FY 2009 President's Budget Request for NIAAA - Director's Statement before the House Subcommittee on Labor-HHS Appropriations, March 5, 2008

Wednesday, March 5, 2008

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

Today I would like to present our vision for medicine in the future as it relates to alcohol-related health issues and how we intend to achieve this vision. Through translation of NIAAA supported research findings, we have an unparalleled opportunity to significantly reduce the burden of illness due to alcohol-related problems. Our vision is that research on the health effects of alcohol will reduce the burden of illness attributable to excessive alcohol consumption thereby enhancing the well-being of individuals at risk, their families, and society-at-large.

CURRENT SCOPE OF THE PROBLEM AND RESEARCH

According to the Centers for Disease Control and Prevention, alcohol is the third leading cause of preventable death in the U.S. Even more importantly from a public health perspective, alcohol misuse negatively affects the quality of life for millions of Americans. The World Health Organization ranks alcohol as one of the top ten causes of Disability Adjusted Life Years (DALYs) in the United States. Alcohol also contributes to a number of the other leading causes of DALYs, e.g., motor vehicle accidents, brain and liver disease, and cancer. Alcohol problems cost the U.S. an estimated $185 billion annually, with almost half the cost resulting from lost productivity due to alcohol-related disabilities. According to NIAAA’s National Epidemiologic Survey on Alcohol and Related Conditions, over 18 million people ages 18 and older suffer from alcohol abuse or dependence and only 7 percent of them receive any form of treatment. Furthermore, heavy drinkers who do not have dependence but are nevertheless at risk for adverse health and psychosocial outcomes are seldom identified. The consequences of alcohol misuse can affect both drinkers and those around them at all stages of life, from damage due to alcohol exposure of the developing embryo, to injuries, to tissue and organ damage resulting from chronic, heavy alcohol use. Therefore for NIAAA to achieve its goal of reducing the heavy burden of illness from alcohol misuse, the Institute’s research focus must be broader than simply reducing alcohol-related mortality; it must encompassreducing the risk for all of the aforementioned negative alcohol-related outcomes at all stages of life.

Research supported by NIAAA in the past 5 years has reframed our understanding of alcohol dependence in several ways by demonstrating that: 1) it is a developmental disorder that often has its roots in childhood and adolescence; 2) the highest prevalence of alcohol dependence in the U.S. general population occurs in 18-24 year olds; 3) there is substantial variation in the severity and chronicity of dependence among individuals; and 4) a large percentage of individuals with alcohol dependence are functional, and some are even leaders in society, and therefore go largely unnoticed by the healthcare system.

These findings underscore the opportunity to: 1) be able to better predict individuals at risk for future dependence by understanding the complex interplay between genetic, environmental, and developmental factors; 2) preempt future problems by focusing research on prevention efforts on children and adolescents as well as screening and guidance to people of all ages about how drinking patterns, especially binge drinking, relate to risks for adverse health outcomes; 3) conduct research to develop treatment options that arepersonalized to individual needs and lifestyle; and 4) engage individuals, communities, and professional groups to be actively participatoryin shaping the future of healthcare as it relates to alcohol misuse.

OUTLOOK FOR THE FUTURE

Reducing the burden of illness associated with the misuse of alcohol requires that individuals and their health care providers understand the risks associated with different drinking patterns. NIAAA continues to support research to refine this knowledge which will lead to the dissemination of better advice regarding alcohol use by healthcare providers and informed decision making by the public.

Current research indicates that health care providers should routinely screen for alcohol-related risk and provide brief interventions (including referral for treatment when appropriate). NIAAA will continue to support research to develop research-based tools and approaches for delivery of screening and brief interventions applicable to a wide variety of health care settings including primary care physicians, mental health care providers, college health centers, emergency departments, trauma centers, and counselors. The combination of early identification of risk for alcohol problems and brief counseling to encourage behavior change will reduce the number of individuals who develop alcohol dependence. Those who have already developed alcohol dependence will benefit from NIAAA’s research focusing on the development of new treatments including behavioral therapies and medications that will shorten the duration, number, and severity of episodes of dependence and prevent, for most, the development of chronic, relapsing dependence. These treatment approaches will generally be appropriate for delivery by primary care and general mental health care clinicians, and will consist of brief counseling and medications. Studies suggest that as a result of these types of intervention, most people with mild to moderate dependence will recover.

