Reflections on the NIAAA/NIDA Merger, Part 2

Francis Collins

Part 1 here.

The current merger plan arose out of a request by the U.S. Congress, accompanying the FY2001 appropriations act, that NIH engage the National Academy of Sciences to conduct a study of “whether the current structure and organization of NIH are optimally configured for the scientific needs of the twenty-first century.”(21) The resulting 2003 NAS report sought to define principles via which to better organize and coordinate the research enterprises across NIH’s 27 separate institutes.(22) Collapsing NIAAA and NIDA into a single institute was one of two possible institute mergers suggested for further study in the NAS report.(23) NIH devoted still more energy to the question of optimal organizational structure later in the decade. NIH’s Scientific Management Review Board (SMRB) was created under the National Institutes of Health (NIH) Reform Act of 2006 “…to advise the NIH Director and other appropriate officials on the use of certain organizational authorities reaffirmed under the same act.”

Four working groups were constituted in the SMRB, including the Deliberating Organizational Change and Effectiveness (DOCE) Working Group and the Substance Use, Abuse, and Addiction (SUAA) Working Group.(24) In November, 2010, the SMRB published a report offering a series of guiding principles for organizational change at NIH, developed by the DOCE Working Group.(25) Also in November, 2010, and after considering the assessments and options offered by the SUAA Working Group, the full SMRB issued a report recommending the dissolution of NIAAA and NIDA, and the creation of a new institute “for substance use, abuse, and addiction-related research.”(26) NIH Director Francis S. Collins’ statement of November 18, 2010 recommended the creation of the merged institute and requested NIH Principal Deputy Director Lawrence A. Tabak and National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMSD) Director Stephen I. Katz to impanel an NIH task force to make recommendations as to which substance use, abuse, and addiction research programs should be imported into the new institute and which current NIAAA and NIDA programs should be relocated to other NIH entities.(27) On September 12, 2011, NIAAA and NIDA advisory councils held their first joint meeting, at which various aspects of merger were discussed.(28) In a presentation dated December 8, 2011, Tabak offered an “action timeline” for the new institute, projecting its launch in October, 2013 (FY2014).(29)

Along the way, NIAAA’s Advisory Council reacted sharply against the evolving merger plan. The Council passed an unopposed resolution (14 favored, 0 opposed, 1 abstained) in February, 2010, “strongly advising NIH against a reorganization that eliminates NIAAA as an independent institute.”(30) (NIDA’s Advisory Council, on the other hand, voted unanimously in favor of merger on March 1, 2010.)(31) The NIAAA Council’s resolution offered fully a dozen reasons for rejecting merger, each discussed in turn: (32)

  1. Alcohol is the only legal, socially acceptable, recreational drug; research on alcohol requires a different approach than research on drugs of abuse.
  2. Alcohol use disorders are different than [sic] drug addiction.
  3. Alcohol misuse disorders produce enormous medical, economic, and social costs.
  4. Much of the public health burden of alcohol use disorders is caused by the non-addictive use of alcohol.
  5. The existence of certain commonalities in the brain pathways that mediate the rewarding effects of alcohol and other drugs of abuse does not justify the merger of NIAAA and NIDA.
  6. Most individuals with alcohol use disorders do not abuse other drugs.
  7. Alcohol differs from other drugs of abuse in the degree to which heavy use damages the brain and other organs.
  8. A systems approach is essential to the study of alcohol’s beneficial and adverse effects.
  9. A merger will sacrifice the diverse approaches of two Institutes to addiction research.
  10. The loss of an independent NIAAA will damage NIH’s initiative on improving global health.
  11. The loss of an independent NIH Institute dedicated to alcohol research will discourage young scientists from entering the field.
  12. What we stand to lose through the merger of NIAAA and NIDA is far more than what we stand to gain. What we stand to gain through merger can be accomplished through alternative approaches, including enhanced collaboration between NIAAA and NIDA.
Senator Harrison Williams and Nancy Olson

Why merger now? And why did resistance by NIAAA and its constituencies fail to thwart merger this time? To an outside observer a number of observations might be suggested. First, it appears that the push for merger of NIAAA and NIDA started high up in the organizational food chain this time, beginning with the U.S. Congress’s 2001 request that NIH investigate its 27-entity structure with an eye toward timely reorganization. Given NIAAA’s and NIDA’s nominal similarities and a past history of questions about the advisability of merging the two institutes, it was perhaps to be expected that the resulting 2003 NAS report would recommend a study aimed at assessing a potential conflation. The SUAA Working Group and the SMRB, in turn, carried the merger plan farther forward – without troubling themselves, it might be noted, with an in-depth or historically informed examination of the sources of the two institutes’ longstanding past separateness.

