FY 2008 President's Budget Request for NIAAA - Director's Statement Before the House Subcommittee on Labor-HHS Appropriations
Statement by Ting-Kai Li, M.D., Director
National Institute on Alcohol Abuse and Alcoholism
National Institutes of Health
Department of Health and Human Services
March 26, 2007
Mr. Chairman and Members of the Committee, thank you for giving me the opportunity to update you on the activities of the National Institute on Alcohol Abuse and Alcoholism. I am Ting-Kai Li, Director of NIAAA, the lead agency for research on the health effects of alcohol. I am pleased to join my distinguished colleagues from NIH and SAMHSA. Those of us addressing you today have a fundamental mission – to reduce the substantial burden of illness caused by mental disorders, and drug and alcohol abuse. Because these disorders (be they fetal alcohol syndrome, alcohol dependence, autism or drug addiction) tend to manifest early in life, they produce lifelong disability, derailing individual potentials, creating tremendous burdens for families and significant cost to society. In fact, excessive alcohol use alone costs the United States an estimated $185 billion annually . [1] The FY 2008 budget for NIAAA includes $436,505,000.
The Centers for Disease Control and Prevention rank alcohol as the third leading cause of preventable death in the United States and the World Health Report also ranks alcohol as the third leading risk factor for disease in developed countries. While fetal alcohol syndrome occurs at lower frequency than other disorders, the cost per affected individual is much higher than for many diseases that present later in life. Underage drinking also has a high burden of illness associated with it. Analyses of NIAAA’s National Epidemiologic Survey on Alcohol-Related Conditions, NESARC(which also received funding support from NIDA), showed that 40% of individuals who reported drinking before the age of 15 also described their drinking behavior in a way consistent with a diagnosis of alcohol dependence. In fact, the highest prevalence of alcohol dependence in the United States occurs in the 18-24 year old age group. In addition, binge-drinking, i.e. drinking five or more drinks per occasion, which is popular with today’s young people results in acute consequences such as traffic fatalities, alcohol poisoning, suicides, homicides and drownings. Non-fatal, but potentially life altering consequences such as sexual assault and violence also result.
Today I would like to give you an overview of how NIAAA is working to reduce the burden of illness due to alcohol. First, I will describe some of our prevention efforts, including joint efforts by SAMHSA and NIAAA on prevention of underage drinking. Second, I will describe new findings that can be used to improve the diagnosis of alcohol problems. Finally I will describe our efforts to personalize medicine.
PREVENTION
As part of a comprehensive strategy for reducing the burden of illness due to alcohol-related problems NIAAA has a strong research and prevention focus on pregnant women, children and adolescents. Exposure of the developing embryo/fetus can result in alcohol-induced birth defects, t he most severe of which is fetal alcohol syndrome (FAS). FAS is a devastating developmental disorder characterized by abnormalities of the head and face, growth retardation, and nervous system impairments that may include mental retardation. NIAAA is supporting research, to develop effective outreach to pregnant women, and approaches to intervene to protect injury in the affected fetus and ameliorate deficits in the affected child.
The period from birth to age 10 is a remarkable period of development and although relatively few children in this age group are drinking alcohol, much is happening that will influence their path toward or away from early alcohol use. A number of the factors that put children at risk for early alcohol use are common to a wide range of adverse behavioral outcomes such as delinquency and other substance use. Even as young as preschool age, such children often have difficulties with impulse control and exhibit unusually high levels of aggression. NIAAA is interested in determining what common factors underlie these behaviors in order to improve existing interventions for future alcohol use and other problems.
NIAAA is investing in a number of research projects to determine the short and long-term effects of alcohol on the developing brain and the degree to which the brain can recover from these insults. One of these is in collaboration with NIMH intramural scientists. In addition, given the difference in patterns of alcohol use between boys and girls as they move through adolescence, NIAAA is investigating the interplay between hormones, brain development and alcohol use. Finally, in an attempt to prevent and reduce the acute and chronic consequences of underage drinking, the Institute has been working closely with SAMHSA to provide the scientific foundation for the work of the Interagency Coordinating Committee for the Prevention of Underage Drinking and for the forthcoming Surgeon General’s Call to Action on underage drinking.
