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National Institute on Alcohol Abuse and Alcoholism (NIAAA)



146th Meeting of the

September 14, ​2017 

The National Advisory Council on Alcohol Abuse and Alcoholism (NIAAA) convened for its 146th meeting at 10:20 a.m. on Thursday, September 14, 2017, at NIAAA headquarters in Rockville, Maryland. The Council met in closed session at 9:00 a.m. to review grant applications and cooperative agreements; the review session recessed at 10:10 a.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.

Council Members Present: 
Carmen Albizu-Garcia, M.D. (by telephone)
Louis E. Baxter, Sr., M.D
Daniel J. Calac, M.D.
Carlo C. DiClemente, Ph.D.
Tom B. Donaldson
Alex M. Dopico, M.D., Ph.D.
James. H. Eberwine, Ph.D.
Tatiana M. Foroud, Ph.D.
Robert J. Hitzemann, Ph.D. (by telephone)
Paul J. Kenny, Ph.D.
Joe L. Martinez, Ph.D.
Adolf Pfefferbaum, M.D.
Arun J. Sanyal, M.D.
Vijay H. Shah, M.D.
Rajita Sinha, Ph.D.
Frank A. Sloan, Ph.D.
Susan M. Smith, Ph.D.
Constance M. Weisner, D.R.P.H. 

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

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

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

Senior Staff: Vicky Buckley, M.B.A.; David Goldman, M.D.; Ralph Hingson, Sc.D., M.P.H.; Robert Huebner, Ph.D.; M. Katherine Jung, Ph.D.; Raye Litten, Ph.D.; Antonio Noronha, Ph.D.; Kenneth Warren, Ph.D.; Bridget Williams-Simmons, Ph.D.

Other Attendees at the Open Session: 

Approximately 65 observers attended the open session, including representatives from constituency groups, liaison organizations, NIAAA staff, and members of the general public. 

Call to Order and Introductions 

NIAAA Director George Koob, Ph.D., called the open session of the Council meeting to order at 10:20 a.m. on Thursday, September 14, 2017. Council members and senior NIAAA staff introduced themselves. Dr. Koob presented Department of Health and Human Services (DHHS) Certificates of Appreciation to retiring members Adolf Pfefferbaum, M.D., and Rajita Sinha, Ph.D.. 

Director’s Report 

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

  • NIAAA Staff Transitions: Matthew Reilly, Ph.D., a program officer in NIAAA’s Division of Neuroscience and Behavior, passed away unexpectedly on May 15, 2017. Youngshim Choi, Ph.D., postdoctoral fellow with B.J. Song, Ph.D., in the Laboratory of Membrane Biochemistry and Biophysics, left NIAAA to join the faculty at Johns Hopkins University as an Assistant Professor. Patricia Powell, Ph.D., Acting Deputy Director since November 2015, will be officially appointed Deputy Director of NIAAA effective September 17.

  • Budget: NIAAA is currently closing out FY 2017. H.R. 244, the Consolidated Appropriations Act of 2017, passed into law on May 5, providing FY 2017 funding of $34.1 billion for NIH, $2 billion above the FY 2016 enacted level, and $483.4 million for NIAAA, $16.7 million above the FY 2016 enacted level. This NIAAA budget included $1.9 million for the BRAIN Initiative. Overall, the new law provided a general increase to all NIH Institutes and Centers (ICs), and specific increases for Alzheimer’s disease research, antibiotic research, the BRAIN Initiative, and the Precision Medicine Initiative (now the All of Us Research Program). It also continued support for the Gabriella Miller Kids First Pediatric Research Program. Because of the new budget, NIAAA increased the number of grants and training positions funded. NIAAA does not have an overall payline for grant applications, but is committed to a 25% payline for early stage  investigators to encourage them to remain committed to research careers. Currently, the government is operating under a Continuing Resolution (short-term spending bill) signed into law that extends funding through December 8, 2017.

  • New NIAAA and NIH-wide Funding Opportunities: New NIAAA Notice of Funding Opportunities (NOFOs) include: Alcoholic Hepatitis Clinical and Translational Network (U01, U24, UH2/UH3); NIH Blueprint for Neuroscience Research: Dynamic Neuroimmune Interactions in the Transition from Normal CNS Function to Disorders (R01); Secondary Analyses of Existing Alcohol Research Data (R01, R03); Alcohol-Induced Effects on Tissue Injury and Repair (R01, R21; and Understanding Processes of Recovery in the Treatment of Alcohol Use Disorder (R01, R21). NIH-wide NOFOs with NIAAA participation include: Alcoholic Hepatitis Clinical and Translational Network (U01, U24, UH2/UH3); NIH Blueprint for Neuroscience Research: Dynamic Neuroimmune Interactions in the Transition from Normal CNS Function to Disorders (R01); Secondary Analyses of Existing Alcohol Research Data (R01, R03); Alcohol-Induced Effects on Tissue Injury and Repair (R01, R21); and Understanding Processes of Recovery in the Treatment of Alcohol Use Disorder (R01, R21).

