What's in a name? Proposed name changes of the US National Institute on Drug Abuse and the US National Institute on Alcohol Abuse and Alcoholism

Field: Social Sciences (Social Sciences)

On 6 March 2007, US Representatives Joseph Kennedy (Democrat—Massachusetts) and Jim Ramstad (Republican—Minnesota) introduced a bill in the House of Representatives entitled the ‘NIDA and NIAAA Name Redesignation Act’ (HR 1348). The purpose of this bill was to rename the National Institute on Drug Abuse (NIDA) to the National Institute on Diseases of Addiction (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to the National Institute on Alcohol Disorders and Health (NIADH). On 28 March 2007, a companion bill was introduced in the US Senate by Senator Joseph Biden (Democrat—Delaware) with co-sponsors Senators Michael Enzi (Republican—Wyoming) and Edward Kennedy (Democrat—Massachusetts) entitled the ‘Recognizing Addiction as a Disease Act of 2007’ (S 1011). Both bills would amend the Public Health Service Act and related enactments to rename NIDA and NIAAA, and both bills stated that the missions of NIAAA and NIDA would remain the same. Several news stories about these bills noted that Representatives Kennedy and Ramstad utilized the 1 March 2007 occasion of the debut of HBO's 13-part series called ‘Addiction’ to announce their support of the House bill. This legislative launch included personal statements about their own experiences with addiction along with film clips that illustrated the devastation of addiction and the promise of topiramate, a new medication that may help to treat some addicted individuals. Despite the news events preceding the introduction of both bills, there has been a notable absence of public dialogue, specifically in the scientific community, around these proposed name changes and particularly around the meaning of these name changes. Are these new names a first step towards further changes in the mission of each agency, even though the bills state that this is not the case? Are these proposed name changes intended to align more closely the titles of the agencies with their current missions? Based on materials written on NIDA and NIAAA and these two bills, interviews with NIDA and NIAAA senior staff, and alcohol and drug researchers, this editorial will present several possible explanations for the proposed name changes and will argue that these new agency names may have serious implications for the agencies themselves, their political constituents, the general public and for those who apply and depend on funding from these agencies for their research. One explanation of the need for these name changes is reflected in a 29 March 2007 press release from Senator Biden's office [1]. In it, an argument is put forward that the proposed name change for NIDA ‘removes the pejorative term “abuse”’ and thus separates abuse from ‘diseases of addiction’. Further, the name change links conceptually the concepts of disease with addiction and, as stated in the press release, ‘identifying addiction as a neurobiological disease will diminish . . . social stigma, discrimination, and personal shame . . .’. Thus, this first explanation for the name change seeks to codify NIDA's commitment to focusing on disease and addiction. For NIDA, it appears that the impetus for this change comes from consumer recovery groups, such as Faces and Voices of Recovery. Many members of these groups feel quite strongly that ‘abuse’ is a pejorative and stigmatizing term and thus should not be included in the agency's name at all. For NIAAA, a different explanation is put forth in the Biden press release. The press release argues that NIAAA's current name is an awkward remnant of their organizational past, when the agency was housed within the former Alcohol, Drug Abuse and Mental Health Administration (ADAMHA). Today, NIAAA's research function is under the aegis of the National Institutes on Health (NIH). Moreover, there is a growing sense that ‘excessive alcohol use and alcohol dependence (alcoholism) are not separate diagnostic categories, but exist along a single continuum of alcohol-disorders associated with increased frequency of a harmful drinking pattern’. Thus, the proposed NIDA name change affirms the view that the term ‘abuse’ is no longer a useful or informative way to describe the goals or functions of the agency. In this regard, some have suggested that ‘alcohol abuse’ may not even appear in the next iteration of the DSM, which is due within the next 5 years. Another explanation, not necessarily mutually exclusive from the first, is that NIDA and NIAAA are responding to pressures within the NIH to view their purpose and mission as primarily biomedical, or as stated in Biden's press release, ‘neurobiological’. It appears that the currency within NIH may not be health per se but, rather, ‘disease’, and that these name changes reflect a pervasive and continuing biomedicalization of both health and disease [2]. NIH thus provides the context for framing alcohol and drug issues predominantly in biomedical (or neurobiological) terms. Using the language of addiction, disease and disorders in agency titles further legitimizes these agencies as biomedical, thereby allowing them to better compete for recognition and funding within the NIH. This explanation lends itself to the critical question of where the nexus might be for research on non-addictive drug and alcohol use, such as vitally needed research on the social and economic consequences of their use. From a public health perspective this is particularly