A special panel at the National Institutes of Health (NIH) has recommended a formal study on the possibility of merging the National Institute on Drug Abuse (NIDA) with the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to form a National Institute on Addiction, but another putative merger — between the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) — has been dismissed as nothing more than a “rumor” by a SAMHSA official.
At an April 28-29 meeting on the NIH campus, the research agency's Scientific Management Review Board (SMRB) — formed in 2006 to examine how NIH should be optimally organized — recommended that the merger of NIDA and NIAAA be formally considered, under the rubric of “whether organizational and/or management change within NIH could further optimize research into substance use, abuse, and addiction research.”
“There seemed to be a reasonable case for putting this on the table for discussion,” said Lawrence A. Tabak, D.D.S., Ph.D., acting deputy director of NIH.
The SMRB members voted unanimously in favor of studying the merger despite the fact that every outside group and individual testifying live at the hearing opposed combining the two agencies. The topic is “not going away and the uncertainty is worse, I'm sure, than some definitive recommendation that we can make to who ever implements it,” reasoned SMRB member Arthur Rubenstein, M.D., dean of the University of Pennsylvania School of Medicine.
Tabak said that a study committee would be formed to consider the merger, with results expected back by the next full meeting of the SMRB, likely in October or November. Membership of the study committee has not yet been determined, however.
“One argument we heard loud and clear is that the science of addiction has converged across the agencies (NIDA and NIAAA) — the science has got a bit of commonality,” said Tabak. “On the other side, the are also some issues that NIAAA deals with that are not 'addictive' in nature, such as binge drinking.”
Tabak insisted that “in no way, shape or form should this be viewed as a cost-savings issue.”
The merger discussion “is going to be driven by the scientific opportunities, not by any hope that if we merge the agencies there will be cost-savings,” said Tabak, who said that the money saved through consolidating NIDA and NIAAA would be “very modest.”
Eric Nestler, a member of the NIDA National Advisory Council and chair of the department of neuroscience at the Mount Sinai School of Medicine, said that the concern that Congress might use the merger as an excuse to cut the combined NIDA/NIAAA budget is valid, but said that putting the two institutes together would make it possible for available funds to be devoted more efficiently and effectively toward research, public education, and other priorities.
“The basic biology of drug abuse and addiction are highly overlapping for all drugs of abuse,”said Nestler. “I can't think of a rationale why alcohol should be treated differently from all other drugs of abuse. Some point to alcohol's beneficial effects. But nicotine, opiates, stimulants, and marijuana all have beneficial effects under some circumstances.”
“There's huge confusion — not only among the lay public but among some treatment providers too — that alcohol is 'not a drug,'” said Nestler. “This is absurd, yet the current separation of alcohol into a separate institute provides credence to that notion.”
During the April hearings, representatives from the Research Society on Alcoholism (RSA) and the American Association for the Study of Liver Diseases were among those who spoke out against the merger. Appearing on behalf of RSA, Brown University professor Peter Monti, M.D., said that NIAAA's harm-reduction mission regarding alcohol use was fundamentally at odds with NIDA's focus on illegal drugs. “The advocates of change have not identified deficiencies in the present structure, and have not shown how proposed changes would improve performance without creating new problems,” said Monti.
Michael E. Charness, M.D., associate dean of the Department of Neurology at the Harvard Medical School's School of Medicine and a member of the NIAAA National Advisory Council, said that the arguments against a merger far outweigh the case for consolidation.
“The fundamental reason we think NIAAA should remain independent is that alcoholism is a sufficiently large public-health problem that a separate public-health agency is appropriate,” said Charness, pointing to a host of alcohol-related problems that have little to do with addiction per se, such as traffic fatalities and violent crime.
NIAAA's research also is more “nuanced” than NIDA's, contends Charness, because, “Alcohol is the only substance used by a significant number of Americans in a way that is healthy and may improve health. The challenge in studying alcohol is differentiating between healthy and harmful use.”
“There are no barriers to collaborative research projects between NIDA and NIAAA,” said Charness, who fears that a merger could result in a “loss of focus” on the unique problems related to alcohol addiction.
The National Association of Addiction Treatment Providers (NAATP) cited similar concerns in a statement opposing the merger.