  • Request for Information (RFI): NIAAA issued a Request for Information (RFI) on the NIAAA Initiative for Collecting, Archiving, and Sharing Individual-Level Human Subjects Data, seeking public comments on a proposed data-sharing initiative to create a repository of all future NIAAA-funded studies that include human subjects. It would require all NIAAA-funded researchers to make individual-level data obtained from NIAAA-funded human subjects research available to the general research community through the National Institute of Mental Health Data Archive (NDA). The public comment period ran from May 26-July 21, 2017; however, Dr. Koob encouraged Council members to submit comments, if they have not already done so. He also noted that the Adolescent Brain Cognitive Development (ABCD) Study, which had approximately 4,500 participants enrolled as of August 8, is partnering with the NDA to share study data with the public. In the future, there will be an NOFO soliciting applications that will use ABCD data to answer questions about risk/protective factors for alcohol, drug, and nicotine misuse and their effects on the developing brain.

  • Women and Alcohol Misuse: This topic is a research priority at NIAAA in response to recent epidemiology studies that have shown that alcohol use disorder (AUD) among women is a growing public health concern, with women’s alcohol consumption levels approaching those of men. On June 22, 2017, Dr. Koob, Deidra Roach, M.D., Barbara McCrady, Ph.D., Carlo DiClemente, Ph.D., and journalist Martha Woodroof, participated in a well-attended Congressional briefing, “The Changing Patterns of Women’s Drinking and Their Impact on Public Health,” sponsored by the Friends of NIAAA in cooperation with the Addiction, Treatment, and Recovery Caucus. On October 26-27, 2017, NIAAA is sponsoring the National Conference on Alcohol and Opioid Use in Women and Girls: Advances in Prevention, Treatment, and Recovery in Washington, DC, coordinated by Dr. Roach.

  • Research Society on Alcoholism Annual Meeting: NIAAA sponsored a symposium “Everything You Ever Wanted to Know about Alcohol Treatment but Were Afraid to Ask: A Primer for Non-Clinicians.” A video of the symposium is available on the NIAAA website. NIAAA also screened the HBO documentary Risky Drinking followed by a Q&A session; conducted a grantsmanship workshop for junior and senior investigators; held a New Investigator/Early Stage Investigator Meet and Greet; and organized or co-chaired a number of satellite meetings, symposia, roundtables, and workshops.

  • 2017 NIAAA-NIDA Mini-Convention: Frontiers in Addiction Research, the 2017 NIDA-NIAAA Mini-Convention will be held on November 10, 2017, as a satellite event to the annual meeting of the Society for Neuroscience. This year’s theme is The Sciences of Astrocytes, Stress Response, and Translational Research. The convention will also feature an Early-Career Investigator Showcase and the Jacob Waletzky Memorial Award Lecture.

  • Notable Media Coverage: Dr. Koob was featured in a segment on AUD treatment on NBC Sunday Night with Megyn Kelly. He also participated in a live TV interview on summer risky drinking, in which he promoted NIAAA’s online cocktail calculator and Rethinking Drinking website (WBFF/Fox-45 Morning News [Baltimore]). Dr. Koob and Lorenzo Leggio, M.D., Ph.D., were interviewed in the NIAAA intramural research program’s bar laboratory on the topic of low risk drinking limits, NIAAA’s research on AUD treatment, and online resources (WMAR/ABC-2 ([Baltimore]).

  • Telly Award: Dr. Koob congratulated the Office of Science Policy and Communication for winning a Telly Award, honoring excellence in television, digital and streaming video, and non-broadcast productions, for the NIAAA summer safety fact sheet and social media series.

  • New Research Training Website Landing Page: NIAAA redesigned its website with an improved navigation aid to help users find “Research Training.” Dr. Koob encouraged Council members to report problems navigating the Institute’s website that may require further improvements.

  • NIAAA Research Highlights: Dr. Koob presented highlights of NIAAA-funded studies, both extramural and intramural: 

“Magnitude and Trends in Heavy Episodic Drinking, Alcohol-impaired Driving, and Alcohol-related Mortality and Overdose Hospitalizations Among Emerging Adults, 18–24 in U.S., 1998–2014” was published in the Journal of Studies on Alcohol and Drugs (2017) 78(4), 540–548, by R Hingson, W Zha, and D Smyth. They found that alcohol-impaired driving and heavy episodic drinking among 18 to 24-year-olds in the U.S. appear to have declined since 2005. However, alcohol-related hospitalizations and overdose deaths among this age group have continued to increase since 1998. Moreover, persistent high levels of heavy episodic drinking and related problems among emerging adults underscore a need to expand individually oriented interventions, college/community collaborative programs, and evidence-supported policies to reduce their drinking and related problems. 

