DEPARTMENT OF HEALTH AND HUMAN SERVICES
NATIONAL INSTITUTES OF HEALTH

NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOLISM

141st Meeting of the
NATIONAL ADVISORY COUNCIL ON ALCOHOL ABUSE AND ALCOHOLISM

February 12, 2016

 

The National Advisory Council on Alcohol Abuse and Alcoholism (NIAAA) convened for its 141st meeting at 9:03 a.m. on Friday, February 12, 2016, at NIAAA headquarters in Rockville, Maryland. The Council met in closed session at 2:45 p.m. on February 11 for a report of the Board of Scientific Counselors by Dr. Kathleen Brady and to review grant applications; the meeting recessed at 4:10 p.m. Dr. Abraham Bautista, Director, Office of Extramural Activities, presided over the Council’s review session, which, in accordance with the provisions of Sections 552b(C)(6), Title 5, U.S.C., and 10(d) of Public Law 92-463, excluded the public for the review, discussion, and evaluation of individual applications for Federal grant-in-aid funds. 

 

 

Carmen E. Albizu-Garcia, M.D.

Carol A. Casey, M.D.

Carlo C. DiClemente, Ph.D. 

Tom Donaldson

James H. Eberwine, Ph.D. 

Joseph Thomas Flies-Away, J.D., M.P.A.

Paul J. Gruenewald, Ph.D.

Paul J. Kenney, Ph.D.  (via telephone) 

Joe L. Martinez, Ph.D.

Sarah N. Mattson Weller, Ph.D. 

Robert O. Messing, M.D.

Patricia E. Molina, Ph.D. 

Adolf Pfefferbaum, M.D.

Arun J. Sanyal, M.D.

Rajita Sinha, Ph.D.

Frank A. Sloan, Ph.D.

Constance M. Weisner, D.R.P.H.

Karen Drexler, M.D., ex-officio (via telephone)

 

NIAAA Director and Chair: George F. Koob, Ph.D. 

 

Acting NIAAA Deputy Director: Patricia Powell, Ph.D. 

 

Executive Secretary: Abraham P. Bautista, Ph.D.

 

Vicki Buckley, M.B.A.; Ralph Hingson, Sc.D., M.P.H.; Robert Huebner, Ph.D.; Raye Litten, Ph.D.; Gary Murray, Ph.D.; Antonio Noronha, Ph.D.;  Kenneth Warren, Ph.D.  

 

Approximately 40 observers attended the open session, including representatives from constituency groups, liaison organizations, NIAAA staff, and members of the general public. 

 

 

 

Dr. George Koob called the open session of the Council meeting to order at 9:03 a.m. on Friday, February 12, 2016. He opened the meeting by introducing new Council members: Dr. Tatiana Foroud (not present), Dr. Carmen Albizu-Garcia, Tom Donaldson, Dr. Joe Martinez, Dr. Arun Sanyal, Dr. Frank Sloan, Dr. Constance Weisner, and Dr. Karen Drexler, Ex-Officio. Council members and senior NIAAA staff introduced themselves. 

 

 

Dr. Koob highlighted key recent NIAAA activities, referring to the written Director’s Report which was distributed to Council members.  

 

NIAAA Research Highlights:  Dr. Koob presented highlights of studies, both extramural and intramural, funded by NIAAA.  The highlights reflect significant progress in NIAAA priority research domains. 

 

“Rsu1 Regulates Ethanol Consumption in Drosophila and Humans,” published in the Proceedings of the National Academy of Sciences, used a well-established Drosophila model to determine that the Ras suppressor 1 (Rsu1) gene is important for alcohol-related behaviors such as alcohol sensitivity and preference. 

 “Leptin Levels are Reduced by Intravenous Ghrelin Administration and Correlated with Cue-Induced Alcohol Craving” published in Translational Psychiatry provides evidence of a ghrelin-leptin cross-talk in individuals with AUD and suggests that the relationship between ghrelin and leptin may play a role in alcohol craving which, in turn, may be associated with relapse and may predict alcohol-related outcomes.

 “Dissociating Motivational from Physiological Withdrawal in Alcohol Dependence: Role of Central Amygdala K-Opioid Receptors” published in Neuropsychopharmacology reveals the selective involvement of the kappa-opioid receptor in the motivational post-withdrawal syndrome but not the acute physiological syndrome, and lends support to its potential value as a medication target.

 “TLR2 and TLR4 Expression and Inflammatory Cytokines are Altered in the Airway Epithelium of Those with Alcohol Use Disorders,” published in Alcoholism:  Clinical and Experimental Research, provide evidence of alcohol’s modification of alveolar epithelial cells and the resulting change in the inflammatory state of the airways. This hypothesized to be a mechanism by which alcohol consumption disturbs pulmonary lines of defense, which is noteworthy because people with AUD have higher rates of pneumonia than the general population. 

 “Short- or Long-term High Fat Diet Feeding Plus Acute Ethanol Binge Synergistically Induce Steatohepatitis in Mice: An Important Role for CXCL1,” a study published in Hepatology, demonstrated that feeding mice a high-fat diet combined with acute ethanol consumption synergistically induces acute liver inflammation and injury through the elevation of hepatic or serum free fatty acids and subsequent up-regulation of hepatic CXCL1 expression and promotion of hepatic nutrophil infiltration. Such work provides evidence for the observation that obesity and alcohol consumption often coexist and work synergistically to promote steatohepatitis.

