The “merger” of the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) is moving ahead slowly, secretly, but—in the views of most—inexorably to a conclusion, which will emerge as a draft after the election in November and in final proposed form in the president’s budget for fiscal year 2014 next February. One thing is clear, however: “Merger” is a misnomer.
The two institutes will not be merged into the sum of both current parts. Most of the institutes’ current research portfolios—but not all, and in fact quite possibly not the biggest—will be incorporated into the new institute. Portfolios from other National Institutes of Health (NIH) institutes outside NIDA and NIAAA might go to the new institute as well.
The most important question, involving which portfolios will go where, still hasn’t been answered. The current portfolios for AIDS, fetal alcohol syndrome (FAS), liver disease and smoking—where the most money is at the two institutes—may or may not stay within the new institute. Also unknown to many is whether the new institute will cover all addictions (including those such as food and gambling) or will be devoted to the health effects of alcohol and drugs only. The interviews conducted for this article leave the impression that the new institute will be about all addictions, not just drugs and alcohol.
But the alcoholism research field, which believes it would lose out under such a definition, is still fighting the reorganization. And some openly question whether the “merger” ever will come to pass at all.
A done deal?
Barbara McCrady, PhD, president of the Research Society on Alcoholism (RSA), says she doesn’t necessarily think the reorganization is going to happen. “Many alcohol researchers, including myself and including RSA, have not given up expressing our concerns and opinions about this,” she says. “I don’t think it’s a done deal yet.”
McCrady, professor of psychology at the University of New Mexico Center on Alcoholism, Substance Abuse, and Addictions, says taking FAS out of alcoholism research and putting it into child health and development would make no sense. “How do you separate them, and how do you prevent FAS if you separate them?” she says.
Noting that NIDA’s budget already is more than twice the size of NIAAA’s, despite the fact that alcohol causes a much heavier public health burden than drugs, McCrady says that if this continues under a new institute, alcohol would be “completely overshadowed.” But, she adds, there is now “serious consideration about whether this new institute makes sense in our economic climate.”
Not everyone within NIAAA is so sanguine about the possibility of a change in direction, however. High-level people are leaving the institute this year, and more plan to leave after the reorganization takes place. NIAAA currently is led by an acting director (Kenneth R. Warren, PhD), while NIDA has longtime director Nora Volkow, MD. The Lancet reported last year that Volkow thinks there should be one institute for drugs and alcohol and that she would like to be its director (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61236-1/fulltext).A further ironic twist is that Volkow’s lab at Brookhaven is funded by NIAAA; technically, she is an NIAAA intramural scientist, which preserves an arm’s-length distance between NIDA and her lab, which focuses on drug abuse and brain scans.
No one from NIAAA or NIDA would speak to Addiction Professional on the record for this article. Yet discussions with others who closely monitor the institutes say that at NIAAA, it is believed that the new institute will be about all kinds of addiction, and that the current top funding categories will go to other institutes.
Under this scenario, FAS would go to the National Institute of Child Health and Development, liver disease and the entire organ damage portfolio would go to the National Institute of Diabetes & Digestive & Kidney Diseases, and cancer-related research would go to the National Cancer Institute (NCI). What would happen to drunk driving research is still unknown.
NIDA is worried about losing its AIDS funding, because it represents one-third of the institute’s budget. In the 1980s, NIDA’s budget doubled because of AIDS. However, under the reorganization NIDA’s AIDS funding could go to the National Institute of Allergy and Infectious Diseases, headed by the powerful Anthony S. Fauci, MD.
Nicotine addiction, however, seems like something in which NIDA would be interested in incorporating. The smoking budget is creating a great deal of controversy, because patient advocacy groups such as the American Lung Association want it to stay in the large and influential NCI.
Sources report that over the past few months there have been closed meetings where people from different institutes go before the NIH Substance Use, Abuse, and Addiction (SUAA) task force and say, “Here’s what should go into the new institute, and here’s what we think we should take.”
The historical differences between NIAAA and NIDA have a lot to do with Alcoholics Anonymous (AA), which was a force behind NIAAA’s creation. Historically, NIAAA has been divided into two factions: one based on AA and driven by Marty Mann and Sen. Harold Hughes. At the same time, NIAAA cultivated some researchers who thought AA was more like a religion than a science. At the upper echelons of NIAAA, there is pride in the non-AA driven research, with the issue of recovery seen as being more under the auspices of the Substance Abuse and Mental Health Services Administration (SAMHSA).
The history of NIDA is very different. The Special Action Office for Drug Abuse Prevention (SAODAP), NIDA’s predecessor in the Nixon administration, was concerned with liberalizing drug control laws and making it possible for addicts to have access to treatment.
It’s true that there is some long-term envy on the NIAAA side—not only internally, but by researchers. NIDA and drug abuse always has received more money and, especially recently, more attention in Congress, despite the fact that alcohol is much more significant in terms of contributing to widespread health problems. NIDA’s budget of just over $1 billion is more than double that of NIAAA’s budget of just under $460 million.
The often poignant sense of alcoholism research being on the verge of losing its identity can be seen through the testimony before the Scientific Management Review Board (SMRB) of NIH on substance use, abuse, and addiction research (any of the videocasts may be viewed by visiting http://videocast.nih.gov and searching “SMRB”).