“Drinking Beyond the Binge Threshold: Predictors, Consequences, and Changes in the U.S.” was published in the American Journal of Preventive Medicine (2017 Jun), 52(6):717-727 by R Hingson, W Zha, and A White. They reported that recent studies show drinking, binge drinking, and related health and social problems are declining among underage persons. Among all other age groups, binge drinking and drinking at levels beyond the binge thresholds have increased. Drinking 2-3 and 3+ times the gender-specific binge thresholds were associated with more negative consequences that pose health risks to those drinkers and others. 

“Vulnerability for Alcohol Use Disorder and Rate of Alcohol Consumption” was published in the American Journal of Psychiatry, (2017, Aug 4) [Epub ahead of print. PMID: 28774194] by JL Gowin, ME Sloan, BL Stangl, V Vatsalya, and VA Ramchandani. They demonstrated the rate of achieving binge-level alcohol exposure is associated with risk factors for AUD, including male sex, family history of alcoholism, and impulsivity, in non-dependent drinkers. Given the association of vulnerability of AUD with rates of binge drinking, rates of consumption should be assessed as part of a thorough clinical evaluation of alcohol use and problems. 

“Relationship Between the Aldosterone-Mineralocorticoid Receptor Pathway and Alcohol Drinking” was published in Molecular Psychiatry (2017 May 2) [Epub ahead of print. PMID: 28461696] by EG Aoun, V Jimenez, LF Vendruscolo, NAR Walte, E Barbier, A Ferrulli, CL Haass-Koffler, P Darakajian, MR Lee, G Addolorato, M Heilig, R Hitzemann, GF Koob, KA Grant, and L Leggio. Koob and Leggio. They examined the relationships between alcohol craving, drinking, and anxiety, and the aldosterone pathway using aldosterone concentrations and brain expression of mineralocorticoid receptors (MR). Higher aldosterone concentrations resulted in higher craving, drinking, and anxiety. Lower expression of MR was associated with higher drinking and anxiety.  Results show a relationship between ethanol driniing and the aldosterone/ MR pathway in three different species and may be a putative target for pharmacotherapies for AUD. 

“Alcohol-Associated Intestinal Dysbiosis Impairs Pulmonary Host Defense Against Klebsiella Pneumoniae” was published in PLOS Pathogens (2017 Jun 12) 13(6): e1006426 [PMID: 28604843] by DR Samuelson, JE Shellito, VJ Maffei, ED Tague, SR Campagna, EE Blanchard, M Luo, CM Taylor, MJJ Ronis, PE Molina, and DA Welsh. They investigated the effect of alcohol-induced microbial imbalance in the gut (dysbiosis) on lung pathophysiology. Microbiota from alcohol-fed mice were transferred into germ-free, alcohol-naïve mice. Results were compared to mice receiving microbiota from untreated healthy mice. Mice with microbiota from alcohol-fed mice had higher susceptibility to pneumonia and gut barrier damage, even though the recipient animals had not been fed alcohol. Thus, gut dysbiosis caused by alcohol directly impairs immune function in the lung. 

“Intestinal Fungi Contribute to Development of Alcoholic Liver Disease (ALD)” was published in the Journal of Clinical Investigation (2017 Jun 30) 127(7): 2829-2841 [PMID: 28530644] by AM Yang, T Enamine, K Horwath, P Chen, L Wang, C Llorente, S Bluemel, P Hartmann, J Xu, Y Koyama, T, Kosheleva, MG Torralba, K Moncera, K Beeri, CS Chen, K Freese, C Hellerbrand, SM Lee, HM Hoffman, WZ Mehal, G Garcia-Tsao, EA Mutlu, A Keshavarzian, GD Brown, SB Ho, R Bataller, P Stärkel, DE Fouts, and B Schnabl. Like gut bacteria, fungi contribute to chronic alcohol-induced liver damage, potentially by inducing an inflammatory response. The researchers reported that altered gut fungal community and exposure to antifungal medications correlate with mortality from alcoholic cirrhosis in humans. If more evidence confirms that fungi contribute to worsening ALD, antifungals may be useful as treatments or treatment adjuncts. 

“Adolescent Alcohol Exposure Decreases Frontostriatal Resting-State Functional Connectivity (fcMRI) in Adulthood” was published in Addiction Biology, (2017 Jul 9) [PMID: 28691248] by MA Broadwater, S-H Lee, Y Yu, H Zhu, FT Crews, DL Robinson, and Y-Y I Shih. The researchers used fcMRI imaging to track changes in functional connectivity in adult animals after adolescent alcohol exposure. Acute exposure led to increased responses to alcohol as an adult and decreased functional connectivity between brain regions that control impulsivity, risk-taking, and drug use. Results indicate adolescent alcohol use alters brain circuity, leading to increased susceptibility to adult AUD. 

