are being performed, with periodic follow-up examinations, to determine the relationship between the occurrence of alcohol-related problems and various markers. The study is currently in progress.
Development of treatments for alcohol-use disorders
Treatments for alcohol-use disorders should reflect the drinking status and cultural background of the country. Based on this idea, our centre has developed brief intervention methods for heavy drinkers, comprehensive treatment programmes for alcoholics (consisting mainly of cognitive–behavioural therapy) and female and elderly alcoholic-specific treatment programmes. These methods and programmes have been disseminated throughout Japan .
Development of screening tests
The ethanol patch test , which examines the skin response to alcohol, and a screening test for flushing using a simple questionnaire  to identify the phenotype of ALDH2 are often used in clinical practice and prevention education. In addition, the Kurihama Alcoholism Screening Test (old version and new versions) [25, 26], which is a screening test for alcohol use disorders, has often been used for treatment interventions and for epidemiological surveys regarding alcohol use disorders.
Studies on drunk driving and alcohol-use disorders
First, the actual status of alcohol-use disorders was examined in various ways among habitual drunk drivers to reduce drunk driving [27, 28]. In addition, the effects of treatment interventions on the drinking and driving behaviour of these drivers were examined . The results of these studies have been incorporated into anti-drunk driving measures taken by the National Police Agency and the Ministry of Justice.
The great earthquake and alcohol-related problems
Since the great earthquake on 11 March 2011, alcohol-related problems have gradually become apparent in the disaster-affected areas. Our centre has conducted a survey of alcohol use in those areas . We have also developed and implemented measures to prevent and intervene in the problems and have evaluated the effects of these measures.
Other studies have been conducted on the following major research themes: complications associated with alcohol and drug-use disorders ; rehabilitation of patients with alcohol and drug-use disorders ; alcohol and bone metabolism [33, 34]; brain imaging in patients with alcohol-use disorders ; epidemiology and pathogenesis of internet addiction ; treatment of internet addiction; epidemiology and pathogenesis of gambling addiction ; and colorectal examinations for irritable bowel syndrome [36, 37].
In cooperation with the Centre for Prevention of Alcohol-related Problems, the Department of Education and Information at our centre provides training programmes for staff development, as described below. Of these programmes, the ‘Alcoholism Clinicians Training Course’ has the longest history. This course, for the training of alcoholism treatment specialists, was started in 1975 at a time when medical care for alcohol-use disorders was not yet well developed in Japan. Through this training, the treatment model used at our centre has spread throughout Japan, and specialized treatments for alcohol-use disorders have been established. This training programme is commissioned by the Ministry of Health, Labour and Welfare (MHLW), and training is provided for various occupational categories. A 4–5-day training course is provided twice a year for physicians, nurses, social workers and clinical psychologists, and once a year for public health nurses and occupational therapists. The training content includes an understanding of the disease concept of alcohol-use disorders and their diagnosis, treatment and prevention. A total of 6319 trainees, including 1543 physicians, 1749 nurses, 1373 public health nurses and 1486 social workers and clinical psychologists have participated in the training course as of 2012.
Since 2008, another training course, also commissioned by the MHLW, for the staff of alcohol- and drug-related rehabilitation facilities has also been provided. Many of the staff are themselves recovering alcoholics or drug abusers. Through this training course, we hope to provide qualifications for these staff members in the future. In relation to this programme, we are planning an educational training programme for the families of alcoholics and drug abusers.
Our centre has cooperated with the planning, implementation and evaluation of many alcohol-related problem measures at local, national and international levels. It would not be too much to say that our centre has been involved in almost all policies related to alcohol problems in Japan.
With respect to public health and welfare, our centre has dispatched professionals specialized in alcohol-related problems to the Health Service Bureau of the MHLW, thereby playing an important role in the administration of primary and secondary prevention measures for alcohol-related problems at the national level and in the management of WHO-related activities. Members of our staff also participate in various committees and councils related to alcohol policies in the MHLW, contributing to relevant policymaking. For example, to achieve a reduction in life-style-related diseases and the resultant premature deaths, a national health campaign, ‘Health Japan 21’ (National Health Promotion in the 21st Century), was launched under the leadership of the MHLW in 2000 . As part of this activity, the MHLW selected nine important areas, including alcohol and tobacco, and set specific targets for each area to be achieved by fiscal year 2013. Our centre has played a pivotal role in conducting both interim and final assessments, and in the development of a new plan for the next 10 years until 2022.
As mentioned above, our studies have revealed the effects of alcohol use disorders on habitual drunk driving [27, 28]. Based on this finding, beginning in 2013, the National Police Agency decided to implement screening and treatment for alcohol use disorders at a lecture that drivers whose licenses have been revoked because of drunk driving are mandated to attend in order to renew their licences. The contents of the lecture were developed jointly by our centre and the National Police Agency, and our centre provides education for the officials in charge of this lecture, held at local police stations and driving schools throughout Japan in 2012.
We also assist the Ministry of Justice, which provides remedial education for people who have been identified with alcohol-use disorders by screening people who are imprisoned or on probation following involvement in drunk-driving accidents. Our centre has been deeply involved in establishing and implementing these screening and treatment methods. Consultation activities at the international level are described in the next section.