(To see Addiction Professional's 2010 article on the NIDA-NIAAA proposal, visit www.addictionpro.com/should-two-research-institutes-become-one.)
In November 2010, the SMRB recommended creating a new institute, integrating the “relevant” portfolios of NIAAA, NIDA and other institutes (in particular, NCI) and moving some of the NIAAA and NIDA portfolios to other institutes. NIH agreed with the review board and solicited internal and external feedback this year.
There will be two plans: a draft scientific strategic plan, which will be published for public input, and a separate plan for internal portfolio integration. Both are scheduled to be released in mid-November, and then NIH director Francis S. Collins, MD, PhD, will issue his final recommendations by Dec. 31. Ultimately, the plan will be known when the president’s proposed budget is released in February.
In the past, the addiction treatment advocacy community (with its attention to the alcoholism roots of the treatment field) would have cared very much about keeping NIAAA separate, but now seems relatively silent about it. The recovery movement is mainly concerned that the new institute focus on recovery; one of the problems for NIDA and NIAAA is that they have never wanted to fund recovery research that isn’t based in treatment first.
Faces & Voices of Recovery never formally commented on the merger, but sent a memo to recovery-oriented groups in May noting that research into how people get into recovery is “noticeably absent from the list” of grant opportunities that the new institute could offer. “Faces & Voices and allied researchers and supporters have long advocated for a robust recovery research agenda,” the memo stated.
Faces & Voices circulated comments it had prepared on the merger as part of the memo, which went to the Association of Recovery Community Organizations. In the comments, Faces & Voices stated, “Recovery is much more than abstinence from the use of alcohol and other drugs and should be researched to understand and disseminate how people can and do get well.”
In addition, it said that NIDA’s brain studies “should also focus on brain resilience and recovery,” asking, “To what extent and how does the brain heal? How does long-term recovery affect this process?” And NIAAA should focus not only on the health impacts of alcohol dependence but also on the health impacts of recovery from addiction, the comments stated.
There remains a possibility that the merger will not go ahead. One rumor is that the alcohol beverage industry is lobbying Kentucky politicians, including U.S. Rep. Hal Rogers, chairman of the House Appropriations Committee, to keep the institutes separate because it doesn’t want alcohol to be associated with cocaine. Others say the alcohol industry’s lobbying effort is scattered across so many different issues that even if this is true, it might not prove to be significant.
It’s true that NIH is likely to want to avoid a scuffle with Congress over this issue. Director Collins was forced this spring to appear before an angry congressional committee to defend his decision to bypass Congress and fast-track the National Center for Advancing Translational Sciences. That’s why this merger process is taking so long, many observers believe.
And it is possible that Congress will not want to fund the reorganization. The House appropriations bill for fiscal 2013 (which is not official because it was never marked up, but still sheds light on how the Appropriations Committee feels about the merger) included a line that said funding could not be used for combining agencies. So, although NIH does not have to get Congress’s permission to reorganize NIDA and NIAAA, it needs the funding.
“From our perspective, NIH could create a new institute, but what good is that if Congress doesn’t fund it?” asks Andrew Kessler, president of Slingshot Solutions, a lobbying firm that represents behavioral healthcare interests.
The move to reorganization is secret, but at least it is slow. Last April, Lawrence A. Tabak, DDS, PhD, principal deputy director of NIH, led a public hearing on a request for information (RFI) that had been issued about the reorganization. The purpose of the public hearing was to collect stakeholder feedback, but almost every question resulted in Tabak’s urging the commenter to respond directly to the RFI. All of those comments are now available to be read (http://feedback.nih.gov/index.php/suaa/comments-received-on-scientific-strategic-plan).
Whether the comments, which are anonymous in most cases, will be taken into consideration (they vary from urging that yoga be funded to saying the merger itself is a bad idea) is unclear. The process simply may have been an opportunity for responders to “vent."
The RFI was not published in the Federal Register, but in the NIH guide only, and was not publicized at all. Asked why, NIH senior press officer Renata Myles said that the NIH “is the official NIH communication tool with our extramural community,” adding that the RFI was also sent to stakeholders.
Meanwhile, people at NIAAA are convinced that no matter what, the combining of the institutes will happen, and that there remains a need to be prepared organizationally for it.
The proposed name for the new entity is “The National Institute of Substance Use and Addiction Disorders” (NISUAD), but Tabak said in April that this is just a “placeholder,” adding somewhat facetiously that he knows people are “passionate” about names.
In fact, Kessler says the name does matter. “They were calling it an Institute on Addictive Disorders,” he says. His comment about that, when it was solicited by NIH, was that addiction isn’t a disorder; it’s a disease (“disorder” being seen as weaker than “disease”).
Some observers of this murky situation say that if NIAAA were to stop fighting the battle to stay separate—a battle that they say it cannot win—it could instead fight for money based on the size and scope of the alcohol problem. As one observer puts it, “The alcohol treatment and prevention lobby has a golden opportunity to rewrite the books, building from scratch funding for the new institute that addresses the biggest problem with addiction in America—and that is alcohol.”