“Metabolomics Biomarkers to Predict Acamprosate Treatment Response in Alcohol-dependent Subjects” was published in Scientific Reports. (2017 May 31);7(1):2496 [PMID: 28566752] by DJ Hinton, MS Vazquez, MJ Hitschfeld, AMC Ho, VM Karpyak, JM Biernacka, and DS Choi. The researchers tested the possibility of establishing a model incorporating biomarkers to predict response to acamprosate treatment for AUD. Baseline serum metabolites and clinical scores were used in multivariable predictive models to determine response during three months of treatment. Results suggested that while the model performed well at predicting responders, it did not perform as well in identifying non-responders. More potential biomarkers may be needed to expand the clinical utility of predictive models for medication treatment response in AUD. 

“A Preliminary Randomized Controlled Trial of Contingency Management for Alcohol Use Reduction Using a Transdermal Alcohol Sensor” was published in Addiction. (2017 Jun) 112(6):1025-1035. Epub 2017 Feb 22 [PMID: 28107772] by NP Barnett, MA Celio, JW Tidey, JG Murphy, SM Colby, and RM Swift. Contingency management is an effective strategy for promoting abstinence in substance use disorders (SUDs), but its use in AUD has been restricted by limitations in detecting alcohol consumption. Transdermal detection has shown promise for shaping behavior in AUD. These researchers demonstrated its utility in a between-subjects’ comparison using yoked non-contingent reinforcement. These results provide more certainty that positive outcomes are contingency-based and provide support for proceeding to randomized controlled trials using continuous transdermal alcohol detection. 

“Effects of Varenicline on Alcohol Cue Reactivity in Heavy Drinkers” was published in Psychopharmacology (2017Jun 9) doi: 10.1007/s00213-017-4667-9. [Epub ahead of ptint. PMID: 28600734] by W Roberts, ELR Harrison, and SA McKee, Clinical trials and human laboratory studies have established that varenicline can reduce rates of alcohol use among heavy drinkers. Less is known about how varenicline has this effect on drinking behavior. In this human laboratory study, the researchers demonstrated that varenicline reduced alcohol-induced craving in both heavy drinking smokers and non-smokers. Varenicline continues to show promise as a pharmacological treatment for alcohol use disorder. 

“Effects of Varenicline on Alcohol Self-administration and Craving in Drinkers with Depressive Symptoms” was published in the Journal of Psychopharmacology (2017 Jul) 31(7):906-914 [PMID: 283512003] by W Roberts, TL Verplaetse, K Moore, L Oberleitner, MR Picciotto, and SA McKee. They examined whether depressive symptoms moderated the effectiveness of varenicline in reducing risk of drinking in individuals with AUD. Those with higher levels of depression showed the largest reduction in drinking and alcohol craving with varenicline. This study suggests a role of varenicline in treating patients with AUD and elevated depressive symptoms. 

  • Research Priorities Based on NIAAA Strategic Plan: Dr. Koob identified the following research priorities at NIAAA, based on its strategic plan for 2017-2021: Neurobiology of tolerance, blackouts, and low response to alcohol; epidemiology, pathophysiology, and neurobiology of response to alcohol in the aging population; new pathways for preventing, diagnosing, and treating alcohol-related disease; biomarkers to guide diagnosis, prevention, and treatment; Addictions Neuroclinical Assessment; extreme binge drinking – epidemiology and prevention; long-term recovery; and new approaches for identifying drug targets.   

Hughes Award Presentation 

Dr. Koob presented the 2017 NIAAA Senator Howard Hughes Award to Penny S. Mills, executive vice president and Chief Executive Officer (CEO) of the American Society of Addiction Medicine (ASAM). He stated that under her leadership, ASAM has expanded training for physicians to treat addiction, established guidelines for addiction treatment providers, and launched major advocacy efforts to raise awareness of alcohol and drug use disorders. In accepting the award, Ms. Mills described her job as making sure that policy makers and the public understand the science behind addiction, noting that it is important to keep a focus on the impact of alcohol and other legal drugs even as the opiate crisis commands attention. 

STAR Awards 

Abraham P. Bautista, Ph.D. highlighted the new Supplements To Advance Research (STAR) from Projects to Programs that NIAAA will implement in FY 2018. The proposed administrative supplement NOFO is intended to promote innovation and exploration of high-risk ideas by providing supplemental funding of up to $150,000 direct cost per year for 1 to 2 years, to Early Established Investigators (EEIs) (individuals with an Early Stage Investigator [ESI] award in the past 10 years); expand and explore new opportunities within the broader scope of a currently funded, peer-reviewed research project; facilitate the transition from a single, structured research project to a research program; and facilitate the success of the second renewal application. Eligibility requirements include being an Early Established Investigator (EEI) grantee, who successfully renewed his/her first R01 that was awarded as an ESI; has a single Principal Investigator grant/application that is an NIAAA-funded R01; and who is in the third year of the current Type 2 R01 grant. The review criteria include the significance and potential impact of the STAR Program award on the current research project and the field as a whole; potential innovation, risks, and challenges of the proposed activities; importance of the research area; the ability of the investigator to develop a research program based on his/her history of innovation and productivity; the commitment of the Principal Investigator (PI) on the field of research based on past research activity and the supplied short-and long-term vision; and the strength of the institutional recommendation letter. Members of the National Advisory Council on Alcohol Abuse and Alcoholism, with input from NIAAA program staff, will consider the ability of the proposed supplement activities to enhance the parent award’s overall impact within the broad scope of the original award.  