The Kurihama Medical and Addiction Centre has long been involved in the activities of the WHO and currently serves as the only Collaborating Centre related to mental health, including addiction, in Japan. Since 2005, activities to reduce the harmful use of alcohol have been undertaken by the WHO at both regional and global levels, and our centre has supported these activities in various ways. At the regional level, our centre sent government representatives and temporary advisers to the WHO's Technical Consultation Meeting in 2006  and the Regional Meeting in 2008 . Also at the global level, our centre contributed a temporary adviser to the Expert Committee meeting in 2006  and sent government representatives to the World Health Assembly.
We have also been engaged actively in collaborative research and projects with foreign research institutions. In particular, our centre and the National Institute on Alcohol Abuse and Alcoholism in the United States have exchanged letters of intent on collaborative research and have promoted collaborative research and personal exchanges. We have also promoted exchanges with our neighbouring country, Korea. For example, since 2010 the ‘Kurihama–Pusan Joint Workshop’ has been held annually, alternately at our centre and at Pusan University, to promote research in the field of alcoholism. In addition, Korea has the most serious internet addiction problem in the world, but also leads the world in implementing measures against this problem. To promote research on this new type of addiction, which is also becoming increasingly serious in Japan, the centre has hosted the first ‘International Internet Addiction Workshop’ in Yokohama City in 2012, and will continue to host future meetings.
Lastly, we are also engaged in inviting researchers, mainly from developing countries, to conduct collaborative research at our centre. Although the number of researchers accepted and their duration of research are limited because of budgetary constraints, we expect to continue this project in the future.
Contributions to Scientific Societies
The Japanese Society of Alcohol-Related Problems is clinically, rather than scientifically, orientated and has more co-medical staff members than doctor members. However, the society has the largest number of members and an overwhelming number of participants in annual meetings among the four scientific societies related to addiction in Japan. This society, with its unique characteristics, has already been introduced in this journal . The permanent office of this society is located at our centre, and the position of society president has also been occupied by successive directors of our centre (currently Dr Higuchi). The society covers not only alcohol but also other fields of addiction, such as drug dependence, gambling and internet use, and is expected to develop further in the future.
In addition, our centre has also hosted annual meetings, thereby contributing to domestic scientific societies related to alcohol and drug abuse. For example, in 2009 the centre hosted the annual meetings of three major domestic societies in 2008 and the annual meeting of the Japanese Medical Society of Alcohol and Drug Studies, which has the longest history among alcohol- and drug-related societies.
The Asia–Pacific region has a major drug-producing area, the Golden Triangle, and serious drug problems have long been a matter of concern . In addition, this area encompasses developing nations, such as China and India, and Southeast Asian countries, where alcohol consumption is increasing; thus, the future exacerbation of this problem is also of concern . Under such circumstances, the Asia–Pacific Society for Alcohol and Addiction Research (APSAAR) was founded in 2008 to promote research on alcohol and drug dependence and addiction in these regions. Our centre was involved closely in the constitution of the APSAAR, the permanent office of which is also located on our premises.
Regarding other international societies, the Director of our centre, Dr Higuchi, serves as the vice president (president-elect) of the International Society for Biomedical Research on Alcoholism (ISBRA). He is also the Membership Promotion Director and 2014 Congress President of the International Society of Addiction Medicine.
Our centre encourages its staff to make presentations at international society meetings. Our staff presented two lectures, 10 symposium presentations and 15 poster presentations in 2010; one lecture, 10 symposium presentations and 20 poster presentations in 2011; and one lecture, 17 symposium presentations and 21 poster presentations in 2012.
The centre plans to strengthen its research activities regarding the prevention and treatment of alcohol use disorders. The following four areas are particularly important: first, a system will be constructed that can periodically monitor alcohol consumption, its pattern and alcohol-related problems using appropriate methods. Such systems exist for underage drinking in Japan, although they are insufficient, but no system has yet been established for adult drinking. Secondly, efficacious screening and brief intervention (SBI) methods for heavy drinkers will be established according to the drinking culture and medical situation in Japan, to be disseminated at various levels. SBI has been described as one of the best methods to reduce alcohol-related problems at the population level in Japan . Thirdly, research will be conducted to improve the treatment outcomes of alcohol use disorders. In particular, the development of new treatment methods and an evaluation of their effects will be promoted. For various reasons, the therapeutic drugs that are available for the treatment of alcohol dependence in Japan continue to be limited to disulfiram and cyanamide; therefore, the development of new therapeutic drugs will be supported. Finally, evidence-based treatment guidelines and manuals will be prepared. Unlike current guidelines, these new guidelines and manuals will respect domestic evidence, be user-friendly and consider mental disorder complications.
With regard to biomedical research, the centre plans to focus future research on studies related to genetic variations of ADH and ALDH2. Specifically, studies on the relationship of these enzymes to the risk of cancer, central nervous system disorders and circulatory disturbances and studies on risk factors for the development of alcohol use disorders will be designed and conducted.
Research on behavioural addiction is another important area upon which the centre plans to focus. As a first step, the centre is accumulating epidemiological and clinical data on internet overuse and gambling problems for analysis and publication. Biomedical research on this topic, such as brain imaging studies, will soon be launched.
Declaration of interests