“Unhealthy Alcohol Use is Associated with Monocyte Activation Prior to Starting Antiretroviral Therapy” in Alcoholism: Clinical and Experimental Research, addressed the fact that alcohol use may accelerate HIV disease progression, but the plausible biological mechanisms have not been clearly elucidated. It found that unhealthy alcohol use was independently associated with a marker of monocyte activation (i.e., higher sCD14) that predicts mortality in treated HIV-infected individuals. 

 “Association Between Physical Pain and Alcohol Treatment Outcomes: The Mediating Role of Negative Affect” in the Journal of Consulting and Clinical Psychology, used a secondary analysis of two clinical trials for AUD to show that pain scores were positively associated with both drinking outcomes and negative affect and negative affect mediated the association between pain and drinking outcomes. 

“Finding Translation in Stress Research” in Nature Neuroscience provides a perspective on how translational research across rodents and humans on stress-related mental disorders is being powered by an ever-developing appreciation of the shared neural circuits and genetic architecture that moderate the response to stress across species. This paper emphasizes research approaches that have the potential to deliver a new generation of risk biomarkers and therapeutic strategies for stress-related disorders. 

“Management of Alcohol Use Disorder in Patients Requiring Liver Transplant” in the American Journal of Psychiatry critically reviews and discusses the clinical, public health, and bioethical issues related to the treatment of AUD in patients before and after liver transplant. The conclusions of the study are that an integrated team approach, use of comprehensive contextual evaluation of substance use, and behavioral, psychosocial, and pharmacologic interventions before transplant optimize outcomes in AUD patients. 

 “Can a Criminal Justice Alcohol Abstention Programme with Swift, Certain, and Moderate Sanctions (24/7 Sobriety) Reduce Population Mortality? A Retrospective Observational Study” in The Lancet Psychiatry reported on a rigorous evaluation of a 24/7 sobriety program for alcohol-involved offenders in South Dakota that found the program was linked to a surprisingly large (4.2%) reduction in all-cause mortality. 

“Sex Differences in Animal Models: Focus on Addiction” in Pharmacological Reviews  provides a review of the literature on sex differences in animal models and concludes that female rats, in general, acquire the self-administration of drugs and alcohol more rapidly, escalate their drug taking with extended access more rapidly, show more motivational withdrawal, and (where tested in animal models of "craving") show greater reinstatement. The one exception is that female rats show less motivational withdrawal to alcohol than do males.

“Converging Patterns of Alcohol Use and Related Outcomes Among Females and Males in the United States, 2002-2012,” published in Alcoholism:  Clinical and Experimental Research, used National Survey on Drug Use and Health (NSDUH) data to explore changes in alcohol use and associated outcomes among females and males aged 12 and up between 2002 and 2012, and concludes that differences in alcohol consumption and related outcomes have narrowed for females and males.

“A Randomized Controlled Trial Targeting Alcohol Use and Sexual Assault Risk Among College Women at High Risk for Victimization” in Behaviour Research and Therapy, assessed the effectiveness of a web-based, combined sexual assault risk and alcohol use reduction program for college women using a randomized controlled trial. Findings suggest that web-based personalized feedback programs targeting sexual assault may be a cost-effective option for reducing sexual assault and heavy episodic drinking on college campuses.  Dr. Koob concluded by noting that he wants NIAAA to continue to pursue the domains covered by these studies, particularly those related to health disparities.  He encouraged researchers to be optimistic because there may often be a breakthrough after years of research.

Discussion:  Dr. Patricia Molina commended Dr. Koob for not ignoring the biomedical consequences of alcohol abuse and giving credit to research beyond the areas of the brain, his personal interest. In particular, she championed the importance of physiology, because many physiological mechanisms are impacted by alcohol, but not always in the same direction in different organs, citing TLR4 expression as an example. She urged all Divisions within NIAAA to take physiology into consideration.  Dr. Koob concurred that the innate immune system is a significant area to study.  Dr. Rajita Sinha endorsed Dr. Molina’s emphasis on physiology and recommended translating knowledge about physiology and the brain to human studies and treatment outcomes, using a collaborative team science approach.  Dr. Koob agreed, noting that the Integrative Neuroscience Initiatives on Alcoholism (INIA) are starting to integrate neuroscience initiatives and that the Division of Medications Development is setting up human studies laboratory.  NIAAA will consider how to adopt this approach in future NOFOs. Dr. Arun Sanyal urged that NIAAA go beyond Dr. Sinha’s recommendation for translational studies to actual clinical practice, pointing to the need for evidence if liver transplantation guidelines are to change. Dr. Koob said the NIAAA Liver Consortia could address this issue.  Dr. Gary Murray commented that the American Association for the Study of Liver Diseases (AASLD) held several sessions at a recent meeting with behavioral experts on how to address liver transplantation and treatment, citing the importance of cooperation across fields. Dr. Sanyal stated that the ultimate goal is the development of drugs to treat liver disease; he urged that NIAAA engage more broadly with the FDA around a larger umbrella of alcohol-associated disorders in an integrated manner, rather than the focused discussions that have occurred around alcoholic hepatitis.  Dr. Koob encouraged Dr. Raye Litten, Acting Director of the Division of Medications Development, to follow up.