Discussion: Vijay Shah, M.D., praised the approach. He noted that a previous Council discussion about a new NIH program for young investigators identified some potential downsides, and observed that decisions on this issue appear to have been left to individual ICs. Dr. Bautista responded that only NIAAA and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) are implementing this program. Dr. Koob noted that it was related to the NIH effort, but separate from it. James Eberwine, Ph.D., concurred with Dr. Shah, stating that the supplement will lead to more creative science. Paul Kenny, Ph.D., encouraged NIAAA to pay particular attention to female investigators. 

Intramural Research: Alcohol: Pain, Pleasure, and the Prefrontal Cortex 

Dr. Koob introduced Andrew Holmes, Ph.D., Chief of NIAAA’s Laboratory for Behavioral and Genomic Neuroscience. Dr. Holmes’ Laboratory is striving to understand the neurobiology that governs the transition from the controlled to the compulsive drinking stage. He defined compulsive drinking as continuing to consume alcohol, even if one knows there will be adverse consequences. Since his research involves animal studies, one challenge has been how to model compulsive drinking in mice. One classic approach is to adulterate the alcohol with something bitter like quinine, and observe if the animal will continue to drink; the other is to train the animal on an operant task (e.g., pushing a lever) to obtain alcohol, punishing it intermittently with an electric shock when it performs the task, and then testing it again in the absence of the punishment to observe if the animal is still willing to make a response for alcohol, knowing it may be punished. His Laboratory uses the latter approach. 

Researchers in the Laboratory have observed that most of the punished mice are hesitant to press the ethanol lever, post-punishment. A subset of the animals, however, continue to make responses at the lever. The researchers then sought to make the mice dependent on alcohol by repeatedly exposing them to alcohol vapors over two to four weeks to produce highly elevated blood alcohol levels. These now alcohol-dependent mice continued to press the lever despite the knowledge that it’s associated with potential punishment. Thus, they are modeling the compulsive alcohol seeking seen in addiction among those with AUD. In contrast, they will suppress their response for a food reward; therefore, there is something specific about the continued compulsive drive to respond to alcohol that is different from the drive to seek other natural rewards.

Dr. Holmes then reviewed a series of experiments conducted by Lindsay Halladay, Ph.D., while she was a postdoctoral research fellow in the Laboratory. These studies focused on changes in neuronal activation in various brain regions as the animals are tested in the punishment suppression task by looking at c-fos, which is an immediate early gene marker for neuronal activity. The four brain regions she examined were the ventral striatum, the amygdala, and two areas of the prefrontal cortex. Using in vivo neuronal recordings in these different regions, Dr. Halladay found neurons that were firing in lockstep with different behaviors. In some parts of the prefrontal cortex, there was little change in neuronal activity across the tasks prior to punishment, during punishment, and post-punishment. But in the infralimbic cortex, there were a subset of neurons associated with the animals approaching and then moving away from the lever that was associated with punishment, i.e., these neurons increased their activity after punishment to potentially act as a signal that suppressed the animal’s responding to the lever. The number of mice who exhibited this behavior increased after the punishment. These findings are consistent with what has seen in the field of cocaine modeling. 

The researchers next sought to manipulate the activity of the neurons in the brain to see if they could produce changes in behavior, using in vivo optogenetics. This powerful technique allowed the researchers to express viral vector-mediated opsins in particular areas of the brain and then shine lights of varying colors onto those infected neurons to either reduce or increase their activity. In one experiment, they expressed an opsin called ArchT in the infralimbic cortex and then shone a green light on those neurons; the light shut off the activity of the neurons to suppress the compulsion for alcohol. The researchers found that the animals whose neurons had been silenced continued to make responses at the alcohol lever post-punishment. This finding suggests that the infralimbic cortex is part of the medial prefrontal cortex that is broadcasting a suppression signal. One region of the brain that is probably receiving such a signal is the amygdala. Thus, the researchers conducted another experiment using the same design, but inhibiting the activity of the basolateral amygdala. But when this area was silenced, the same effects were not observed. 

The researchers then sought to examine communication between brain regions, particularly between the affected area of the prefrontal cortex and downstream structures like the amygdala and ventrial striatrum. In collaboration with Tom Kash, Ph.D., University of North Carolina, the researchers conducted an anatomical tracing study in which they identified cells projecting to the amygdala and to the nucleus accumbens ventral striatum. They found that the infralimbic cortex is broadcasting to the different brain areas using different cell populations. Next, they used the optogenetics technique described above to silence the communication between the infralimbic cortex and the nucleus accumbens. They learned that silencing the output to the accumbens was sufficient to make the animals compulsive, i.e., to make them continue to respond on the alcohol lever after punishment. 

