FY 2003 President's Budget Request for NIAAA - Acting Director's Statement Before the House and Senate Appropriations Subcommittees
Statement by Raynard S. Kington, M.D., Ph.D., Acting Director
National Institute on Alcohol Abuse and Alcoholism
National Institutes of Health
Department of Health and Human Services
I am pleased to present the President's budget request for the National Institute on Alcohol Abuse and Alcoholism (NIAAA) for Fiscal Year 2003, a sum of $418,487,000, which reflects an increase of $32,541,000 over the comparable Fiscal Year 2002 appropriation.
Alcohol-use disorders are among the most pervasive of the behaviorally manifested diseases. One-quarter of our Nation's urban hospital beds are occupied by patients with behavioral or physical problems stemming from alcohol use 1. Nearly 14 million adults meet diagnostic criteria for alcohol abuse or dependence 2. More than 18% of Americans experience alcohol abuse or dependence at some time during their lives 3.
The consequences of alcohol misuse cost society $185 billion every year, $47 billion more than the annual cost of smoking 3.Alcohol misuse affects every age group, from fetuses exposed to alcohol in the womb to the elderly, and it affects these age groups differently. It cuts across genders and minority groups, which also respond to alcohol's toxic effects differentially. All of these consequences are preventable.
ADVANCES IN PREVENTION RESEARCH
About half of the risk of alcoholism is genetic, but environmental factors -- peer pressure, culture, and community attitudes toward alcohol use, for example -- can attenuate that risk. NIAAA conducts research on neuroscience and on environmental and behavioral strategies designed to prevent abusive drinking and its consequences. Investigators develop and test interventions at the individual, community, and policy levels, in specific populations, age groups, and settings.
In the past year alone, we have made significant advances in these areas. For example, a community-wide approach that focused on reducing the supply of alcohol available to youths achieved significant reductions in drinking by children and adolescents. Another program that took a comprehensive, community-wide approach to reducing drinking resulted in significantly fewer violent assaults and car crashes.
Preventing children and adolescents from drinking is a major focus of NIAAA's research, which reveals that people who start drinking early in life are more likely than others to become alcoholic. Behavioral scientists found that this increase in risk may be the result of a common pathology that underlies a number of behavioral disorders.
Epidemiologic data identify disease trends that require preventive interventions. NIAAA epidemiologists discovered a change in racial and ethnic trends in mortality rates of cirrhosis, the primary cause of which is alcohol misuse, by examining improved methods of reporting on death certificates. White Hispanic males now show a higher rate of deaths from cirrhosis than do Black non-Hispanic males, who were thought to have higher rates.
A collaborative epidemiology project by the NIAAA, the National Institute on Drug Abuse, and the National Institute of Mental Health is examining the burden of co-occurring alcohol, drug, and mental disorders and associated disabilities, world-wide. This NIH-funded World Health Organization project also is developing standardized methods of collecting, analyzing, and reporting resource utilization and costs of these diseases and disabilities in diverse cultural settings.
ADVANCES IN NEUROSCIENCE AND GENETICS RESEARCH
Intricate biological mechanisms are the intermediaries of alcohol's physical actions in the nervous system, which manifest themselves as behaviors toward alcohol. NIAAA's neuroscience and genetics research have generated significant findings in this area during the past year.
For example, NIAAA-supported researchers established preliminary evidence that increasing production of specific proteins in the brain through genetics techniques may some day have utility in reducing drinking. Investigators also strengthened the evidence that specific genes, on chromosomes 1 and 7, are involved in alcoholism.
Through a collaboration with the National Institute of Mental Health, our intramural researchers found that a genetic variation in the serotonin neurotransmitter system plays a role in the sensitivity of nerve cells to the toxic effects of alcohol. NIAAA's intramural researchers also found further evidence that some of the same mechanisms in the nervous system that regulate appetite for food may play a role in risk of alcoholism.
By understanding the interplay of biological and environmental factors that contribute to alcohol-use disorders, we are better positioned to identify markers for people and populations at risk, and points for pharmaceutical and behavioral interventions.
ADVANCES IN RESEARCH RELATED TO THE TOXICITY OF ALCOHOL
The tissue-damaging effects of alcohol are not limited to the nervous system. Alcohol is a toxin, and it can injure any tissue in the body, with significant medical sequelae; for example, liver disease, some kinds of cancer, and brain damage.
Among the tissues most vulnerable to alcohol's toxicity are those of unborn fetuses, whose nervous systems are particularly susceptible to alcohol's effects. The most severe outcome is fetal alcohol syndrome (FAS), which results in a lifetime of neurobehavioral deficits and disabilities. For the first time, using living mammalian models, investigators have found that administering two different, naturally-occurring substances, choline and nerve-growth factors, can prevent alcohol-induced brain damage to the developing fetus. This is a significant finding, since no treatment for FAS exists, currently.
Intramural investigators discovered a potential explanation as to why chronic, heavy drinkers are completely unresponsive to treatment for hepatitis C virus infection. Hepatitis C infection is a prevalent disease, particularly among alcoholics, and the current treatment of choice is expensive. Investigators found that a protein produced in response to inflammation suppresses the biochemical pathway of the drug used for treatment and boosts activity of the genes whose protein products block the effects of the treatment drug.
RECENT INITIATIVES
During the five-year doubling of the NIH budget, NIAAA has established major new initiatives designed to advance research in each of the areas essential to its mission.