Dr. James Eberwine congratulated Dr. Koob on working with NIH Director Francis Collins to achieve a 5% increase in budget. 

 

Dr. Carmen Albizu-Garcia asked if there was a role for anti-leukotrienes in protecting lungs in people with an alcohol use disorder.  Dr. Sanyal responded that caution is needed because it’s not yet known whether this is an adaptive mechanism or whether these changes actually are driving the disease.

 

 

 

Dr. Koob introduced Dr. Changhai Cui, Program Director of Neuroscience and Behavior at NIAAA, who gave a presentation on “Targets in Low-dose Alcohol in the Brain.” It is well-established that alcohol at relatively high concentrations, such as 50 mM, modulates a variety of receptors, channels, and signaling molecules that are associated with alcohol use disorders.  However, significant gaps remain in understanding how that the brain responds to low-dose alcohol and what molecular and cellular targets mediate alcohol's effect at concentrations of 10 mM and below.

 

A number of studies have demonstrated that alcohol around 10 mM concentration impacts certain aspects of human cognitive functions and behavior, including reward, working memory, attention, emotional processing, and motor behavior. Animal studies have also shown that low doses of alcohol are discriminative stimuli. However, the mechanisms of how this occurs are largely unknown. 

 

A very limited number of studies have begun to demonstrate that certain biological systems and a few brain areas are sensitive to low-dose alcohol. For example, a PET imaging study, using a radio ligand for µ-opioid receptors, demonstrated one standard drink caused increased release of endogenous opioid in the nucleus accumbens. This study demonstrated that one standard drink, which resulted in blood alcohol concentration around 10 mM, caused a significant decrease of radioligand binding, suggesting increased release of endogenous opioid peptides and/or endorphin, which replaced the binding of radioligand.  Thus, the µ-opioid system may play a role in low-dose alcohol effect.

 

There are several other brain regions that are sensitive to low-dose alcohol at the IP injection of 0.5 gram per kilogram alcohol, but not all brain subregions are equally sensitive to alcohol. For any given brain area, heterogeneous populations of neurons exist, which have distinctive connectivity and molecular signatures.  Thus, it is important to study the alcohol sensitivity in the neurocircuitry level in the impacted neuronal network. Studies have also shown that certain receptors, ion channels, and signaling molecules are sensitive to low doses of alcohol.  However, which molecular targets mediate the low-dose alcohol effect in vivo is unknown. Therefore, the challenge is to determine which subtype of receptors or channels mediate sensitivity to low-dose alcohol in which cells and circuits in vivo, to determine how alcohol and targets interact, and to examine whether disruption of such interaction will alter specific neurocircuits and shape the dose/response curve of alcohol behavior effect.

 

The goal of this new initiative is to identify targets of low-dose alcohol at the molecular, cellular and circuitry levels by determining the responses of neuro-chemically defined neuronal activity with high temporal and spatial resolution to low-dose alcohol in real time in vivo; defining specific types of neurons and associated neural pathways that are most sensitive to alcohol; investigating how changes in neural pathways and circuits orchestrate the sensitivity to low-dose alcohol; identifying  molecular specificities of proteins that mediate the high neuronal sensitivity to alcohol in vivo; and understanding the molecular mechanisms underlying the interactions of alcohol with the most sensitive target(s).

 

Dr. Cui concluded her presentation by addressing questions she received from Council members. The first was an inquiry if the plan is to keep the Request for Applications (RFA) focused on behavioral science or expanded to reveal impacts on central regulation of peripheral processes such as metabolism.  Dr. Cui stated that the focus of this RFA is on how low-dose alcohol works in the brain and the identification of molecular targets.  The second question addressed whether research funded by this RFA should be extended to low-dose effects in humans and the development of explicit linkages between human and animal models in this regard. Dr. Cui explained that human studies are not excluded; if the focus of a proposed human study is on the neuro-circuits of associated molecular targets, then it is within the scope of the RFA. The third question concerned why genetic and developmental considerations were not highlighted since genetic pathways and brain age are critical elements in the impact of low-dose alcohol. Dr. Cui emphasized that the focus of this RFA is to fill in the gaps in understanding exactly how low doses of alcohol work in the brain. The final comment pointed to the need to specify dosing ranges and match those to the range of effects at molecular, cellular, and circuitry levels, while also extending those to behavioral and cognitive levels. Dr. Cui reminded Council members that the range specified in the RFA is 10 mM and below. This RFA requires studies to measure ethanol concentration in the tissue and to emphasize temporal resolution of blood alcohol levels.

 

Discussion: Dr. Koob emphasized the importance of the initiative by explaining that if scientists could identify exactly where alcohol is working on a molecular level, the field can start to identify some of the primary and most sensitive areas for neuroadaptive changes that occur when people drink. He pointed out that NIDA’s understanding of how illegal drugs such as cocaine initially affect the brain is much more highly advanced than NIAAA’s understanding of alcohol’s initial effect on the brain.  