In summary, these preclinical studies provide emerging evidence that the prefrontal cortex is a critical locus in the brain for compulsive behavior. This is consistent with solid evidence from imaging and other studies in humans showing that the prefrontal cortex is compromised at both the anatomical and functional level in long-term alcohol abusers. The research presented here indicates that the prefrontal cortex is the source of signals to stop seeking alcohol when one has explicit knowledge that it could lead to adverse consequences. The data suggest a potential model in which suppression signals are sent to the ventral striatum that is signaling a craving response. In alcohol abuse, what most likely happens is that the integrity of this system for reducing compulsive alcohol seeking becomes compromised, i.e., the signal from the prefrontal cortex is progressively lost and the craving signal driven by the ventral striatum becomes unrestrained, thus driving compulsive drinking behaviors. 

Discussion: Joe Martinez, Ph.D., commented that the idea of a broadcasting neuron is descriptive but not heuristic, and that something very complex must be occurring between the proteins and the stimuli that shuts down the system or activates it. Dr. Holmes responded that one of the next stages of research that is now becoming feasible is to record the activity of neurons that are defined in terms of their molecular phenotype but to also further identify particular neuronal populations and use various genetic engineering techniques to limit the expression of viruses within those cell populations with the goal of either silencing them or imaging them in vivo using calcium imaging techniques. Understanding the molecular neurochemical phenotypes of cells allows for potential clinical applications, e.g., drug targets that are specific to neuronal circuits. Dr. Koob inquired if Dr. Holmes knew the neurochemical makeup of the neurons going to the nucleus accumbens, e.g., were they glutamatergic. Dr. Holmes replied that in at least one of the studies he reported, the researchers used the RNAscope method to not only identify cells that are activated by fos activity in the prefrontal cortex, but also to double label them for glutamatergic or GABAergic identity. The vast majority of the output from the prefrontal cortex to the accumbens is likely to be glutamatergic projection cells. Dr. Koob suggested using the Daun02 approach, but noted it still wouldn’t identify exactly which neurotransmitter is involved. Dr. Kenny inquired if there’s any indication that interneurons are contributing to the process, when taking into account the waveforms of the cells. Dr. Holmes responded affirmatively, noting that scientists are very hesitant to say cells that are low firing and have long waveforms are definitely pyramidal glutamatergic cells; these experiments are challenging to conduct. 

Consideration of Minutes of the May 2017 Council Meeting and Future Meeting Dates   

Council members unanimously approved the Council Standard Operating Procedures (SOP). Council members also unanimously approved the minutes of the NIAAA Advisory Council meeting held May 2, 2017, and the minutes of the Collaborative Research on Addiction at NIH (CRAN) Joint Council meeting held 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. Council meetings in 2019 will be held on February 7, May 14, and September 12; the CRAN Council will meet in 2019 on May 15. No meeting days have yet been set for 2020. 

Council broke for lunch at 12:08 p.m. and reconvened at 1:15 p.m. for the afternoon session. 

NIH Clinical Trials and Transparency Reforms 

Dr. Koob introduced Michael Lauer, M.D., Deputy Director for Extramural Research at NIH. Dr. Lauer commenced with a story from January 2012, when the British Medical Journal published an article about what happened to the results of 635 clinical trials funded by NIH between September 30, 2004 and December 31, 2008. Within 30 months after completion of the study, only 46% had been published in a peer-reviewed biomedical journal. After a median of 51 months after trial completion, a third of trials remained unpublished. The article concluded that “no policies exist to make sure that the public has access to results from NIH funded research that is not published.” 

NIH undertook its own study, examining the time between completion of the trial and publication of the main results in a peer-reviewed journal of 244 extramural randomized clinical trials of cardiovascular interventions that were supported by the National Heart, Lung, and Blood Institute (NHLBI) between 2000-2011. The NIH investigators found that studies with clinical outcomes (e.g., deaths, unintentional hospitalizations) had high rates of publication. However, over 80 percent of the funded trials did not focus on clinical outcomes, but on surrogate ones. After two years, only 12% of those studies had published results. The study authors, reporting in the New England Journal of Medicine (2013) concluded that “A number of parties share responsibility, including funders, investigators, academic medical centers, [universities], clinical research organizations, and ... journals.” 

Researchers at Yale University examined the publication record of 4,347 interventional clinical trials funded by NIH across 51 academic medical centers in the British Medical Journal. They found that most centers published results from only 30-40 percent of the studies. The authors concluded that “Despite the ethical mandate and expressed values of academic institutions, there is poor performance and noticeable variation in the dissemination of clinical trial results across leading academic medical centers.” The lead author also wrote a commentary for National Public Radio in which he concluded that the failure to publish results is a systemic problem within the biomedical research culture. He continued: “Not reporting results violates the basic principle of the scientific method. It hurts patients, society and science. It dishonors the people who gave their consent and bore the risk of participating. The holding back of the results impedes progress toward scientific breakthroughs, corrupts the medical literature and wastes research funding.” 