It is impossible to say whether NIAAA’s old guard constituency might have been able to thwart the current merger plan. Whether the answer to that question is “yes” or “no,” the old guard – comprising Hughes, Wilson, Mann, Pike, Smithers, Olson, et al. – has of course left the scene. NIAAA and its early constituencies, moreover, have grown apart over the intervening years. Strains and fractures appeared in several forms. The controlled-drinking controversy, which emerged early in the institute’s history, raised the ire and disappointed the expectations of many early NIAAA supporters in the recovery movement.(33)  NIAAA Director Ernest P. Noble’s(34) rejection of “responsible drinking” as a prevention theme similarly drew the beverage industry’s displeasure.(35) The broadening of NIAAA’s problem domain over time thinned the alcoholism paradigm’s salience, thus also undermining constituency support over the long haul.(36) The block grant program, introduced in 1981, shifted NIAAA’s direct involvement in treatment to the state level, thus also further redirecting the institute’s main attentions toward research.(37) The creation of the Substance Abuse and Mental Health Services Administration (SAMHSA) in 1992, which coincided with NIAAA’s transfer to NIH, ended NIAAA’s service oriented roles and confined the institute’s mission solely to research. The inevitable professionalization implied by the turn toward research both brought new players, with new perspectives, into the institute’s orbit and estranged older players, with their recovery movement commitments. Distancing changes happened outside NIAAA as well. For example, Mrs. Marty Mann’s NCA, which in an earlier day might have been expected to vigorously oppose merger, was itself reconstituted and renamed the National Council on Alcoholism and Drug Dependence (NCADD) in 1990, thus undergoing its own alcohol-drug merger. When one looks around today at the roster of interest groups objecting to NIAAA’s conflation with NIDA, NIAAA’s cohort of grant receiving researchers appear to be complaining the loudest. This constituency group, of course, suffers from an obvious strategic weakness in making its influence felt.

The balkanization of the alcohol social arena over the course of NIAAA’s four-decades-long history resulted in a situation approximating what might be termed an experiment in “organizational hydroponics” – insofar as the developing organism in due course no longer drew benefit from the social soil that initially created it, nurtured it, and defended its institutional identity and separateness. A flywheel-like momentum maintained NIAAA’s independence for a time, even after its constituency had fragmented. But the flywheel ultimately ran down. It will be interesting to see how long a broad complement of alcohol-related research endeavors will endure as a recognizable preoccupation in the new tentatively titled “National Institute of Substance Use and Addiction Disorders.”

Alan Leshner

The merger of NIAAA and NIDA certainly represents a crossroads in the story of science’s relationship to alcohol- and drug-related public problems in the U.S. NIAAA’s alcohol science tradition is chiefly threatened (i) by NIDA’s significantly larger size and larger budget(38) and as well (ii) by NIDA’s commitment to a reductionist brain disease or brain pathways model — what historian David Courtwright has recently termed the “NIDA paradigm.”(39) The former threatens that NIAAA’s research preoccupations will simply be swallowed up into NIDA’s preoccupations; the latter threatens alcohol science’s longstanding commitment to research spanning a broad reach of disciplines and perspectives, including research not necessarily focused on alcohol-related problems and other phenomena not stemming from addiction. Neither NIAAA nor NIDA may be said to have produced a Salk or Sabin over the course of their respective organizational histories, and nor are they likely to in the future. Both the modern disease concept of alcoholism and the brain disease perspective on drug addiction began life as medicalizing and destigmatizing metaphors that in turn became field-defining master concepts and “boundary objects.”(40) Dwight Anderson, in a seminal 1942 paper, initially proposed the disease conception of alcoholism as an adept symbolic device for differentiating mainstream, post-Repeal alcohol science from an earlier tradition of discredited temperance movement science.(41) Alan I. Leshner recently suggested that the brain disease appellation became known as “NIDA’s mantra” during his tenure as institute director.(42) Leshner did not claim credit for “inventing” the brain disease metaphor.(43) “But it did resonate with me,” he wrote, “and I saw its powerful potential to change the way the public sees addiction and, perhaps, to help reduce the stigma associated with it.” But, and unlike polio, with its relatively fixed biological character, the social dimensions of alcohol and drug problems are subject to broad changes and transformations over historical time. The long historical view of Courtwright’s Dark Paradise: A History of Opiate Addiction in America, for example, illustrated this transformative dynamic respecting illicit drugs;(44) over a shorter historical period, my essay on transformations in U.S. conceptions of its alcohol problem since Repeal illustrated a similar dynamic potential for alcohol-related problems.(45)

