• Merger;
  • NIAAA;
  • NIDA;
  • NIH

There may be pros and cons associated with retaining or changing the present structure of separate institutes for alcoholism and drug addiction at the US National Institutes of Health (NIH), but the position paper by Dr John Grabowski [1] is unhelpful to a consideration of the issues. His piece includes attacks on the accomplishments of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) [relative to the National Institute on Drug Addiction (NIDA)], as well as some major and minor historical inaccuracies and personal criticism of two past directors of the National Institute on Alcohol Abuse and Alcoholism and current staff at the Institute.

Multiple institutes at the NIH support research on genetics, molecular and cellular biology and clinical research; but no one proposes that the disease and organ system-based structures and functions of most of the separate Institutes be changed to avoid redundancies and foster more efficient funding. However, Dr Grabowski offers a magical belief in the benefits that might accrue (to whom?) from a merger of two bureaucracies within a larger bureaucracy. Indeed, if one were to follow his logic, a merger of National Institute of Mental Health (NIMH), NIDA and NIAAA, or of all Institutes at NIH with a central nervous system (CNS) focus, might be the most ‘efficient’ outcome. The promise of benefits from mergers in the pharmaceutical industry, which has led to the creation of behemoths seemingly incapable of real innovation and effective decision making, should certainly give pause to anyone proposing any sort of merger of two otherwise well-functioning entities. The Department of Homeland Security (DHS), which emerged from the merger of a number of separate agencies following the 11 September 2001 terrorist attacks in New York and Washington, DC, is a striking example of a misbegotten merger in the government sector, in the context of its serial failures following Hurricane Katrina and the more recent oil spill in the Gulf of Mexico.

As an independent Institute, NIAAA has been able to recruit outstanding and knowledgeable leadership in alcoholism research that would not be possible in a merged Institute. Submerging the NIAAA into NIDA, at a time when the DSM-V is about to add a number of non-drug-related ‘addictions’ to the generic diagnostic category and to NIDA's research portfolio (gambling, internet, etc.), will downgrade the significance of alcoholism research at a time of particular promise, while not providing any additional resources to addictions research. At a time of growing budget deficits in the United States, and an inevitable decrease in resources at NIH, reducing the visibility of an independent alcoholism institute at NIH will mean a serious setback for the field of alcohol research. Finally, the overall research mission of NIAAA is based upon the principle of harm reduction and health promotion in relationship to the consumption of alcohol. The mission of NIDA, and its step-parent at the White House Office of National Drug Control Policy, has been focused upon abstinent outcomes. The latter defines the function of NIDA-funded research: eventually, leading to abstinence associated with more effective prevention and treatment of addiction to illegal drugs and tobacco. Advocates of drug legalization (or their opposites in the temperance community) will have a field day in contemplating the chaotic message from a merged entity.

Dr Grabowski builds his argument on his version of history and a critique of NIAAA which requires a vigorous rebuttal. The NIMH actually separated from NIH in 1967 in the context of its burgeoning mission and funding of community mental health centers. When three Institutes finally emerged out of NIMH under the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) in 1974, NIDA and NIMH (in particular) still carried major responsibility for funding clinical service and/or prevention programs that dwarfed their research mission. The Reagan administration changed the service programs into block grants to the States, and the Institutes refocused their funding and energies upon research. In 1992 (not 1989), the three Institutes returned to NIH, and the residual support for clinical services and prevention were separated into a new agency. Dr Grabowski asks rhetorically whether anyone would ‘argue that the institutes are worse off for their NIH affiliation’. After nearly 20 years, the question should not be ‘are they worse off’, but rather has there been a substantial improvement in research? On this, there is no supportive evidence but one can, in fact, argue (as some did in 1992) that the research funded by ADAMHA was targeted, more relevant to the field and more innovative than research that was reviewed and funded at NIH because the review functions at ADAMHA were at the Institute level, and the reviewers were drawn from people who were specifically knowledgeable about the field. Moreover, in the past 20 years, the distance between the research and the prevention and service communities has grown apart—despite periodic efforts by NIDA Directors to try to make their mission more relevant to real-world practice.