 

Dr. Molina suggested that NIAAA partner with the National Heart, Lung, and Blood Institute (NHLBI) to investigate why low levels of alcohol consumption we have protective effects in the heart which disappear with high alcohol consumption.  Dr. Koob thanked her for an excellent idea. Dr. Antonio Noronha stated that the challenge right now is to see what effect low-dose alcohol has on neurotranslation and how that relates to behavior.  For example, there are certain potassium channels which are activated and they, in turn, activate other channels and other neurotransmitters in terms of the circuitry. Once that is better understood, the research can be expanded to other organ systems. Dr. Molina responded that potassium channels drive cardiac function and EKG changes; thus, the same mechanisms affect different organ systems.  Dr. Murray interjected that the low dose here is much higher than what is considered a cardioprotective dose.  It is important to recognize the micro-environment and what is going on in the brain and what is going on in the heart are very different. However, NIAAA can reach out to NHLBI on the low-dose protective effects

 

Dr. Joe Martinez directed a question to Dr. Cui, asking if the more important question is:  how alcohol could be affecting all these different receptors.  He suggested that it may this may be the more central question than low-dose alcohol, or it could at least be included in the RFA—how does alcohol affect channels?  Does it go into the neuron to affect the channel there or does it work in the fatty matrix on the outside of the cell? Dr. Cui responded that answering that question is the ultimate goal, i.e., to identify the molecular targets, may be one type of receptors, channels, or signaling molecules, and determine how alcohol and the target interact. 

 

Dr. Koob assured Council members that NIAAA would take their comments under consideration.

 

 

 

Dr. James Eberwine, Elmer Holmes Bobst Professor of Pharmacology in the Perelman School of Medicine, University of Pennsylvania, presented “The Challenge for the 21st Century.”  Dr. Eberwine represents NIAAA on the Multi-Council Working Group which is the organization at NIH that oversees and provides some advice for the White House BRAIN Initiative. 

 

The rationale for the BRAIN Initiative is the recognition that brain disorders, both neurodevelopmental and neurogenerative, will be the most disabling and costly of the chronic diseases, and brain diseases will be in the 21st century what infectious diseases were in the 20th century. The goal of the BRAIN Initiative is to implement basic research and clinical research to understand the brain and to develop therapeutic modalities for a number of brain illnesses.  The first five years of this ten-year project emphasize technology development, while the second five years will emphasize discovery driven by science in terms of how behavior and other physiological processes evolve from the fundamental functioning of cells.

 

For FY 2015, there was an $85 million actual budget. The budget is anticipated to be $150 million in FY 2016, with contributions from several ICs.  With the increase in funds, NIH hopes to issue RFAs twice a year instead of only once.

 

FY 2016 opportunities include: Short Courses,  (MH-16-700); Novel Tools – Cells and Circuits, (MH-16-775);  Foundations of Human Imaging, (MH-16-750); Next Generation Human Invasive Devices, (NS-16-009/010/011/018); Large-scale Recording & Modulation, (NS-16-006/007; EY-16-001); Research Opportunities Invasive Neural Recording:,(NS-16-008); Non-invasive Neuromodulation, (MH-16-810/815); Technology Sharing and Propagation, (MH-16-725); and Theories, Models, Methods, (EB-16-006).

 

Fifty-eight awards were made in FY 2014 and 67 awards in FY 2015 in these areas:  Short Courses, 3 awards (MH-15-215); Cell-Type Classification, 10 awards (MH-14-215); Novel Tools – Cells and Circuits, 25 awards (MH-14-216; MH-15-225); Next Generation Human Imaging, 14 awards (MH-14-217; MH-15-200); Next Generation Human Invasive Devices (2 RFAs), 3 awards (NS-15-006/008); Large-scale Recording & Modulation (5 RFAs), 53 awards (NS-14-007/008; NS-15-003/004; EY-15-001); and Integrating Approaches to Understand Circuit Function, 17 awards (NS-14-009; NS-15-005).

 

One of the important components of the BRAIN Initiative is that it provides cross-NIH and cross-government agency interactions with a committee that includes representatives from the Food & Drug Administration (FDA). In terms of device development, the Committee is seeking advice from that individual for fast-track approval of the use of these devices in humans, in order to generate data more quickly.

 

A new BRAIN Neuroethics Committee, under the leadership of Dr. Christine Grady of NIH and Hank Greely of Stanford University, met for the first time this week. Its mission is to advise NIH on neuroethics questions important for BRAIN that could be answered through focused empirical research; draft relevant guidance documents to address critical ethical issues associated with BRAIN research; and consider proposed funding areas for BRAIN projects for questions of ethical risk.

 

There is also a BRAIN Alliance to coordinate and facilitate communications from its members related to the White House BRAIN Initiative. It includes NIH, FDA, the National Science Foundation (NSF), the Defense Advanced Research Projects Agency (DARPA), the Intelligence Advanced Research Projects Activity (IARPA), the Kavli Foundation, the Simons Foundation, the Howard Hughes Medical Institute, and the Allen Institute for Brain Science.  There has been an international reach as well; Denmark and Canada are now part of the Initiative.

 

Grantees funded under the BRAIN Initiative must attend mandatory meetings and phone conferences to assure that investigators are working synergistically to make progress.  The 2015 BRAIN Investigators meeting attracted 500 scientists and clinicians, federal staff, non-government foundations, and the scientific press, and was well-received.  It is anticipated that the 2016 meeting will include public sessions.