Changes in problem focuses and meanings over time, in turn, highlight the differences between (i) a scientific problem arena defined by the concerns of the wider society versus (ii) a scientific problem arena defined by the intrinsic development of a theoretical and empirical scientific tradition. The manifest aim of alcohol and drug science is to increase knowledge and improve responses in these problem domains. Yet the alcohol and drug realms also harbor important latent functions for science as well. NIAAA’s existence, for example, may be said to reduce potential social frictions and conflict over alcohol – of the kind, say, that gave rise to the temperance movement in the 19th century – by in effect referring popular anxieties to a research process. The presence of an alcohol research tradition also fosters an expertise-based scientific elite, which in turn exerts a measure of scientific “ownership” of the problem domain and exercises commensurate authority with respect to public policy or therapeutic issues.(46) The RFP(47) process provides a medium for responsiveness by NIAAA to the changing focuses of the American public’s alcohol-problems concerns. Opinions will differ, of course, on the value or disvalue attached to such latent functions. Whatever that judgment may be, the melding of NIAAA and NIDA may well weaken both institutes’ abilities to serve their respective complements of latent functions, functions we as a nation have grown accustomed to having fulfilled since NIAAA and NIDA appeared on the scene in the early 1970s. Time, of course, will tell.

Acknowledgment:

Thanks are owed Kaye Fillmore, William L. White, and Loran Archer for comments on an earlier draft. I also thank Marc Schuckit for suggesting I should write something on the merger.

Notes:

(21) Quoted in NAS (2003), ibid., p. 22.

(22) National Academy of Science, Enhancing the Vitality of the National Institutes of Health: Organizational Change to Meet New Challenges, Washington, D.C.: National Academies Press, 2003.

(23) The other suggested merger, the National Institute of General Medical Sciences with the National Human Genome Research Institute.

(24) The other two groups: the Translational Medicine and Therapeutics (TMAT) Working Group and the Intramural Research Program (IRP) Working Group. On the activities of these four groups, see http://smrb.od.nih.gov/category/working_groups, accessed 3/5/2012.

(25) Scientific Management Review Board, Deliberating Organizational Change and Effectiveness, November, 2010.

(26) Scientific Management Review Board, Report on Substance Use, Abuse, and Addiction at NIH, November, 2010, available at: http://smrb.od.nih.gov/Sept2010_SUAA_Working_Group.pdf, accessed 3/1/2012.

(27) See http://www.nih.gov/news/health/nov2010/od-18.htm, accessed 3/1/2012.

(28) See http://www.niaaa.nih.gov/about-niaaa/our-work/advisory-council/agenda-minutes/advisory-council-meeting-minutes/first-joint, accessed 3/5/2012.

(29) See http://acd.od.nih.gov/reports/SUAAandNCRRTaskForceUpdate_122011.pdf, accessed 3/5/2012.

(30) Scientific Management Review Board, Report on Substance Use, Abuse, and Addiction at NIH, November, 2010, p. 12.

(31) Loc. cit.

(32) Ibid., Appendix B, pp. 32-36.

(33) See Ron Roizen, [Comment on the ‘Rand Report’], Journal of Studies on Alcohol 38:170-178, 1977 and Ron Roizen, “The Great Controlled-Drinking Controversy,” pp. 245-279 in Marc Galanter (ed.), Recent Developments in Alcoholism (vol. 5), New York: Plenum Press, 1987.

(34) Noble’s tenure as director, February, 1976 to April, 1979.

(35) See Robin Room, “Former NIAAA Directors Look Back: Policymakers on the Role of Research,” The Drinking and Drug Practices Surveyor, 19:38-42, (April) 1984, see p. 42.

(36) On “mission creep” in NIAAA’s early history, see the perceptive analysis in Ch. 10 of Robin Gerald Walden Room, Governing Images of Alcohol and Drug Problems: The Structure, Sources, and Sequels of Conceptualizations of Intractable Problems, Ph.D. dissertation, sociology department, University of California, Berkeley, 1978.

