For several months, the advocacy community for addiction prevention and treatment has followed the review process that is examining whether a merger between the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) is in the best interests of research and the public. Both institutes are part of the National Institutes of Health, located in Bethesda, MD.
The task of investigating whether a merger is in the best interest of science and the NIH falls to the Scientific Management Review Board (SMRB.) Not less than once each seven years, the Board must provide advice to the NIH Director and other appropriate agency officials, through a report to the NIH Director, regarding the use of organizational authorities reaffirmed by the NIH Reform Act of 2006. A working group of the Board, the Substance Use, Abuse, and Addiction workgroup, has been charged with investigating the plausibility of a merger. The working group thus far has been soliciting comments from experts in addiction research, from the public, and experts in NIH administration. Their work to date has been transparent and open.
The two institutes differ greatly in size. The budget of NIDA is more than double that of the NIAAA. NIDA’s budget for FY 2008 was just over $1 billion, compared to $438 million for NIAAA. This is indicative of Congress- and the publics- view of the disease of addiction. Most consider addiction to illicit drugs to be a bigger danger and threat to the public health than alcohol. The numbers, however, tell a different story. Alcohol use and abuse causes more physical and economic damage each year than all other substance use and abuse combined.
Some in the addiction advocacy community have “taken sides” on the issue, either for or against the proposed merger. Those in favor believe it is more efficient approach to research. Those opposed to the merger fear that funding for research could end up being decreased. Some opponents of the merger claim the study of alcohol abuse deserves its own institute, since it is legal to purchase and is not an illicit drug. This is a curious argument, since NIDA also studies the abuse of legal substances, such as tobacco, and the abuse of both prescription and over-the-counter medications. Others claim that the underlying principles of addiction, regardless of what substance to, are similar enough that only one institute should administer research on the subject, just as there is only one cancer institute and one institute for heart disease.
The advocacy community has been clear that a top priority be, at a minimum, maintaining a status quo for the funding of addiction research. Yet many have assumed that if the merger does take place, research (especially for alcoholism and alcohol use) will suffer as a result, since funding for one institute is cheaper than funding for two. Opponents of the merger believe that research on alcohol use will be impacted to an even higher degree, that the bigger institute will trump the smaller. The assumption is that alcoholism research will suffer, since there is the appearance of a smaller institute being absorbed into a larger one. However, nothing produced by SMRB has given this line of thought any credence. If the two institutes are merged, this will create one new institute, not the absorption of one into the other.
Critics of the merger have also recommended that a better alternative is for the two institutes to simply collaborate. However, the two institutes collaborate frequently. Projects funded in FY 2008 alone include: NIDA assisting NIAAA in performing a multicenter trial for quetiapine for the treatment of alcohol dependence through the Veterans Administration Cooperative Study Program; both collaborating along with NIMH on Strategic Planning for Domestic and International NeuroAIDS Research; both collaborating with NIDDK on an Action Plan for liver disease research: and both institutes worked together on an NIH Roadmap Pilot to establish the groundwork for a unified science of behavior change that capitalizes on both the emerging basic science and the progress already made in the design of behavioral interventions in specific disease areas.
One of the most outspoken critics of the merger has been the Research Society on Alcoholism. Both their president, Sara Jo Nixon, and their executive director, Dr. Raymon Anton, have testified before the SMRB, as have several of their members. Their former president, Dr. Peter Monti, expressed his concerns in a written statement to the SMRB in April, citing the importance of research on issues such as liver disease and fetal alcohol syndrome. He also cited the importance of NIAAA as a stand-alone institute that fostered interest in the field of alcoholism research. “Prior to the creation of NIAAA, the field of alcohol research had labored in a climate of public denial that alcoholism was even a problem,” he wrote. ”There was a widespread lack of attention among health professionals to the need for finding ways to treat and prevent alcoholism and alcohol-related illness. NIAAA’s emergence as an Institute brought the importance of alcohol problems to national attention. It also signaled to researchers outside the community that alcohol research was an important area of scientific inquiry and thus attracted the best and brightest investigators to the field.”
The largest organization to openly support the merger is the American Psychiatric Association. In a recent letter to the SMRB, signed by their CEO and medical director Dr. James Scully, wrote, “Given commonalities in areas such as biology, culture, and frequent use of multiple substances, there are logical reasons to have a single Institute devoted to substance use disorders. The field of addictions research and medicine – and ultimately patients – would be well served if there is greater dialogue and work between current research groups,”
He added, “The science of addiction research, the potential for improved treatments, and the promise for improving the lives of patients and their families, leads the APA to support a proposed merger between NIAAA and NIDA.” At a recent meeting of the SMRB, APA submitted oral testimony, by Dr. Darrel Regier, their Director of Research.
Even if the SMRB recommends a merger, several complex steps remain in the process. Their recommendation will be sent to NIH director Dr. Francis Collins. Dr. Collins may then decide to accept or ignore the recommendation. If he chooses to ignore the recommendation, he must explain his reasons in writing. If he accepts the recommendation, he will notify Congress via the Office of the HHS Secretary. Congress then may refute the recommendation, or accept it by taking no action. This procedure is guided by statute, the aforementioned NIH Reform Act of 2006, which is also responsible for the creation of the SMRB. The SMRB, it should be noted, has more than two options (merge or leave status quo.) They can recommend any number of actions, again for Director Collins to accept or deny.
By law, the NIH may contain no more than 27 institutes, the number that currently exists. Some have speculated that the merger is being investigated so that another institute may be created. However, such an idea is no more than conjecture at this point, and no NIH or government officials have mentioned this as a possible motive for the merger.
Author’s note: Andrew Kessler currently represents the International Certification and Reciprocity Consortium, which is on the record as a supporter of the merger.