NISUD—PROGRESS, BACKLASH OR SIDETRACK?

Authors


In his paper, Grabowski [1] argues that the organization of US alcohol and drug research in separate National Institutes of Health (NIH) institutes is obsolete. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Addiction (NIDA) have different historical origins, different roles in policy development and research agendas. Currently, however, the situation is characterized by overlapping scientific methods, research questions and projects. Competing training programs drain insufficient resources. Cost–benefit and cost-effectiveness considerations would favor joint organization. One should build an integrated organization logically and possibly save costs needed for research activities. There is a potential for ‘stunning synergy’.

In a way, the suggested reforms are overdue. Present neurobiological understanding gives undisputable evidence on the joint basis for all substance use dependencies. Behavioural and neurobiological research methods are basically the same, and what is more, the substance users seem to increasingly neglect the differences related to the origin and type of psychoactive drugs. In spite of regulations and guidelines, the typical use pattern is mixed. Alcohol, tobacco, prescription drugs and illegal drugs are used without regard for public systems and research organizations.

Grabowski argues that NIH should take the lead in integrating science. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)—the large European monitoring centre established in 1994—focuses upon illegal drugs and excludes alcohol [2]. The United Nations (UN)-based international conventions to regulate production and trade of addicting drugs also omit alcohol. The World Health Organization (WHO), on the other hand, has merged the Department of Mental Health and the Department of Substance Abuse in a combined department within the Division of Non-communicable Diseases and Social Determinants of Health [3]. This department has separate offices or expert groups on alcohol and illegal substances, illustrated by differing review publications [4,5]. The Nordic countries have a collaborating and planning office for both alcohol and drugs research financed by the Nordic Ministerial Council. In Norway, the National Alcohol Research Institute incorporated drug research in 2001 and changed the name accordingly to the National Institute for Drug and Alcohol Research. Clearly, strong integrating influences are already noticeable.

What is the message? First, the US discussion is neither unique nor original. The overlap between illegal and legal drugs research is widely recognized—as are the similarities in treatment approaches. Secondly, in spite of obvious similarities, there are also important basic differences related to context and history. This constitutes realities important both for research and for treatment. Grabowski points at the NIDA background in ‘War on Drugs’ and NIAAA's origin in political concerns for public health [1]. As the recent WHO publication illustrates [4], there is a growing international skepticism towards the war concept while the public health approach has increasing support. Nevertheless, both heavy investments and important contextual differences create realities. Even if NIDA, as emphasized by Grabowski, also focus increasingly upon public health instead of war, there is a parallel development of over-focus on addiction as a brain disease.

However, one warning should be signalled. The last decades have brought a sort of international furore of structural reforms, fuelled partly by new management ideologies developed in US university institutes and partly by the belief that large is beautiful. However, organizational changes are usually costly, with new liaisons, often new data technology and new managerial levels. The synergy is often less than expected and the costs larger, particularly when the partners for marriage are organizations with different traditions and culture as described by Grabowski. High-level science and efficient treatment units depend to a large extent on the human relations in relatively small units. Is it wise to integrate adversaries in monolithic structures? One possibility is stifling of creativity and top-down management.

So: yes the barriers between alcohol and drug research belong to the past; but the past lives in the present. It would probably be wise to prioritize agreements of over-riding goals and clarify differences in ideology and belief systems. Possibly, it would be better to increase coordination in a way that promotes the sensible; cooperation should bring obvious benefits more than burdens and new meetings. Finally, one should beware that one-headed systems might be more vulnerable for political influence—not necessarily a problem when the governments and their administration are sensible; but then, sometimes they are not.

Conflicts of interest

None. No external funding

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