Having recently chaired a policy study group in the White House Office of National Drug Control Policy (ONDCP), which concluded unanimously that a merger of the US National Institute on Drug Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism would benefit research and public health [1], I was cheered to see Grabowski [2] come to the same conclusion. Both of us are echoing an earlier recommendation from the Institute of Medicine [3]. In this commentary, I supplement Grabowski's case for a combined institute with some historical evidence on the changing face of substance use in the United States. Because support of the proposed merger is often attributed to being the inbuilt bias of ‘NIDA people’, let me aver for the record that I have never applied for a grant from NIDA, nor served on any NIDA committee. Indeed, I have in fact been extensively funded by and involved in the operations of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) for many years (e.g. study section member, research portfolio advisor, center grant advisory board member and reviewer).

A basic and reasonable premise of the organization of the National Institutes of Health (NIH) is that individual institutes are structured to map onto (1) how health problems are experienced in the population and (2) how prevention and treatment for those disorders is provided. On those bases, I would have supported separate alcohol and drug institutes in the early 1970s. On the same bases, I support combining them today. If that seems to show a lack of logical consistency, consider Keynes' quote: ‘When the facts change, I change my mind. What do you do, sir?’[4].

The ‘pure alcoholic’ who populated US alcoholism hospitals in the 1970s has largely gone the way of the buffalo. By 1992, only 37% of treatment admissions were primary alcohol patients who did not also have an illicit drug problem [5]. This proportion has continued to shrink, and was down to 22.7% of treatment admissions in 2007 [6]. Meanwhile, as smoking has become a rare behavior among people with otherwise healthy habits, its association with alcohol misuse has become pronounced: fully 58% of heavy drinkers in the US population use tobacco [7].

Separate alcohol and drug treatment programs, which were prevalent at the time that NIDA and NIAAA were founded, have also receded into history. Between 1982 and 1990, the number of combined alcohol and drug treatment programs in the United States nearly tripled, while the number of exclusively alcohol programs decreased by about 75% and the number of exclusively drug programs decreased by nearly 60% [8]. Since 1992, the federal government's administration of combined treatment and prevention funds has been conducted by a merged agency without alcohol or drug in its name, the Substance Abuse and Mental Health Services Administration.

Let me make an analogy about where these changes in substance use patterns and services put a country with separate alcohol and drug research institutes. If a team of US diplomats prepared in 2010 for an upcoming negotiation with Spain by looking at a map from the early 15th century, they would be frustrated that the meetings they had scheduled with Kingdoms of Aragon, Castille and Navarre were poorly attended. Although some members of the diplomatic team might have an impulse to rebuke Spain for having the temerity to cease abiding by the once-trustworthy map, wiser heads would wonder why the diplomats were clinging to a superannuated map that no longer reflected the territory.

The disparity between the map and the territory at NIAAA and NIDA is not merely an academic or bureaucratic nicety, but a significant barrier to promoting public health. For example, NIAAA treatment outcome studies frequently forbid enrollment of alcohol patients who have illicit drug problems [9]. By restricting treatment research participation to the ‘pure alcoholics’ who were prevalent in the 1970s, the institute is producing a body of knowledge that is increasingly irrelevant to clinical practice. NIDA-supported studies of people who use drugs and tobacco but not alcohol are similarly of declining public health value. When the AIDS epidemic hit, NIDA quite appropriately initiated a large AIDS portfolio because the problems of AIDS and drug addiction were merging in the population and in the world of treatment services. However, as alcohol problems have become comparably intertwined with tobacco and illicit drug use, the structure of NIAAA and NIDA has remained inert.

By continuing to use an organizational structure that reflects the realities of the 1970s rather than the present day, NIH and the addiction field are missing opportunities to contribute to public health, public education and the research enterprise. Old maps belong in museums, not at the world's premier supporter of cutting-edge health research.

Declarations of interest



Preparation of this paper was supported by a Senior Career Research Scientist Award from the US Department of Veterans Affairs. This paper represents my own policy analysis and does not necessarily reflect the official position of any US government agency.