DEPARTMENT OF HEALTH AND HUMAN SERVICES

NATIONAL INSTITUTES OF HEALTH

Fiscal Year 2006 Hearing on

Substance Abuse and Mental Health

Witness appearing before the

House Subcommittee on Labor-HHS-Education Appropriations

Faye J. Calhoun, D.P.A., M.S.

Deputy Director

National Institute on Alcohol Abuse and Alcoholism

April 27, 2005

William Beldon, Deputy Assistant Secretary, Budget

Mr. Chairman and Members of the Committee, thank you for inviting me to
update you on the activities of the National Institute on Alcohol Abuse
and Alcoholism (NIAAA). I am Ting-Kai Li, Director of the Institute. I
am pleased to join my distinguished colleagues here today, whose
Institutes and agencies are involved in several productive
collaborations with NIAAA. The fiscal year 2006 President's budget
request for NIAAA is \$440,333,000.

The Centers for Disease Control and Prevention rank alcohol the
number-three preventable cause of death in the United States (*Figure
1*). Alcohol's biological and social reach is remarkably pervasive and
requires research collaborations with many fields, from social policy
and behavior to genetics. The problems attributable to alcohol abuse and
alcohol dependence exceed the scope of any single institute or agency.

Adults legally can, and will, continue to use alcohol. *Figure 2* shows
the physiology of drinking too much, too fast, and not accounting for
the delayed absorption of alcohol in the stomach. Blood alcohol levels
go quickly from that which is stimulatory to those that are
sedative-hypnotic and cause death. A recent analysis of our National
Epidemiologic Survey on Alcohol and Related Conditions, or "NESARC," has
revealed that drinking in excess of four drinks per occasion for men,
three drinks for women, even less often than once a week is associated
with a 33-fold increased chance of being alcohol dependent (*Figure 3*).
Developmental factors also influence the risk in underage youth, a
troubling number of whom drink, even though alcohol is illegal for them.
Our mission is to understand the complex biological and environmental
factors that contribute to alcohol abuse and alcoholism, so that we may
better understand how to prevent and treat them in people of every age.

Last year, I reported to you that 18- to 24-year-olds have a much higher
rate of alcohol dependence than any other age group in the U.S. Alcohol
also is the drug of choice of adolescents (*Figure 4*). This year, I
will report to you on NIAAA collaborations that are advancing our
research on reducing underage drinking, and collaborations in other key
areas of NIAAA research. Advances in science, particularly neuroscience,
and technology have enabled us to make remarkable progress in these
areas. Our advances often are accelerated by collaborations with other
Institutes, such as the National Institute on Drug Abuse (NIDA) and the
National Institute of Mental Health (NIMH), whose diseases of interest
have some common underlying biological and behavioral pathways.
Collaborations with groups that share concerns about the clinical
applications of research findings are equally important.

In addition to the finding that 18- to 24-year-olds have the highest
prevalence of alcohol dependence -- the data generated by NIAAA's NESARC
studies -- other troubling findings on underage drinking are being
revealed. For example, youth who began drinking before age 15 are four
times more likely to become alcohol dependent at some point in life than
are those who started at 21, and are more likely to have the more severe
and recurring kind of alcoholism.

The Institute of Medicine developed recommendations on underage drinking
in 2003. Since that time, NIAAA has taken on the role of scientific lead
in the Interagency Coordinating Committee on Prevention of Underage
Drinking chaired by the Substance Abuse and Mental Health Services
Administration (SAMHSA). Last month, NIAAA held a second meeting of
experts convened to guide the field of research on underage drinking,
including research on strategies to ensure that relevant study results
are incorporated in clinical practice and community prevention efforts.
Participants included the National Institute of Child Health and Human
Development, NIMH, NIDA, SAMHSA, the National Highway Traffic Safety
Administration, Federal Trade Commission, and experts from the media and
the public policy arena, including Governors' spouses. Representatives
from Mothers Against Drunk Driving, the Center for Science in the Public
Interest, and the alcohol industry also attended.

Several NIAAA initiatives on preventing underage drinking are underway
(*Figure 5*), including a Center to Prevent Alcohol-Related Problems
Among Young People; a research collaboration with colleges, to provide
rapid responses to those with urgent alcohol problems; the Mississippi
River Delta Project, which is examining whether a prevention strategy
recommended for college students by the NIAAA Task Force on College
Drinking is effective for rural adolescents; a collaboration with the
Office of Juvenile Justice and Delinquency Prevention, to determine if
enforcement of existing laws will reduce underage drinking; and a new
collaboration between NIAAA and NIDA, to examine the consequences of
drug abuse and alcohol exposure on development of the brain and
behavior.

We also have several projects under development, including a major
effort to improve the response of health-care systems to underage
drinking, in collaboration with academic health centers in rural areas;
and discussions with the Department of Agriculture regarding potential
research collaborations with 4-H Clubs.