important, because alcohol-related problems affect a large number of ‘non-addicted’ people. For example, approximately 16 900 people died in alcohol-related traffic crashes in 2004 [3]. One wonders if alcohol problems such as drinking and driving or underage drinking will ‘fit’ as ‘alcohol disorders’ under NIAAA's new name? Similarly, would studies that compare social and economic factors associated with drug use also be categorized as ‘diseases of addiction’? Would all levels of abuse be subsumed under addiction by NIDA or alcohol disorders by NIAAA? If so, this new schema can be best understood as a position based less on scientific evidence and based more on a reigning ideology. By explicitly linking virtually any form of abuse to addiction, there is the significant political and economic advantage of ‘widening the net’; that is, of expanding the purview of disorders or addiction in both the drug and alcohol fields. Alternatively, with regard to alcohol, if these non-addictive alcohol-related problems fit more closely under the ‘health’ portion of the new agency title, this presents consumers, researchers and policy planners with additional significant issues. Health problems due to alcohol use may be classified appropriately under ‘health’. However, health issues are only one dimension of a range of alcohol-related problems, which are currently encompassed by the term ‘abuse’. Other areas, such as work-related problems and legal problems due to alcohol use, are not necessarily encompassed under ‘health’. Moreover, the addition of ‘health’ in NIAAA's new title may serve to over-emphasize two created poles of alcohol use: disorders and health. This may suggest to some that attention should be placed equally on both the problems arising from alcohol use and alcohol's purported health effects. The ‘health’ part of this title and the positive health benefits of alcohol use it could connote to the lay public will no doubt please the alcohol beverage industry which has much to gain by advertising and being seen as selling ‘healthy’ products. Interestingly, to a large extent NIDA's name change encompasses much of NIAAA's claimed area of responsibility. One might presume that the addition of ‘health’ to NIAAA's new proposed name may be the only aspect of NIAAA that keeps it distinct from NIDA and thus has the additional benefit of avoiding attempts to merge the agencies—at least at this point in time. A final explanation revolves around our understanding of which constituencies will benefit from these proposed name changes. One could assume that by ‘de-stigmatizing’ disease with the removal of abuse from the agency name, the public, and most specifically those with addictive diseases or disorders, would indeed benefit. However, other major constituencies also stand to benefit by these changes. Treatment and medical personnel, treatment evaluators and researchers may benefit by this symbolic reaffirmation of their ‘ownership’ of the alcohol and drug problems. However, the pharmaceutical and alcohol beverage industries will, for obvious marketing reasons, also be pleased with these name changes. As long as we view alcohol and drug problems exclusively in terms of diseases, addictions and disorders, the problems and the solutions will almost always be defined on an individual rather than on an environmental and community level [4]. This framing of alcohol and drugs issues lends itself almost inevitably to pharmacological solutions and to individual or small group treatment approaches. ‘Prevention efforts’ become programs to prevent addiction as opposed to problematic alcohol and drug use. We can thus ask, under the new names, where in these agencies' mandates will existing work on environmental strategies for limiting alcohol and drug use fit? Will environmental interventions that limit access and availability receive minimal or no attention, or will they be seen (as they already are to some degree) as peripheral to the overarching concerns of the agencies? While both pieces of proposed legislation say that these name changes do not reflect changes in each agency's mission, we cannot help but assume that those societal problems related to drug and alcohol use that do not lend themselves to biomedical explanations will not be a priority in either NIDA or NIAAA. This is a problematic outcome, intended or not. What is notable about all the potential reasons for the name changes discussed above is that they all appear to produce a ‘win–win’ situation for those who see drug and alcohol issues exclusively through the quite narrow lens of addiction and disease. The ‘losers’ in this tale will be those who adhere to a broader public health framework that encompasses individual issues as well as larger, social policy and environmental concerns. There is little doubt that both NIDA and NIAAA will continue to fund some research in these non-biomedical (currently termed ‘behavioral’) arenas. However, it is clear that priorities will rest with individually focused, biomedically based research agendas as opposed to a wider array of drug and alcohol concerns that relate to social policy [5,6]. What's in a name? Quite a bit! These name changes may better reflect the current identities of NIDA and NIAA, but it should be duly noted that they also reflect the political realities of keeping drug and alcohol issues individual-focused, keeping these issues biomedically based, and keeping NIDA and NIAAA consistent with the interests of two very powerful lobbying groups: the pharmaceutical and alcohol beverage industries.