If lack of timely publication is the first problem, the second problem was revealed in a 2016 Government Accountability Office (GAO) report on NIH entitled Additional Data Would Enhance the Stewardship of Clinical Trials Across the Agency. It concluded that “NIH’s OD reviews some data on clinical trial activity across NIH but has not finalized what additional data it needs or established a process for using these data to enhance its stewardship. NIH is limited in its ability to make data-driven decisions regarding the use of its roughly $3 billion annual investment in clinical trials.”  

To address both problems, NIH proposed a definition of a clinical trial in October 2014 in coordination efforts to revise the Common Rule. NIH Director Francis Collins, M.D., Ph.D., and Kathy L. Hudson, Ph.D. published an article sharing their concerns about reporting the results of clinical trials in the Journal of the American Medical Association (JAMA). NIH proposed a rule in November 2014 that NIH-funded trials must be registered at within 21 days of first enrollment and results must be reported there within 12 months of completion. During the public comment period from November 19, 2014 to March 29, 2015, 240 comments ranging from full support to outright opposition were received from scientists, academic institutions, and professional societies. On September 12, 2016, Dr. Collins published the NIH policy on the Dissemination of NIH-funded Clinical Trial Information in the Federal Register. He stated that “A fundamental premise of all NIH-funded research is that the results must be disseminated. In research involving human beings, scientists have an ethical obligation to ensure that the burden and risk that volunteers assume comes to something, at the very least by ensuring that others are aware of the study and that its findings contribute to the nation’s health.” 

In response to comments about the scope of the policy and the types of trials that should be included, NIH concluded that “We disagree with commenters who suggested that there is no need for coverage of certain types of trials. The benefits of transparency and the need to fulfill the ethical obligation to participants is as relevant to these types of trials as to any other type. We believe that 12 months represents an appropriate balance between investigators’ interests and the interests of the public in having access to the results of a publicly funded trial.” 

The Office of Extramural Research (OER) has developed a variety of tools and information, including an OER website on clinical trials, which continues to evolve. For the new policy to be effective, accountability is required. As outlined in a 2016 article in JAMA by Drs. Hudson, Lauer, and Collins, NIH will withhold future clinical trial funding if it is unable to verify appropriate registration and results reporting of current studies. 

Discussion: Tatiana Foroud, Ph.D., inquired about the reasons that investigators gave to NIH in the 2013 study for not having published their data. Dr. Lauer responded that some stated journals were not interested in publishing the negative results they found, some reported giving up after three journals turned down their article, and others reported lack of time. He concluded that it has simply not been part of the ethos that every study collecting human data should be published. Dr. Sinha asked for comment on the significant change in the definition of a clinical trial. Dr. Lauer reviewed the revised definition: A research study in which one or more human subjects are prospectively assigned to one or more interventions (which may include placebo or other control) to evaluate the effects of those interventions on health-related biomedical or behavioral outcomes. He noted the definition is deliberately broad, emphasizing scientists’ ethical obligation to participants. Dr. Sinha noted that this is the 2014 definition, but investigators have received notice that everything they study will fall within the definition as of January 2018. Dr. Lauer stated that this was not true; not all human studies are clinical trials. What is true is that the application has been revised, so that data only needs to be entered into one place. In addition, a protocol synopsis will be required where investigators can enter additional information that will not count against the 12-page research plan page limit. Clinical trial applications will continue to be reviewed as they have in the past, and not necessarily in a designated clinical trial study section. Dr. Pfefferbaum asked for confirmation that the ABCD and the National Consortium on Alcohol and Neurodevelopment in Adolescence (NCANDA) studies are observational, and not clinical trials. Dr. Lauer affirmed that they are observational. Frank Sloan, Ph.D., inquired about the definition of a surrogate marker. Dr. Lauer responded that a surrogate outcome is one that may interest researchers, such as a subtle change in an image, more than patients who care most deeply about clinical outcomes. He reported that NIH did a follow-up study in which all published papers were graded on nine quality criteria. Those that were marked as high quality were the ones published quickly. As the quality score declined, the publication rate also declined, suggesting that the problem might be that the funded research was not very good. Dr. Shah asked if the protocol synopsis was for reviewers or for compliance. Dr. Lauer responded that it will be read by reviewers and provides an opportunity to expand the discussion of the research plan; it will also provide the metadata that GAO requested. Dr. DiClemente commented that NIH always had the results of clinical trials reported in the study’s closing summary. Dr. Lauer responded that NIH has often had difficulty understanding study results based on the closing summary. Some investigators, for example, had never analyzed the data they collected. Dr. Diclemente asked why information needed to be uploaded at the front end of the process. Dr. Lauer replied that the new system makes it easier for reviewers to find information that they need. 