Medication development is another priority at NIAAA and is among its
expanded initiatives announced for FY 2006 (*Figure 6*). Our scientists
are working in a public-private partnership with a pharmaceutical
company on a clinical trial of a compound that acts on a brain system
not addressed by the three medications currently approved by the FDA for
alcoholism treatment. Neuroscience and genetics research have made
remarkable progress that is enabling us to identify potential molecular
targets for medications. NIDA contributes to our Collaborative Study on
the Genetics of Alcoholism, which identifies genetic and molecular
variants that influence alcohol and drug behaviors, providing potential
targets. NIAAA and NIDA also are collaborating on a pharmacotherapy
project on comorbidity, as noted below.

COMORBIDITY IS COMMON

Comorbidity -- simultaneous substance-use and other mental disorders --
is an area in which collaboration takes on special significance. Last
year, SAMHSA reported that 4 million American adults have this kind of
comorbidity. NIAAA's NESARC, to which NIDA contributes funds, supports
the significance of this relationship, especially in treatment-seeking
populations. For example, forty-one percent of people seeking treatment
for an alcohol-use disorder have a concurrent mood disorder that wasn't
substance-induced.

The challenges that comorbidity presents extend beyond teasing apart the
complex biological and environmental factors that contribute to it and
identifying the most effective treatments, although research in these
areas is essential. The chronic, relapsing nature of these disorders is
not well served by our acute-care model of health-care delivery, and we
must also determine how to increase the likelihood that comorbid
substance-use and mental disorders will be diagnosed and treated
appropriately. The consequences of missing treatment opportunities are
not trivial; the [Journal of Occupational and Environmental
Medicine]{.underline} reported, in 2003, that the 10 mental health
disorders most costly to six major U.S. employers include alcoholism and
mood/anxiety disorders.

NIAAA-funded researchers are making strides in treatment of comorbid
patients. We recently found that the drug valproate reduces drinking in
alcoholics with bipolar disorder, who usually do not respond to
alcoholism treatment. Additional NIAAA studies, many of them
collaborative, are examining medications for a variety of mental
disorders and addictions that co-occur with alcohol-use disorders. In
2004, NIAAA and NIDA jointly issued an announcement seeking applications
for grants to study pharmacotherapy for alcohol and drug comorbidity. As
part of a NIMH project on suicide, NIAAA is funding research at a Center
that is focusing on medication development for suicidal adults and
adolescents with alcohol problems. We also are collaborating in a NIMH
project on the effects of heavy drinking on depression. NIAAA is funding
one of seven Centers that are part of a National Cancer Institute and
NIDA project on tobacco addiction. In addition, we contributed to a
recent SAMHSA conference on improving care for comorbid disorders.

INTERNATIONAL PROJECT TO IMPROVE DIAGNOSTIC CRITERIA

NIAAA, NIDA, and NIMH are leading an international collaboration with
the American Psychiatric Association (APA) and the World Health
Organization (WHO) to improve the accuracy of criteria used for
diagnosing mental disorders and substance-use disorders. Current
criteria in the *Diagnostic and Statistical Manual of Mental Disorders*
(DSM) IV, issued in 1992, provide the basis for diagnoses that
clinicians enter in medical records and related ICD codes for insurance
documents.

Alcohol researchers and others also use the DSM criteria to determine
diagnoses in studies of disorders such as alcohol dependence. The
revision of the DSM criteria will not only improve the accuracy of
diagnoses of alcohol-use and other mental disorders, but also capture
new diagnostic information about their genetic and neurological
underpinnings. The long-term impact on mental and substance-use
disorders will be significant. NIAAA has developed statistical models
that will enable this enhancement.

BENCH-TO-BEDSIDE REQUIRES EDUCATION

Of special concern to us, at this juncture, is ensuring that the public
benefits from the findings that our research generates. The health-care
provider community, including the insurance industry, has not been
responsive to new findings from alcohol-treatment research, a signal
that current education and dissemination efforts -- while necessary --
have not been sufficient. New treatments are becoming available; for
example, within the past decade, the FDA has approved two medications
for alcoholism (naltrexone and acamprosate). One way to help close this
translational gap would be to establish a program to develop clinical
scholars and investigators as core faculty specializing in substance-use
disorders at health-professional schools, a suggestion offered by NIAAA
at the recent *White House Leadership Conference on Medical Education in
Substance Abuse*. We are hopeful that others with similar interests will
join us.

