Federalizing Medical Campaigns against Alcoholism and Drug Abuse

The proposed and narrowly averted reorganization of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) has drawn attention to the national substance abuse research enterprise. Although policymakers rejected similar proposals in 1973 and 1987, citing the need to maintain the visibility associated with independent institutes (Gardner 1973; Lewin and Associates 1988), this time they placed a greater emphasis on achieving “synergies” across the alcohol and drug fields (NAS 2003; SMRB 2010). After launching a two-year, trans-NIH review of substance abuse research portfolios, the director of NIH abruptly terminated the reorganization for reasons that remain unclear. This lengthy and tumultuous process has raised a number of issues. Should the new institute's portfolio be limited to dependence, or should it cover other adverse consequences of alcohol and drug use, such as cirrhosis, fetal alcohol spectrum disorders, and HIV/AIDS? Is it wise to encourage closer collaborations between communities of researchers that have historically maintained separate identities? Would the reorganization result in more or less research funding overall? Underlying all these questions, and exacerbating tensions between alcohol and drug researchers, is the relative size of the two institutes. For many decades, because NIDA is roughly twice as large as NIAAA, alcohol researchers have worried that their programs will be dwarfed in a reorganized institute. Alcohol researchers are also quick to point out that the public health burden of alcohol far exceeds the public health burden of illicit drugs, NIDA's primary focus. This article uses history to reach a deeper understanding of the present. It considers the creation of NIAAA and the Special Action Office for Drug Abuse Prevention (SAODAP), NIDA's short-lived but influential predecessor (figure 1). The establishment of NIAAA and SAODAP in the early 1970s marked a turning point in medical and scientific efforts to control substance abuse. Between 1935 and 1970, research was conducted on a small scale; the Public Health Service treated a handful of drug addicts at facilities in Lexington, Kentucky, and Fort Worth, Texas; and Alcoholics Anonymous (AA) was the dominant treatment modality for alcoholics (Campbell 2007; Roizen 1991). Nevertheless, most alcoholics and drug addicts were sequestered in mental hospitals and jails, if they received any attention at all (White 1998, 178–261). NIAAA, SAODAP, and NIDA were initially created to address this dearth in treatment options. During the 1970s, these agencies spurred the growth of a substance abuse treatment industry, laid the groundwork for today's research enterprise, and institutionalized funding disparities between alcohol and drug programs. Understanding the events surrounding the creation of NIAAA and SAODAP therefore sheds light on the reasons why medical and scientific programs for illicit drugs have outpaced comparable programs for alcohol. FIGURE 1 Federal alcohol and drug agencies, 1966–1974. The first section of this article examines those advocates who attacked punitive approaches to alcohol and drug problems in the 1940s, 1950s, and 1960s, as well as the expansion of alcohol and drug programs at the National Institute of Mental Health (NIMH). The next section considers the passage of authorization legislation for federal alcohol and drug agencies, along with the justifications used to substantiate them. Finally, the third section describes issues surrounding the initial implementation of NIAAA and SAODAP. Overall, the article demonstrates that the early 1970s were a golden age for drug experts, whereas alcohol experts struggled to launch NIAAA and keep it afloat. There are three reasons why this result, in retrospect, is somewhat surprising. First, at the time alcohol was widely considered a bigger problem than illegal drugs. Even though the generation of prevalence figures was notoriously controversial (Josephson and Carroll 1974; Weiner 1981, 177–97), the difference between them was substantial. According to official estimates, there were roughly 9 million alcoholics, compared with 100,000 to 500,000 heroin addicts (NIMH 1969; SCDA 1973; US Senate 1970a, 124). Second, alcoholism was less stigmatized than drug addiction. Self-proclaimed alcoholics regularly spoke about their struggles, and they received sympathetic coverage in the popular media. Drug addicts, in contrast, were typically portrayed as criminals and rarely spoke publicly on their own behalf. Third, and perhaps most important, alcoholics had a stronger special-interest group, whereas advocacy for drug addicts came largely from professional circles, which fought a rearguard action against proponents of law enforcement. Conversely, the advocates for alcoholics had political connections and combined professional and grassroots support into a loosely coordinated but powerful movement. This article argues that SAODAP fared better than NIAAA for two reasons. First, alcohol and drug problems were framed in different ways: alcohol was largely seen as a public health problem, while drug problems resonated with broader concerns about crime and cultural decline. Second, advocates for alcoholics and drug addicts found political allies in different branches of the federal government: the former relied on Senator Harold Hughes (D-IA), while the latter had strong supporters in the Nixon administration. These two factors conspired against alcohol programs. President Richard M. Nixon wanted to decrease the size of the federal government, so he obstructed the creation and implementation of NIAAA. But he made an exception for SAODAP because he was eager to appeal to “silent majority” voters; he was worried about addicted soldiers and what they might do when they returned home; and he thought that drug treatment would reduce urban crime in time for the election of 1972. As a result, alcohol experts had to rely on congressional oversight to compel the administration to act, while drug experts quickly received the authority and resources they needed. Over the long term, these events institutionalized a disparity in funding for federal alcohol and drug programs, an issue considered in the conclusion of this article.