DIAGNOSIS
It is important to identify individuals who are at risk for adverse alcohol-related health outcomes because of their drinking behavior. Diagnostic criteria for Alcohol Abuse currently rely on an individual experiencing a combination of problems related to either the social or legal systems, such as being cited for Driving While Intoxicated (DWI) or problems with a spouse or family member. Diagnostic criteria for Alcohol Dependence rely on the identification of a set of physiological changes in the body such as the development of tolerance to increased amounts of alcohol or the experience of withdrawal symptoms. Unfortunately, both sets of criteria require the individual to have experienced negative consequences from drinking prior to diagnosis of a problem.
Today I report recent findings from analyses of NESARC that will improve the diagnosis of alcohol dependence. Whereas alcohol abuse and dependence have long been treated as independent disorders, new findings indicate that they represent a continuum of severity of alcohol use problems. Further, such analyses are showing how new criteria based on the quantity and frequency of alcohol use can improve diagnosis when used in combination with existing criteria. In much the same way that numerical measurements of blood pressure, cholesterol and triglycerides relate to relative risk for cardiovascular disease, the best indicators of developing alcohol problems are measures of an individual’s pattern of drinking. More specifically, recent findings link data on the frequency of binge drinking and the maximum number of drinks consumed, to risk for organ damage. The science is now available to determine appropriate cutoff points to define harmful use of alcohol. Just as physicians treat high cholesterol before an individual experiences a heart attack, they will be able to intervene before an individual loses control of his drinking or experiences withdrawal.
Information on how quantity and frequency can be used in diagnosis and follow-up care is an integral part of NIAAA’s recently updated Clinician’s Guide which we have distributed and promoted widely with the help of the American Medical Association and other partners. NIAAA is currently developing curriculum for social workers and for nurses based on these findings.
MEDICATIONS DEVELOPMENT
NIAAA is supporting research on a number of fronts to improve treatment options for alcohol dependence. To identify the next generation of medications, NIAAA is testing agents that target different neurobiological substrates of alcohol dependence. Studies in animal models have produced additional targets for human studies that are now underway or planned for the near term. For example, the anxiety that people with alcohol dependence experience when they stop drinking is a powerful motivator for them to resume. In addition, stress can trigger relapse to heavy drinking after a period of abstinence. Therefore, medications being tested include those that target molecules involved in biological pathways that mediate stress and anxiety such as corticotrophin-releasing factor, neuropeptide Y, and nociceptin receptors. Also being tested are medications that target the metabolism of endocannabinoids, naturally occurring substances in the brain that act on the same receptors as the active ingredients of marijuana and have been shown to play a role in regulating appetite for alcohol.
TREATMENT RESEARCH
In addition to developing new medications and determining the genetic and environmental factors that contribute to the initiation and escalation of drinking, it is equally important to understand how individuals change harmful drinking patterns. The majority of young adults will change harmful drinking behaviors without treatment. For adults who seek treatment, generally in the period of midlife, data from clinical trials raise the question of whether treatment itself is responsible for the improvement in drinking behavior or if the positive motivation to seek treatment actually underlies a substantial part of the treatment success. Further, a substantial amount of evidence has shown that a wide array of available therapeutic approaches yields strikingly similar results, suggesting that it is not the particular technique that is responsible for change but other unspecified factors. As a result, NIAAA treatment research is putting more emphasis on addressing the common mechanisms of change across all behavioral treatments, identifying the factors that contribute to change away from harmful behavior and lead to a sustained recovery. Findings from this research will improve clinical practice both by identifying key aspects of therapy that must be present for maximum effect and by facilitating the delivery of more finely tuned individualized treatment.