Despite the prevalence of alcohol-use disorders, and numerous findings
on the benefits of brief interventions in clinical settings, screening
for alcohol problems traditionally has not been a routine part of
medical practice -- in part because policies for reimbursement for this
important activity vary from state to state. In 2003, the NIAAA issued a
practitioner's guide for screening and addressing alcohol problems, and
we were joined by the American Medical Association in distributing it.
An update to the guide, now in progress, will include critical new data
from NIAAA's NESARC studies and will expand the audience to
mental-health professionals. We are working closely with SAMHSA's CSAT,
the Department of Veterans' Affairs, American Society of Addiction
Medicine, American Academy of Addiction Psychiatry, and Association for
Medical Education and Research in Substance Abuse in this effort.

Another avenue for education is the NIH Blueprint for Neuroscience
Research, a collaboration of 15 Institutes. Its training component, in
which NIAAA will participate in 2006, will help neuroscience graduate
students and postdoctoral investigators link research to clinical
applications.

DIVERSITY

NIAAA recognizes that different populations vary in their risk of
alcohol-use disorders, and we conduct research specific to them. For
example, we are funding the alcohol component of a NIDA project on how
Mexican family culture affects risk and resilience regarding substance
abuse. The NIH Office of Research on Women's Health is contributing to
NIAAA studies on alcohol pharmacogenetics in Mexican Americans and
studies on risks and interventions for women.

I hope that these highlights of some of NIAAA's research activities and
collaborations have been helpful to you. I shall be glad to respond to
questions.

Number range CHAPTER **Faye J. Calhoun, D.P.A., M.S.; Deputy Director,
National Institute on Alcohol Abuse and Alcoholism, National Institutes
of Health, Department of Health and Human Services**

Dr. Faye Calhoun was appointed to the position of Deputy Director of the
National Institute on Alcohol Abuse and Alcoholism (NIAAA) in August
2003. The NIAAA is a component of the National Institutes of Health
(NIH) within the U.S. Department of Health and Human Services. As Deputy
Director, Dr. Calhoun promotes partnerships with other agencies and
national and international organizations interested in alcohol research.
She facilitates the development of trans-disciplinary collaborative
research in areas of common interest across NIH institutes and among the
NIAAA research community and with other Federal organizations, including
the Substance Abuse and Mental Health Services Administration, the
National Highway Traffic Safety Administration, the Department of
Justice, and the Department of Education. In appointing Dr. Calhoun,
NIAAA Director Ting-Kai Li, M.D stated, \"Dr. Calhoun brings extensive
experience and expertise to her new position. I am confident that her
imaginative and creative leadership will help the Institute address
future challenges in alcohol research.\"

Dr. Calhoun joined NIAAA in 1995 as the Associate Director for NIAAA's
Office of Collaborative Research. She oversaw a broad portfolio of
programs directly under her leadership, including the expanded National
Alcohol Screening Day, the Alcohol Research Centers and institutional
training grants, the alcohol and HIV/AIDS research program, programs to
address health disparities, the development of a multi-site
international research program on fetal alcohol spectrum disorder, and
the Interagency Coordinating Committee on Fetal Alcohol Syndrome
(ICCFAS).

Prior to joining NIAAA, Dr. Calhoun served as Deputy Chief for Review in
the Referral and Review Branch of the NIH Division of Research Grants
(DRG), currently the Center for Scientific Review. At DRG she was
responsible for the administration and management of personnel involved
in the review of grant applications for research and career development
support. Prior to coming to NIH in 1980, she supervised and directed
extramural programs for the National Institute on Occupational Safety
and Health at the Centers for Disease Control and Prevention, and for
the then Bureau of Drugs in the Food and Drug Administration (FDA). Her
initial appointment at the FDA in l967 was as a reproductive
toxicologist and pharmacologist. Born in Washington, D.C., Dr. Calhoun
obtained the M.S. degree with a focus in endocrinology and biochemistry
from Howard University and the doctorate in public administration from
the University of Southern California.

Throughout her career, Dr. Calhoun has received numerous awards and has
served on many prominent leadership and advisory positions. Dr. Calhoun
has been recognized for her outstanding contributions to advancing
alcohol research through receiving the NIH Director's Award and the
Research Society on Alcoholism (RSA) Seixas Award for Distinguished
Service.

Number range CHAPTERDepartment of Health and Human Services

Office of Budget

William R. Beldon

Mr. Beldon is currently serving as Deputy Assistant Secretary, Budget in
the Department of Health and Human Services. He has been a Division
Director in the Budget Office for sixteen years, most recently as
Director of the Division of Discretionary Programs. Mr. Beldon started
in federal service as an auditor in the Health, Education and Welfare
Financial Management Intern program. Over the course of more than 30
years in the Budget Office, Mr. Beldon has held Program Analyst, Branch
Chief and Division Director positions. Mr. Beldon received a Bachelor's
Degree in History and Political Science from Marshall University and
attended the University of Pittsburgh where he studied Public
Administration. He resides in Fort Washington, Maryland.