(37) The Omnibus Budget Reconciliation Act of 1981 (P.L. 97-35) transferred responsibility and funding for alcoholism treatment services to the states. The Alcohol, Drug Abuse, and Mental Health Services block grant program was administered by ADAMHA.

(38) In 2011, NIH’s funding level for “Alcoholism,” $452M; for “Drug Abuse” at NIDA, $1,051M [See NIH, “Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC),” February 13, 2012, at http://report.nih.gov/rcdc/categories/], accessed 3/6/2012.

(39) David Courtwright, “Addiction and the Science of History,” Addiction 107:486-492, 2012.

(40) For “boundary objects,” see Susan Leigh Star and James R.Griesemer, “Institutional Ecology, ‘Translations’ and Boundary Objects: Amateurs and Professionals in Berkeley’s Museum of Vertebrate Zoology, 1907-1939,” Social Studies of Science 19:387-420, 1989.

(41) Dwight Anderson, “Alcohol and Public Opinion,” Quarterly Journal of Studies on Alcohol 3:376-392, 1942.

(42) Alan I. Leshner, “NIDA in the 90s: 1994-2001,” Drug and Alcohol Dependence 107:99–101, 2010.

(43) He learned the concept, Leshner wrote, from Charles O’Brien, Ibid., p. 100.

(44) David T. Courtwright, Dark Paradise: A History of Opiate Addiction in America, Cambridge, Massachusetts: Harvard University Press, 2001.

(45) Roizen, Ibid., 1994.

(46) See Gusfield, Joseph R., Contested Meanings: The Construction of Alcohol Problems, Madison: University of Wisconsin Press, 1996, pp. 249-250.

(47) “Request for Proposal.”

4 thoughts on “Reflections on the NIAAA/NIDA Merger, Part 2

  1. How is government support for research on alcohol and other drugs organized elsewhere? For instance, UK, France, Germany?

  2. Nice piece, Ron.
    Lorrraine Midanik’s book (The Biomedicalization of Alcohol Studies: Ideological Shifts & Institutional Challenges, Aldine Transaction, 2006) shows how much more biologised NIAAA became over its history, and I remember noting at NIAAA-sponsored meetings in the late 1980s and early 1990s that, prestigiouis as the liver-and-lights doctors might be elesewhere, it was the brain disease folk pursing the will-of-the-wisp of a biologisation of addiction with MRI scans, etc. who had the higher prestige in an NIAAA context. At NIDA, it’s in particular the psychopharmacologists who have long held sway, so it was easy for the brain disease trope to be even stronger. On the other hand, the fact that NIDA’s drug consumers were fewer and more marginalised always left more room for anthropologists and qualitative sociologists there. It’s hard to judge whether alcohol will propser or decline in a combined environment, although the initial framing is bound to be dominated by the much-more-richly-funded NIDA.
    As for David Fahey’s question: alcohol- or drug- or alcohol-and-drug-specific nationl research granting agencies are very rare. Mostly elsewhere, the “invetsigator-initiated” research has to make its way through general biomedical or scientific research granting bodies — in Australia, for instance, the NHMRC for the first, and the ARC for the second. In Canada, alcohol and drug research is funded through a federal mental health grants body. In Britain, mostly through the Medical Research Council, a thin trickle I think through the Economic and Social Research Council. In Swewden, in addition to the main research council (Vetenskapsraadet) there is a practice-social-problems research council which has been where most of the grants for alcohol and drugs come from.
    Neither alcohol nor drugs get any respect from general academic disciplines or professions, whether medicine, sociology, biology or whatever, so the result of having Science grants funded through a general Science or Medicine council is fairly universally that neither alcohol nor drugs get much funding. The Swedish solution of a practical-problems stream goes some way toward solving this. But a large amount of drug and alcohol research in most places is funded through other mechanisms. Specialised research institutes, either on alcohol and drugs or both (mostly these days both) may be set up with specific government or core funding (Australia, Norway, British Columbia, Switzerland, Netherlands), or may be organised within a larger mental health or health institutions (CAMH in Ontario, the Karolinska in Sweden, the NorthWest Observation Centre in UK National Health). As the realities of the predeominane of alcohol problems in the epidemiology and burden-of-disease gradually sink into the political system, I think that the balance of emphasis in research has been shifting to more alcohol and less drugs in a number of places in the last decade or so. But alcohol industry interests have been fairly effective in resisting this happening.

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