 

A new BRAIN Initiative website has been launched at www.braininitiative.nih.gov to report on progress under the Initiative and inform people about funding opportunities announcements that are being considered.  

 

Examples of work conducted under the BRAIN Initiative include the development of new tools, such as the work of Drs. Florian Engert and Alexander Schier, who were funded to identify the form, function, and plasticity of circuits in zebrafish brain. They generated a quantitative model of neural circuits across the brain that explains dynamic processing of information and generation of motor output, and mapped this whole-brain neural activity onto an anatomical atlas of the zebrafish brain, i.e., the “Z-Brain.”

 

A number of articles based on research funded by the BRAIN Initiative have been published in scientific journals. They cover the development of tools using epigenetics, pharmacology, and multiphoton microscopy.  Dr. Eberwine invited Dr. Cui to highlight investigators funded by NIAAA under the Initiative.  According to Dr. Cui, two applications were funded in 2014, including Drs. Tom Kirsch and Dean Wong from Johns Hopkins who are trying to develop a novel imaging technique to detect in vivo neurotransmitter release coupled with a photoacoustic imaging approach.  She encouraged alcohol researchers to apply for funding, a point reiterated by Dr. Eberwine who reviewed the amounts and sources of FY2015 and FY2016 funding.  He noted that NIAAA’s contribution to the Initiative increased from $0.8 million to $2.73 million across the two years.

 

Discussion:  Dr. Martinez noted that the zebrafish has a very large bilateral dopamine projection, which makes it a handy tool for studying the effects of alcohol, yet they have not been fully exploited for research.  Dr. Noronha replied that Dr. Robert Gerlai, previously with the Walem Institute, has done extensive work with alcohol in zebrafish and he is currently using some of the fluorescent techniques that are coming out of the BRAIN Initiative to actually characterize the effects of alcohol more precisely, thus combining activation of SOCRATES to behavior in the zebrafish model. Dr. Kenneth Warren noted that is also a lot of FAS research now that is being done in the zebrafish.  Dr. Eberwine stated that investigators funded under the BRAIN Initiative are committed to sharing their technologies and tools with others.  Dr. Koob concluded the discussion by thanking Dr. Eberwine for his service and noting that applications submitted in response to BRAIN Initiative NOFOs are successful at approximately the same rate, 20%, as all NIH research project applications.  He invited Council members with comments to send them to him.

 

 

 

Council members unanimously approved the minutes of the NIAAA Council meeting held September 17, 2015. 

 

In 2016, the NIAAA Council will meet on June 9 and September 15. In 2017, the NIAAA Council will meet on February 9, May 2, and September 14. The Collaborative Research on Addiction at NIH (CRAN) Council meeting will take place on May 3, 2017. In 2018 the Council will meet on February 8, May 15, and September 13; the CRAN Council will meet on May 16, 2018. 

 

After a short break beginning at 10:49 a.m., the meeting reconvened at 11:04 a.m. 

 

 

 

Dr. Koob introduced Council member Judge Joseph Flies-Away, the Chief Justice of the Hualapai Nation Court of Appeals in Arizona. Judge Flies-Away’s goal was to talk about recognizing the pain of alcoholism--the conflict and the issues that are born in the body and the mind and the heart--in order to reach peace, within the context of therapeutic justice practiced in tribal healing to wellness courts.  Judge Flies-Away introduced his presentation by saying he would be speaking personally from the patient perspective. To do so, he shared poetry that he had written, along with excerpts from a letter to his son.

 

Many of the people seen in the judicial system have substance abuse issues.  In tribal communities, Indian people share a sense of loss and hopelessness.  Ceremonies are events that bring people together; the relationships and sense of community helps heal the sense of loss and contribute to healing. In the justice system, therapeutic jurisprudence focuses on the law's impact on emotional life and psychological well-being, concerned about how legal procedures and paradigms have therapeutic or anti-therapeutic results. It focuses on the physical, the intellectual, the spiritual, and the emotional components of addiction. “Healing to Wellness Courts: Therapeutic Justice+” is an article co-authored by Judge Flies-Away that was published in the 2013 Michigan State Law Review. In it, he wrote: "Therapeutic Justice plus (TJ-plus) is mindful, not only of the act, crime, or conduct that causes one to be referred to wellness court or a drug court in the state system, but also fully considers the sickness or addiction of the participant. An entire treatment, healing regimen is prepared, taking into consideration the participant's chemical and physical nature of addiction, (E) state of mind, (L) and emotional situations."

 

The comprehensive and phased treatment approach of wellness court is intended to reconnect or connect the person to treatment, wellness activities, and positive situations, to provide better connections and relationships that promote healing, and to disconnect the negative ones.  The “+” in “therapeutic jurisprudence+” is spirituality, a sense of connectedness, and ceremonies are on avenue to that aspect of healing.

 

The elements of therapeutic justice+ include team, community, and nation building; entry; eligibility; healing and treatment; support and supervision; discipline and encouragement; respectful communication; keeping and telling stories; enduring knowledge and experience; and, coming full circle, sustained team, community, and nation building.  Wellness courts are staffed by social workers and, in some cases, doctors who can provide some of these components.

 

Judge Flies-Away concluded his presentation by asking Council members to keep the human being in mind as they conduct their research.