Dr Grabowski claims that NIDA supported the development of methadone, buprenorphine and naltrexone. Methadone was developed for the treatment of heroin addiction by Vincent Dole and Marie Nyswander a decade before the establishment of NIDA, and it took NIDA far too long to develop buprenorphine, levacetylmethadol (LAAM) and naltrexone. The cocaine medications development program, which was well-funded, has produced no approved treatment; and NIDA's medication development program has failed to provide investigators and industry with the necessary consensus on a signal of efficacy (short of total abstinence) that might provide some clues about potential drug treatment of cocaine dependence. In fairness, the NIDA Director has moved to bring new leadership to the medications development program, but the contrast between the leadership that NIAAA has shown in working with FDA and industry to advance medications development and the more problematic cocaine medications development program at NIDA is ignored by Dr Grabowski. NIAAA analyzed its large epidemiological and treatment data bases to convince the Food and Drug Administration (FDA) that heavy drinking can be defined such that a sustained moderate drinking outcome is a legitimate end-point for drug efficacy. In addition, following the approval of acamprosate and naltrexone for the treatment of alcoholism, NIAAA funded Project COMBINE in order to examine the relative efficacy of each drug (separately and together), and in combination with evidence-based non-pharmacological treatment. Rather than ignoring non-pharmacological treatment (as Dr Grabowski avers), NIAAA supported the largest psychotherapy outcome study ever conducted in the United States in Project MATCH. In general, these programs, along with support for the Collaborative Study on the Genetics of Alcoholism (COGA) and the alcohol research centers program, have demonstrated that NIAAA has sought to address important questions in the alcohol field that could not be addressed through the typical NIH- investigator-initiated research program. Across the NIH, the latter has been less successful in supporting clinical investigation and in addressing critical and urgent public health questions. Since the development of methadone maintenance (and now buprenorphine maintenance) the question of whether, when and how patients might be transitioned from agonist treatment to a drug-free state has not been addressed satisfactorily. In the context of a burgeoning agonist maintenance program operating out of physician offices, this question has only become more urgent. A merger with NIAAA at this time would only divert the leadership at NIDA from addressing important questions such as this in the near term.

Dr Grabowski demeans the approach that NIAAA took with regard to alcohol administration in challenge studies among alcoholics. When I served on the NIAAA Council in the 1980s with several members of Alcoholics Anonymous (AA), we took the position that the administration of alcohol to alcoholics in treatment-related research was appropriate. The position was consistent with the results of studies that I had conducted in the 1970s with heroin addicts and in the 1980s with alcoholics. In contrast, at around the same time, the NIDA Council, with the support of leaders in the human behavioral pharmacology community, specifically took the position that treatment-seeking individuals should not be subjects in challenge studies—such studies should employ only non-treatment seekers. This was a position that was consistent with the culture of Committee on Problems of Drug Dependence (CPDD) and its long-term studies of abuse liability. It was more problematic for proof of concept treatment studies.

Early in my research career, I was well funded by NIDA for my research on opiate addiction and I served as a member of the CPDD. When I moved from Harvard to Chair the Psychiatry Department at the University of Connecticut, my research focus shifted to alcoholism, and I received substantial research support from NIAAA. I also became a member of the Research Society on Alcoholism (RSA), an organization that impressed me for its extraordinary commitment to the scientific contributions of multiple disciplines in medicine, neuroscience, genetics, molecular and cellular biology, epidemiology and the behavioral and social sciences. At a meeting of the American College of Neuropsychopharmacology in the early 1980s, I participated in a study group with Joe Brady, Bob Schuster and others on the future of the CPDD. I urged my colleagues to follow the model of RSA to become a multi-disciplinary scholarly society rather than continue the paternalistic organization of the Committee, which was at the time dominated overwhelmingly by behavioral pharmacologists. To my delight, the Committee did evolve from its previous incarnation, but Dr Grabowski still seems to identify behavioral pharmacology as the defining discipline for alcoholism and for drug addiction. The slogan ‘addiction is a brain disease’ was not merely the efforts of a new NIDA Director in the 1990s to attract support for addiction research and to reduce stigma; it also stemmed from a concern about needing to expand the scientific base at NIDA beyond the world of behavioral pharmacology, to bring addiction research more firmly into the core of neuroscience.

In the area of acquired immune deficiency virus (AIDS) research, NIDA should be encouraged to collaborate with the National Institute of Allergy and Infectious Diseases (NIAID). In the area of tobacco control, it needs to work closely with the National Cancer Institute (NCI), the Heart, Lung and Blood Institute (NHLBI), FDA and Centers for Disease Control (CDC). Its medication development program could learn a great deal from the NCI and NAIAD. In certain areas of research, NIAAA and NIDA should address common challenges, and both should establish a solid framework for addressing urgent public health, prevention and treatment issues with the Substance Abuse and Mental Health Services Administration (SAMHSA). Dr Grabowski has failed to make the case for submerging NIAAA into NIDA. In contrast, the case for greater collaboration among different institutes at NIH needs to be made forcefully, along with appropriate incentives to encourage essential collaboration during a time of diminishing resources.


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