How Should Addiction-Related Research at the National Institutes of Health be Reorganized?

The decades-old debate about the optimum organizational structure of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and National Institute on Drug Abuse (NIDA) has reached a crescendo with the recent deliberations of the Scientific Management Review Board, which, despite the lack of a crisis, proposed a structural reorganization that would dissolve the two institutes and create a new institute for substance use, abuse, and addiction, in hope of new scientific and public health advances (Collins, 2010). For a new institute to succeed, a multitude of potential challenges need to be negotiated effectively. Notably, new funds will be needed, even in the current difficult national economic climate, to coalesce the infrastructure of NIAAA and NIDA and incorporate addiction-related research currently conducted by other National Institutes of Health (NIH) institutes. To succeed, the new institute would also require an enormous amount of cooperation from other institutes as the portfolios of research in the areas of alcohol, tobacco, and other drug abuse are transferred to it. Thus, in the near term, a structural reorganization would be less efficient and more costly than the individual institutes are currently. Only with careful strategic planning would it be possible to increase efficiency and reduce costs over time. If the process moves forward smoothly, Dr. Francis Collins, NIH Director, has proposed launching the new entity by October 2012. However, if reorganization is to be unveiled slowly and progressively over the next 2 years with gradual integration of two disparate cultures, another approach could be to intensify and strengthen current collaborations through an NIAAA–NIDA Joint Task Force. The NIH Director could determine a specific percentage of resources from each institute to be committed for collaborative research agendas modeled on the same governance and operational structures currently used by the Neuroscience Blueprint and the Basic Behavioral Research Operations Network. In this way, a clearer road map could be developed that provides for due diligence and critical information gathering to understand the practical needs and challenges of developing an informed organizational approach. Predetermined milestones can be used to evaluate progress and adjust course as needed to ensure a viable plan that incorporates all relevant research. Importantly, although there are common mechanisms mediating the rewarding effects of alcohol and other drugs, distinctions also exist. For example, there is considerable evidence that substances of abuse express their addictive potential, in part, through similar brain circuits, most notably the cortico-mesolimbic dopamine circuit (Johnson, 2010). Nevertheless, despite decades of research, the approach of direct antagonism of cortico-mesolimbic dopamine receptors has not yet yielded efficacious medicines to treat addiction. In fact, pharmacological differences between alcohol and other drugs might hold the key to successful medications development for these different disorders. Thus, rather than focusing on a narrow conceptualization of the addiction circuitry, the new institute should seek diligently to understand how diverse and complex mechanisms contribute to abuse of alcohol and other substances. Nutt et al. (2010) noted that in the United Kingdom, the overall harm to both the individual and others was greatest for alcohol. Alcohol is the addictive substance that is most commonly used by the United States population, with a prevalence of about 65.4% (Table ​(Table1;1; Grant et al., 2011). Addiction to alcohol is, however, far less common, as a proportion of its use, than addiction to many other drugs of abuse. Nonetheless, Rehm et al. (2009) found that the total economic cost of alcohol abuse in the United States in 1998 was nearly $235 billion (adjusted to 2007 international dollars). The harm to society attributed to alcohol consumption often results from alcohol use disorders that include the inappropriate use of alcohol in situations such as before driving or by underage drinkers, rather than addiction to alcohol. A 2010 fact sheet from the Centers for Disease Control and Prevention reports that during 2000–2004, annual health-related economic losses in the United States due to cigarette smoking were estimated at $193 billion ($96 billion in direct medical costs plus $97 billion in lost productivity). Data from the Office of National Drug Control Policy in 2002 showed that the total economic impact in the United States of all illicit drugs combined was about $200 billion, but 60% of that amount was related to incarceration. Hence, the new institute should focus on (1) alcohol use disorders, including alcoholism, (2) tobacco addiction, and (3) illicit drug addictions as a group, in that order. Table 1 Past-year liability for various types of substance dependence, based on 200 million United States adults ≥18 years of age (2001–2002). Careful thought is needed to determine the programmatic components of the new institute. Fragmentation or segregation of ongoing programs such as those involving fetal alcohol spectrum disorders, alcoholic liver disease, or prevention and treatment does not serve the public good and must be avoided. Tobacco research should be a major focus of a new institute and not the sole purview of the National Cancer Institute (NCI) or National Heart, Lung and Blood Institute (NHLBI) so that the prevention and treatment of tobacco addiction is not subsumed by the study of its general health consequences. Indeed, tobacco is, by far, the most addictive of all the drugs (Table ​(Table1),1), followed by heroin and crack cocaine (percentage of past-year users with past-year dependence; Grant et al., 2011). It would certainly be unreasonable to expect scientists within NCI and NHLBI to be experts on addiction, and for many, such specialist training would be lacking. Comorbid alcohol and drug addiction is at the interface of a collaborative scientific enterprise and, in the future, should receive appropriate funding and opportunities for development. Because of the strong interrelationship between alcohol and tobacco use, abuse, and addiction, a new institute would not be well grounded if it did not incorporate both. It is intriguing to consider whether parts of the National Institute of Mental Health should also be included within this new institute to address prevention and treatment of comorbid substance use disorder and mental illness, as well as some behavioral addictive disorders. These deliberations have identified an opportunity to increase collaboration and broaden the thinking and vision of scientists to promote public health. If a new institute for substance use, abuse, and addiction is established, new leadership that is credible and respected by both the alcohol and drug addiction communities is needed to drive the new institute, inspire new vistas, build more intensive collaborations, and motivate staff to do what they have always done best – serve the public good. Otherwise, the path toward a structural reorganization of a new institute that meets some of the promise proposed for it, even with careful and strategic planning, could become a famished road (Okri, 1992) that simply consumes people and resources with no tangible gains. Success in this difficult task would be made easier and less costly by first implementing carefully placed building blocks of increasing functional reorganization. Indeed, for the structural reorganization of a new institute to succeed, attention needs to be paid to the devil in the details.