“The fact that we have two separate institutes under NIH may be an administrative challenge, but it nevertheless serves as a firewall against the complete ignoring of alcohol as the number-one drug in this country,” according to NAATP. “Any merger of these two institutes would ultimately result in reduced resources being allocated to alcoholism, which is already receiving less than its fair share.”
However, Charles P. O'Brien, M.D., Ph.D., a professor in the department of psychiatry at the University of Pennsylvania, dismissed the argument about loss of funding and focus on alcohol issues as “not scientific, it's political.”
“There's no scientific rationale to have a separate institute for a single drug,” he said, noting, “Ethanol activates the reward system similar to opioids and other abused drugs using different mechanisms to act on the same structures. Thus addiction to alcohol is similar to other addictions. The DSM-IV symptoms are the same.”
O'Brien added that a majority of people with addictions use both alcohol and illicit drugs, but said that NIAAA limits grant funding to projects for “pure alcoholics, despite the reality of the clinical populations.”
The possibility of merging NIDA and NIAAA has been raised before. In 2003, the National Academy of Sciences recommended combining the two agencies, saying they “have overlapping missions and substantive foci and would work more effectively together than apart.” However, then-NIAAA director Enoch Gordis vehemently opposed the idea — as did the alcohol industry, which didn't like the association of alcohol with other drugs — and the merger discussion was dropped.
More recently, Congress has considered legislation that would change the names of NIDA and NIAAA to the National Institute on Diseases of Addiction and the National Institute on Alcohol Disorders and Health without merging the agencies. The legislation has broad support within the addiction community and the two agencies themselves, but has not advanced to a Congressional vote since its introduction in 2007.
SAMHSA/HRSA Merger: “No Discussions”
Another merger idea with a long history is the idea of combining SAMHSA and HRSA, its $6.85-billion sister agency within the Department of Health and Human Services (HHS). HRSA is primarily tasked with improving healthcare access for underserved populations and will be deeply involved in national healthcare reform.
“I don't think if would be the wisest thing to have SAMHSA subsumed under an agency with a much bigger agenda and assume that mental health and addiction would get the attention it deserves,” said Linda Rosenberg, MSW, president and CEO of the National Council of Community Behavioral Healthcare.
However, unlike the substantive discussions around a potential marriage between NIDA and NIAAA, SAMHSA spokesperson Mark Weber said that there have been “no discussions, none whatsoever” within HHS regarding a merger between SAMHSA and HRSA.
“I've been dealing with this rumor ever since I began working at SAMHSA 14 years ago,” Weber said, attributing the current round to the general atmosphere of change that comes with a new administration taking office.
That doesn't mean the idea of merging SAMHSA with another federal agency is dead, however. Former SAMHSA Administrator Charles Curie points out, for example, that SAMHSA is due for reauthorization by Congress — which has the power to tinker with the agency's structure as well as its mission. Curie recently penned an article detailing the case for a high-level, focused addiction and mental health agency in the federal government, acknowledging that the Obama administration's general interest in consolidation prompted his musings.
“If SAMHSA is merged or split up, then it is likely the three Centers in SAMHSA (the Center for Substance Abuse Treatment, the Center for Substance Abuse Prevention, and the Center for Mental Health Services) will be bureaus or divisions within bureaus, several layers down from having any access to the Secretary or White House,” Curie wrote in a recent blog posting. “We cannot underestimate the political access and credibility a [presidential appointee like the SAMHSA administrator] has in influencing policy and being in a position to at least be a direct participant in the debates. The personal relationships that can develop at the high policy levels many times make the difference as to whether a key element is included in policy or, at times, assuring a key element is not included in policy.”
Curie said that experience at the state level has shown that when state addiction agencies get merged with divisions of health, mental health, or elsewhere, attention on addiction-specific issues has been diluted and funding dissipated.
“When stigma is eradicated, when people are no longer held in institutions who can live in the community, when people with addictive disorders are no longer in and out of the criminal justice system, when financing for all treatment, rehab and prevention services is in place and when once and for all [addictions and mental illness] is considered consistently in all appropriate medical settings, then maybe it would be time to consider an integration of SAMHSA and state authorities into broader health agencies,” said Curie. “But until then, we need a strong SAMHSA.”