 

Discussion:  Dr. Koob expressed his appreciation for Judge Flies-Away’s perspective and acknowledged that most basic researchers have probably never met an alcoholic.  He stated that this personal perspective from Judge Flies- Away is one that all researchers need to take to heart.  

 

 

Dr.  Koob introduced Council member Dr. Carol Casey, Professor in the Departments of Internal Medicine and Biochemistry at the College of Medicine, University of Nebraska, where she specializes in liver disease and alcohol.   Dr. Casey’s work has been supported by NIAAA since 1988.

 

Liver disease and alcohol is the oldest form of liver injury, recognized since 10,000 B.C.  In heavy drinkers, there is a progression of disease from steatosis to alcoholic steatohepatitis, fibrosis, and cirrhosis. About 20% of heavy alcoholics will get cirrhosis. It is a significant healthcare issue. There are many risk factors in the progression of the disease, including being female, obesity, and smoking, as well as comorbidities. 

 

The key to alcoholic liver injury is alcohol metabolism and the metabolites that have caused this injury.  Alcohol metabolism occurs primarily in the liver and two enzymes, alcohol dehydrogenase and aldehyde dehydrogenase, play important roles in the process.  Alcohol can also be metabolized in the peroxisomes and in the microsomes by the CYP2E1 system.  The results in the metabolites are acid aldehyde adducts.  Thus, the first metabolite is a reactive molecule that can bind the proteins and impair function of proteins.  There is increased reactive oxygen species formation, and there is increased NAD-to-NADPH ratios.  These contribute to the problems affiliated with alcoholic liver injury.

 

 

Altered Protein Trafficking in Alcoholic Liver Disease (ALD):  Dr. Casey began studying how alcohol affects liver function by looking at how newly-synthesized proteins are transported in rats with ALD in 1984-85. Since then, she has been collaborated with Benita McVicker, Ph.D., of the University of Nebraska Medical Center and the Veterans Administration Medical Center.  What they knew at the time was that protein synthesis at the level of the endoplasmic reticulum is not impaired by alcohol, but transport through the cell by vesicles is, i.e., there is impaired assembly of newly-synthesized proteins into the plasma membrane.

 

In collaboration with Dr. McVicker, Dr. Casey began by looking at the process of receptor-mediated endocytosis. There are many receptors in the liver cells, including receptors for protein in the cell membrane. They are specific for certain ligands, which could be toxin receptors and/or hormone receptors. If these are internalized into the coated pit areas of the membrane, then they are transported through the cell. In the process, the ligands or the receptor may be degraded or the receptor could be recycled. 

 

Dr. Casey has been examining protein trafficking by endocytosis and lipid droplet trafficking, working with rats (in the data presented here) and mice, using the Lieber-DeCarli model of alcohol administration with a 7% volume-to-volume alcohol in the diet.  Comparing ethanol-fed rats with a control group over a 12-week period, the ethanol group showed increases in liver weight, triglycerides, the alanine transferase (ALT) and aspartate transaminase (AST) enzymes and serum alcohol concentrations.

 

Dr. Casey focused on the hepatic asialoglycoprotein receptor (ASGPR), present in high densities on hepatocytes, which binds glycoproteins. In early studies, she and her colleagues looked at ethanol-mediated alterations to this receptor, comparing the binding in control hepatocytes to that in ethanol hepatocytes. Coincident with the presence of hepatocellular injury and inflammation, classic impairments in the expression of ASGPRs in alcohol-treated rats were detected by a significant reduction in ligand binding activity, internalization, and expression of the hepatic receptor.  

 

Ethanol effects have been demonstrated in animal, cell culture, and human tissue analysis. The data from a well-defined in vitro model of alcohol-induced hepatotoxicity and the evaluation of human liver sections shows that the majority of ASGPRs in untreated cells or healthy liver tissue are found to be localized to intracellular, perinuclear structures.  In contrast, ethanol exposure results in a striking shift of ASGPR localization to the basolateral membrane.  These results are consistent with previously identified impairments in ASGPR internalization that are induced by alcohol. Potential consequences related to the observed ethanol-mediated alterations in ASGPR function include the impaired clearance of dying cells within the liver and the associated activation of resident macrophages.  

 

During alcoholic injury, there is an increase in apoptosis or programmed cell death. Apoptotic cells were found to be recognized by the hepatic ASGP receptor; a protein, cellular fibronectin, that is produced by activated liver endothelial cells, and that further goes on to activate stellate cells to be involved in the inflammatory cascade; and carcinoembryonic antigen, which is a glycoprotein produced by colon tumor cells and other tumor cells that is processed in the liver.  The result of altered clearance of these ligands leads to activation of Kupffer cells and proinflammatory signaling in the liver.

 

In chronic ethanol consumption, there is increased production of apoptotic cells.  Cellular fibronectin (cFn) is also increased in this setting.  Both of them are ligands for the hepatic ASGP receptor. If Kupffer cells from the control and alcohol-fed animals were incubated with those ligands, the Kupffer cells increased the production of pro-inflammatory cytokines, TNF-alpha, and IL 6. Conditioned media from cultures that were incubated with these bodies or with the cFn and were then put them back on hepatocytes or Kupffer cells actually induced apoptosis. Thus, when there is decreased activity of this receptor in the chronic alcohol-fed situation, these enhanced processes were observed in the alcohol-fed animal.