The Integrative Neuroscience Initiative on Alcoholism (INIA) is advancing our understanding of alcohol's actions in the nervous system. INIA integrates findings from multiple disciplines, from the genetic to the molecular and behavioral levels. Our intramural program also established an integrative neuroscience research program that combines cellular and molecular biology studies, considered the most powerful approach to the neural basis of alcohol abuse and alcoholism.
We have established several initiatives that are enabling us to capture the potential of new genetics technologies. On the molecular level, an initiative that focuses on the use of advanced instrumentation soon will enable our scientists to examine directly alcohol's interactions with the brain's neurotransmitter systems. In doing so, scientists can couple molecular events with behavioral events, in real time. This technology will provide essential information for our neuroscience research.
The initiatives described above are moving us closer to identifying optimal targets for therapeutic interventions. We have launched a major effort to develop medications that are more widely effective in treating alcohol abuse and alcoholism. Studies include tests designed to determine what types of patients respond favorably to currently available medications, and whether combining medications with specific behavioral therapies improves success rates.
The increases in the NIAAA budget also have enabled our intramural researchers to establish a liver biology program. Investigators in this program already have produced an important breakthrough; they have found that a specific protein of the immune system protects liver cells from the toxic effects of alcohol. NIAAA recently established two new initiatives on alcohol-related liver disease.
Because some minority groups and women appear to suffer disproportionately from alcohol-induced organ damage, such as liver disease, we have established an initiative to study disparities in alcohol toxicity. A recently established collaborative initiative focuses on FAS prevention. Prominent in these investigations are studies of specific minority groups, such as Native Americans and African Americans, who are disproportionately affected by FAS.
We also are stimulating research to develop biomarkers that detect early, alcohol-induced toxic changes in cells. Another initiative is to develop a biosensor that monitors alcohol levels continuously, to elucidate how drinking behaviors lead to organ damage.
Our prevention program is conducting studies to assess whether interventions that have proven to be successful in majority populations also are effective for specific minority groups. The program also encourages research that examines whether high-alcohol-content, low-cost beverages, such as malt liquor, disproportionately affect minorities.
Youth is a special focus of our prevention research, and the initiatives we have established over the past five years include a major effort to prevent alcohol problems among college students and another to prevent alcohol use among young adolescents. College drinking is more destructive than previously recognized, and the NIAAA Council's Task Force on College Drinking has brought together the college and research communities in an unprecedented national dialogue.
OUTREACH
Ultimately, NIAAA's research is intended to benefit the public's health. We attempt to achieve that goal in a number of ways. For example, our Research to Practice Initiative is a collaboration between NIAAA and the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment. Representatives from these two agencies meet with treatment providers and administrators to exchange information about current research findings and obstacles to providing treatment that practitioners encounter. The agencies then arrange for experts to serve temporary residencies in treatment programs, to ensure success.
Women of child-bearing age are the focus of the D.C. Initiative, a major effort to prevent FAS in the District of Columbia, which has one of the Nation's highest FAS rates. The project is designed to prevent drinking among African-American women who are pregnant or can become pregnant.
On April 9, after three years of investigations, the NIAAA Council's Task Force on College Drinking will release a report that includes recommendations for colleges, researchers, and communities. NIAAA will hold regional workshops that will involve 3,200 colleges, and will provide brochures for parents, college administrators, high-school guidance counselors, and community leaders. Papers and panel reports that served as the basis for the Task Force's report will be published in scientific journals; for example, a supplement to the April 2002 issue of the Journal of Studies on Alcohol, on college drinking, will include 18 review articles adapted from papers commissioned by the Task Force. An interactive NIAAA website serves as a resource for college personnel, researchers, and the public.
Alcohol Screening Day, a nationwide event sponsored by the NIAAA, enables people to receive free screening for alcohol problems and, if needed, referrals. This year's Screening Day will take place on April 11. We anticipate more than 2,000 participating sites, more than half of which will be college campuses.
We are reaching children and adolescents through our Leadership to Keep Children Alcohol-Free. Thirty-three State governors' spouses have joined this project to reduce drinking by young people; a crucial effort, given our research findings that early initiation of drinking portends higher risk of alcoholism later in life. We also are preparing public service announcements on underage drinking.
GOVERNMENT PERFORMANCE AND RESULTS ACT
The NIH budget request includes the performance information required by the Government Performance and Results Act (GPRA) Of 1993. Prominent in the performance data is NIH's third annual performance report, which compares our FY 2001 results to the goals in our FY 2001 performance plan. As performance trends on research outcomes emerge, the GPRA data will help NIH to identify strategies and objectives to continuously improve its programs.
FOOTNOTES
1 Moore, RD; Bone, LR; Geller, G; Mamon, JA; Stokes, EJ; Levine, DM Prevalence, detection, and treatment of alcoholism in hospitalized patients. Journal of the American Medical Association 261(3):403-407, 1989.
2 Grant, BF et al. Prevalence of DSM-IV alcohol abuse and dependence: US, 1992. Alcohol Health and Research World 18(3):243-248,1994.
3 Updated estimate by the Lewin Group, October 1999, of Harwood, H., et al. The Economic Costs of Alcohol and Drug Abuse in the US, 1992. National Institute on Drug Abuse, 1998. US Dept. of the Treasury. The Economic Costs of Smoking in the US and the Benefits of Comprehensive Tobacco Legislation, Washington, DC, 1998.
Prepared: April 2002