However, we can only achieve success if those individuals who are in need of treatment have access to it. Coverage of mental health and drug and alcohol addiction services would allow a greater proportion of afflicted individuals to receive the care they need to recover. In addition, we need to be particularly mindful of health disparities. A recent study suggests that Hispanics and Blacks with higher levels of problem severity were less likely to have used treatment services than Whites with problems of comparable severity.
Taken together, these strategies of improved prevention, better diagnosis and personalized treatment are expected to reduce the burden of alcohol-related illnesses over the long term and lead to better health outcomes for the nearly 18 million American adults who, in any year, struggle with alcohol dependence and abuse[ 2].
Ting-Kai Li, M.D., Director, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Department of Health and Human Services
Dr. Ting-Kai (T. K.) Li was appointed to the position of the Director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in November 2002. The NIAAA is a component of the National Institutes of Health (NIH) within the U.S. Department of Health and Human Services.
Throughout his distinguished research career, Dr. Li has been at the center of advances that have transformed both the way alcoholism is understood and the means of investigating alcohol's effects on the body and brain. A major focus of Dr. Li's research has been to characterize the structure and dynamics of the multiple genetic variants of alcohol dehydrogenase (ADH), the enzyme that catalyzes the first step in the metabolism of ethanol and the differences among individuals in the physiology of these enzymes. Dr. Li also pioneered the development of animal models in which marked differences in the level of voluntary alcohol consumption could be observed, paralleling the same inborn variation seen in human behavior. The development of these animal lines helped cement the once radical notion that alcohol consumption behavior was genetically influenced.
Born in Nanjing, China, Dr. Li earned his undergraduate degree from NorthwesternUniversity, his M.D. from HarvardUniversity, and completed his residency training at PeterBentBrighamHospital in Boston, where he was named chief medical resident in 1965. He also conducted research at the Nobel Medical Research and Karolinska Institutes in Stockholm and served as deputy director of the department of biochemistry within the Walter Reed Army Institute of Research. Dr. Li joined the faculty at IndianaUniversity as professor of medicine and biochemistry in 1971. He subsequently was named the school's John B. Hickam Professor of Medicine and Professor of Biochemistry and later Distinguished Professor of Medicine. In 1985 he became director of the Indiana Alcohol Research Center (IARC) at the Indiana University School of Medicine, where he also was the Associate Dean for Research.
Dr. Li is the author of more than 400 journal articles and book chapters, has been invited to deliver many major lectureships in countries across the world, and is the recipient of numerous prestigious awards for his scientific accomplishments, including the Jellinek Award, the James B. Isaacson Award for Research in Chemical Dependency Diseases, and the R. Brinkley Smithers Distinguished Science Award.
Dr. Li has also served in many prominent leadership and advisory positions, including past President of the Research Society on Alcoholism (RSA), and as a member of the National Advisory Council on Alcohol Abuse and Alcoholism and the Advisory Committee to the Director, NIH. Dr. Li was elected to membership in the Institute of Medicine of the National Academy of Sciences in 1999 and is also an honorary fellow of the United Kingdom's Society for the Study of Addiction.
Department of Health and Human Services
Office of Budget
Richard J. Turman
Mr. Turman is the Deputy Assistant Secretary for Budget, HHS. He joined federal service as a Presidential Management Intern in 1987 at the Office of Management and Budget, where he worked as a Budget Examiner and later as a Branch Chief. He has worked as a Legislative Assistant in the Senate, as the Director of Federal Relations for an association of research universities, and as the Associate Director for Budget of the National Institutes of Health. He received a Bachelor’s Degree from the University of California, Santa Cruz, and a Masters in Public Policy from the University of California, Berkeley.
[ 1] Harwood, H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods and Data (2000) . https://pubs.niaaa.nih.gov/publications/economic-2000/
[ 2] Grant BF, DawsonDA, Stinson FS, Chou SP, Dufour MC, and Pickering RP. Drug and Alcohol Dependence 2004. 74: 223-234.
Updated: September 2009