For those with more severe and/or relapsing dependence, NIAAA research is focusing on new behavioral therapies and pharmacotherapy as these more complex patients require multi-faceted, personalized addiction services that may include medications, counseling, psychotherapy, and case management. These patients often have other health (infectious diseases, mental illness, and liver disease) and psychosocial (family, marital, and workplace) problems that also factor into their treatment needs. NIAAA-supported research will inform treatment of these individuals with multiple health issues. We envision the result of this collective effort will be a substantial reduction in the public health burden of heavy drinking and alcohol use disorders.

Ensuring that appropriate research-based guidance about alcohol use for special populations, including pregnant women, are available will result in a dramatic reduction in the incidence of fetal alcohol spectrum disorders, the most severe forms of which produce lifelong disability. NIAAA research will continue to inform this guidance, including information about the risks of alcohol exposure to the developing embryo and fetus, and will make it accessible to primary health care providers and obstetricians. For pregnant women who drink despite the best advice, research is focused on developing nutritional and/or pharmacological agents that may lessen the negative effects of alcohol exposure.

Biomarkers, stemming from NIAAA-supported genetic and epigenetics research, will be available that: 1) predict individual risk for future alcohol dependence; 2) assess progression of at risk drinking through dependence; and 3) track damage to tissue and organs. These tools will enhance the ability of health care providers to offer guidance to patients about their drinking patterns and determine appropriate health care based on individual risk factors. A repertoire of medications will facilitate treatment tailored to the needs of the patient. Personalized treatment including medications and behavioral therapies will be based on individual genetic make-up, desired drinking outcomes, attention to co-occuring disorders, ease of compliance, and other factors.

MOVING FORWARD

NIAAA supported biomedical and behavioral research is well-positioned to make a major contribution to realizing the vision outlined above. Ongoing studies, as well as new initiatives, will provide the scientific knowledge and tools, especially biomarkers and epigenetic information, to improve our ability to predict individuals at increased risk for alcohol dependence and other alcohol-related problems, preempt the harm from alcohol misuse, and provide personalized treatment.

We believe that the integration of routine alcohol screening, and where appropriate, brief intervention and/or referral to specialty treatment into primary health care for all ages is central to reducing consequences of alcohol misuse. NIAAA will continue to develop teaching and training tools to increase the usage of A Clinician’s Guide: Helping Patients Who Drink Too Much. To aid and encourage pediatricians to address alcohol with their patients, NIAAA is developing guidance on screening and brief intervention in children and adolescents, recognizing that criteria developed for adults may not fit the needs or behaviors of youth. In addition, NIAAA is pursuing basic research on the mechanisms by which alcohol exerts its deleterious effects on the developing embryo and exploring whether nutritional and pharmacological agents could lessen these effects, even when given postnatally.

NIAAA also has a robust medications development program. Emerging data are changing the way we look at alcohol dependence, thereby guiding us to be more strategic about the medications we test, the way we test and design them, and how we determine the subpopulations of patients who are most likely to benefit from them. For example, individual genetic makeup may be used to predict those who will respond positively. Variations in genes linked to an increased vulnerability for alcohol dependence, e.g., mu opioid receptor, have been associated with the efficacy of certain medications. Broadening the desired treatment outcome, from targeting only abstinence to including reduction in heavy drinking, is also influencing the medications that are being tested as well as how they are tested.

Most individuals with alcohol dependence do not access treatment yet many of them recover without the benefit of professional care or facilitated self-help. NIAAA continues to investigate the process leading to a decision to stop drinking or to seek help. The Institute is currently supporting studies to understand mechanisms of change in regard to alcohol as well as other harmful health behaviors.

Given our current state of knowledge and what we are learning from ongoing studies, the outlook for the future is bright. We can substantially reduce the burden of illness for alcohol-related problems and our research is showing us how.

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 Northwestern University, his M.D. from Harvard University, and completed his residency training at Peter Bent Brigham Hospital 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 Indiana University 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

Prepared: April 18, 2008