 

Carcinoembryonic antigen (CEA) is a protein that is processed in the liver, binds to the Kupffer cells by the CEA receptor, and activates Kupffer cells to produce cytokines, TNF-alpha, and IL 6.  It also activates liver endothelial cells to upregulate cellular adhesion molecules, which can bind tumor cells and cause increased tumor cell retention in the liver.  The hepatocytes are also involved because the CEA is desialylated and then taken up by the hepatic ASGP receptor.  Thus, in the presence of CEA, there is an enhanced response in the Kupffer cells of the alcohol-fed animals.  Basically, the liver is a bed that is encouraging this implantation of the tumor cells and there is higher metastasis from colon cancer in alcoholics.

 

In summary, the asialoglycoprotein receptor is important.  It is a functional receptor.  When there is impaired function in the alcohol-fed animals, there is impaired clearance of several of the ligands. An accumulation of these ligands affects Kupffer cells, endothelial cells, and stellate cells to upregulate TNF-alpha, IL 6, and matrix metalloproteinase enzymes as well.  

 

Altered Lipid Droplet Trafficking in ALD:  Dr. Casey and her team have collaborated with Mark McNiven, Ph.D., of the Mayo Clinic to study altered lipid droplet trafficking.  Lipid droplets are dynamic organelles that move around the cell. They are in apposition to mitochondrion and endoplasmic reticulum (ER).  Comparing control-fed and alcohol-fed animals, the lipid droplets in alcohol-fed animals are increased in number and in droplet size.

 

An electron micrograph of a lipid droplet in a cultured hepatoma cell shows the membrane monolayer surrounding the lipid droplet is visible, as are close associations with mitochondria and ER membranes. The structural features of a lipid droplet include 1) polar surface lipids of the monolayer (e.g., phospholipids and sterols), 2) the nonpolar lipids of the core (e.g., sterol esters and triacylglycerols), and 3) a variety of proteins decorating the surface of the droplet. These proteins include DGAT2, Rab18, perilipin, and CCT (CTP: phosphocholine cytidylyltransferase; the rate-limiting enzyme in phosphatidylcholine synthesis).  

 

The investigators knew that alcohol impairs lipolysis, i.e., a general breakdown of fat, as well as very low density lipoprotein (VLDL) secretion. They asked: how would these lipid droplets potentially be different in alcohol versus control cells?  They looked at fat mobilization in addition to glycolysis, based on the principle that starvation is an impetus to remove fat from the cells.  Examining control cells in fed media versus starved after two hours, they observed an efflux or a mobilization that is impaired in the alcohol-fed animal.

 

Casey and her colleagues also examined different proteins within isolated lipid droplets. She highlighted two in her presentation. The first is Rab 7, a small GTPase that is involved in transport between early and late endosomes. Its activation by phosphorylation enhances autophagy and lipophagy. The investigators demonstrated that with isolated liver cells, Rab 7 does associate with the lipid droplets in the rat liver and that there is decrease in that content of Rab 7 on the lipid droplets in ethanol-fed rats.

 

They have also shown in the series of experiments that ethanol impairs Rab 7 activation and phosphorylation.  In McNiven's lab, they examined Rab 7 to determine what happens during starvation in the normal condition, and found that Rab 7 is activated during starvation in controls.  If they reduced Rab 7, they observed impaired lipophagy and autophagy. When they looked at some of the control-fed and ethanol-fed animals, they found impaired activation of Rab 7 and also impaired phosphorylation.  If they inhibit Rab 7 with a chemical inhibitor, this impairment is evident in the alcohol-fed animals compared to controls.

 

The second protein that they examined is Dynamin 2 (Dyn2), a large GTPase. Dr. McNiven previously found that Dyn2 is involved as a pinchase of the plasma membrane and then in the delivery of some of those contents further in the cell. Thus, they hypothesized that Dyn2 would also be involved as a pinchase on lipid droplets.  The first step was to demonstrate that Dyn2 associated with the lipid droplets, and if Dyn2 in lipid droplets was knocked down with siRNA, huge lipid droplets developed.  

 

In animal models, the researchers also observed that Dyn2 impairs triglyceride efflux, which is also impaired by alcohol.  Dyn2 is phosphorylated like Rab 7, and the investigators have shown that that is impaired as well.

 

Drs. Casey and McNiven’s competing continuation project is looking at the balance between lipid droplet synthesis and catabolism, as well as at a 'sampling' effect of lipids as a result of both autophagy and lipophagy.  Dyn2 and Rab 7 involvement would be applicable for these aspects.  They are also looking at SRC kinases and caveolin induction in these studies.

 

Thus, the overall conclusions from Dr. Casey’s work are that 1) the function of the hepatic ASGPR is impaired in the alcohol-injured fatty liver. Impaired uptake and processing of cFn, ABs, and CEA by the ASGPR could contribute to the time course and severity of progression of fatty liver to ASH and cirrhosis, since increased cell death, cytokine production, and liver cell activation are a consequence of altered processing of these ligands; and 2) in addition to altered protein trafficking/function of the ASGPR, they have also identified other vesicle trafficking proteins (Rab 7 and Dyn 2) that are altered in the alcoholic fatty liver, and whose impaired function contributes to altered LD metabolism.

 

Discussion:  Dr. Eberwine inquired if these findings have implications for obesity and alcohol. Dr. Casey responded that obesity plays an important role in liver disease, but alcohol appears to speed up the progression of the disease.  Dr. Eberwine noted that when cells starve, the mitochondria fuse.  He asked if there is any correlation between that appearance and morphology of fusiform mitochondria and the lipid droplets.  Dr. Casey responded that they have not examined that question.  Dr. Sanyal commented that there is mitochondria injury in both alcohol and non-alcoholic conditions.  But in the non-alcoholic state, the lipid droplet comes first and the mitochondrial injury comes in later and ramps up the oxidative stress.  Inflammatory signaling comes later.  Therefore, it may be that the mitochondrial injury occurs a little faster with alcohol. Dr. Casey concurred that that may be a possibility, but it is not possible to distinguish it histologically at an early stage.

 

Dr. Molina asked if Dr. Casey’s team had examined peripheral fat depots in rats fed a high-fat diet. Casey responded that epididymal fat goes down in alcohol-fed animals. Dr. Molina inquired about cell size; Dr. Casey responded that her team had not examined that question. 

 

 

Dr. Karen Drexler, ex-officio member from the Veterans Administration (VA), gave a report about activities at the VA.  She stated that she is the Acting Mental Health Program Director for Addictive Disorders for the Department of Veterans Affairs after Dan Kivlahan's retirement at the end of December. The VA/Department of Defense Clinical Practice Guidelines for Management of Substance Use Disorders were officially published and posted in January of this year. The VA also has updated criteria for use for varenicline from its Pharmacy Benefits Management Section, which will liberalize the availability of that treatment for tobacco use disorders among veterans with alcohol use disorders.  

 

Discussion:  Dr. Koob asked Dr. Litten to share information about a study that NIAAA had done on varenicline.  Dr. Litten explained that NIAAA conducted a clinical trial with the use of varenicline in smokers and non-smokers.  The results showed that the drug reduced heavy drinking in both populations. Its effectiveness with tobacco use disorders as well is positive news.

 

 

 

Dr. Koob opened the discussion by noting that Judge Flies-Away’s presentation made him think about the film about recovery, The Anonymous People, which will be shown this year at RSA. The film was shown at the Psychiatric Association meeting last year.   It charts the history of development of NIAAA and of two waves of the recovery movement from Alcoholics Anonymous to the present day. 

 

Dr. DiClemente asked if the Council could have some data on the success rates of young investigators and early stage investigators. Dr. Koob responded that Dr. Bautista will get the data and give a presentation on it. He suggested they also enlist Mike Lauer’s assistance for more global data. He also noted that it can be challenging to get hard data, but that it would be helpful to look at the success rates of individuals with K99s, as well as to evaluate the success rates of individuals with NRSAs vs. those in T32 training programs. 

 

He also asked Dr. Bautista to send an email to Council members about the venues for grant approval and options available to Council members.  He invited them to highlight grants that need to be promoted, perhaps because the portfolio is low in those grants, or other grants where they perceive the score to be inflated.  Dr. Koob asked to be copied on their responses.  He also asked Dr. Bautista to include information about the appeal process, and options within that process, in his email. 

 

Dr. Martinez commented that there was always a difference between Center for Scientific Review (CSR) review scores and reviews done internally within Institutes; he asked if there is data about the success rates on CSR versus in-house reviews within NIAAA.  Dr. Koob responded that NIAAA reviews this information regularly and has taken steps, such as vetting in-house reviewers more rigorously, to assure a fair process.  Therefore, there currently does not seem to be big discrepancy in CSR and internal review scores at NIAAA.  Dr. Kenneth Warren concurred.  Dr. Koob continued that, given the highly competitive nature of funding at NIH, 90% of the time the Institute goes with the peer review scores after assuring that grants are appropriately distributed across Divisions. Dr. Sanyal noted that scoring patterns vary significantly across study sections and asked how that could be normalized.  Dr. Noronha responded that occurred through the use of percentiles.  Dr. Bautista commented that percentiles normalize scoring differences for R01s, but that R21s are more challenging.  For these grants, NIAAA also shadow-percentiles the applications in order to correct for some variations in different panels' votes.  Dr. Warren stated that that approach has been needed for other funding mechanisms, such as fellowships, as well.  Dr. Koob reminded Council members that there is no evidence whatsoever that applying for an R21 offers a higher likelihood of being funded.  The purpose of the R21 is to generate data and a program that will support the development of an R01 application.  Dr. Warren reinforced this comment by stating that preference is given to new investigators on the R01s across ICs as NIH wants to encourage the R01 as its mainstay funding mechanism.

 

 

 

Pamela Walters, Al-Anon Family Group Headquarters, shared a podcast comment received on the organization’s website from a woman who lost her romantic partner to cirrhosis of the liver. Dr. Koob thanked her for sharing this and other meaningful vignettes over the years that help anchor NIAAA to the real world and to the Institute’s goals. Tracy Ober stated that she brought good wishes from the Headquarters of Alcoholics Anonymous. As the liaison with the professional community in New York, she offered to connect Council members with local AA members who work with professionals.

 

 

 

The meeting adjourned at 12:33 p.m.