Council Member Presentation: Habenula Regulation of Addiction and Addiction-Relevant Diseases 

Dr. Koob introduced Dr. Paul Kenny, the Ward-Coleman Professor and Chair of Neuroscience at the Icahn School of Medicine at Mt. Sinai. Dr. Kenny explained that his presentation focuses on the habenula and its concentration of nicotine receptors because this region of the brain and habenula nicotinic receptor signaling is very relevant to nicotine and, potentially, alcohol dependence. He also noted that the nicotine contained in tobacco smoke is the most likely cause for various tobacco-related diseases, including Type 2 diabetes and hypertensive heart disease. The etiology of these diseases may lie within the habenula. 

The vast majority of nicotinic receptor subunits in the brain are the alpha-4 and beta-2 subunits; they are critical for the rewarding properties of nicotine. However, they are not the major drivers for genetic vulnerability for smoking. Instead, allelic variation in the alpha-5, the alpha-3, and the beta-4 subunit genes which are clustered together in Chromosome 15 in humans play a larger role. The alpha-5 subunit has been most heavily associated with tobacco dependence vulnerability. Rather than being located in the ventral tegmental area within the key region regulating the rewarding properties of nicotine, they are located more in the medial habenula  and in the interpeduncular nucleus (IPN). The habenula-IPN pathway has a particularly dense expression of alpha-5 subunits, yet little is known about this brain structure, even though it’s one of the two major parts of the brain that connect the forebrain and the midbrain. Another part of the brain densely inhabited by alpha-5 subunits in the nucleus tractus solitarius (NTS) in the hind brain; a region that negatively regulates food intake. Thus, the question: does the alpha-5 transcript in either circuit play any role in regulating the motivational properties of addictive drugs such as nicotine? 

In an experiment with mice, researchers compared the motivational properties of nicotine self-administered to wild type mice and knock-out mice who can no longer make the alpha-5 subunit. They found the wild type mice titrated the amount of nicotine they consumed, whereas the knock-out mice continued to consume high doses, even after experiencing a seizure from an overdose. However, when the scientists cloned the missing alpha-5 subunit gene into a virus and injected it back into the habenula-IPN circuit of the knock-out mice, they behaved normally. These findings about the role of alpha-5 and the circuit parallel current human data. The researchers believe that the mechanism is some kind of satiety signal, i.e., there is a protective system in the brain that tells humans and animals to stop using. If it’s compromised, the person with this allelic variation will continue to use the drug and will be more likely to transition into a habitual drug user. There are published data suggesting that the same allelic variation that increases the likelihood someone will become a smoker also increases his or her likelihood to become a drinker. Dr. Kenny and his colleagues are testing in the laboratory if alcohol is being consumed in part because of its ability to turn the circuit off (e.g., producing a reinforcing effect of alcohol) or if alcohol is numbing this part of the brain and by doing so may allow someone to use drugs like nicotine that otherwise would activate the circuit. Thus far, the data suggests that both phenomena may be occurring. 

The researchers also considered whether the alpha-5-dense NTS, which is a key player in the addictive properties of nicotine as well as the regulation of appetite, is also playing a role in regulating nicotine and/or other drug consumption. One of the food-relevant neuropeptides produced in the NTS is GLP-1, a glucagon-like peptide-1. Using FOS, their research showed that nicotine activates neurons in the NTS, but not the tyrosine hydroxylase (TH) cells that might be expected to be activated. Instead, nicotine activates the GLP-1 neurons in the NTS that express alpha-5 nicotinic receptor subunits. This finding led the scientists to examine whether nicotine can act on these cells to play a role in regulating consumption of the drug. First, they used a pharmacological approach. Two drugs that boost GLP-1 transmission—sitagliptin and exendin—delivered to mice who self-administer nicotine depressed their use of the drug. The reverse was true if the GLP-1 receptor was genetically deleted; the knock-out mice consumed more. The two compounds, which produce a signal to stop using nicotine, are already used in the treatment of diabetes in humans. Thus, scientists and NIAAA are optimistic about the potential of GLP-1 receptor modulators to be used for the treatment of various addictions, including alcohol, cocaine, and amphetamines.

 The densest concentration of alpha-5 receptor subunits in the brain is in the interpeduncular nucleus (IPN). To better understand the circuit between the NTS and the IPN, Dr. Kenny and his colleagues conducted two separate studies in which they modulated alpha-5 signaling or modulating GLP-1 signaling. They found that the GLP-1 neurons directly projected the IPN; when GLP is secreted, it excites the local IPN neurons in exactly the same way that the alpha-5 nicotinic receptors are able to regulate activation of the IPN neurons. Thus, there appears to be a functional connection between the NTS and the IPN. They also found that if the GLP-1 receptors and the habenula-IPN pathway is knocked out or if they’re activated pharmacologically, there are profound increases and decreases in nicotine taking, respectively. The size of the inhibitory effect of GLP-1 receptor agonists in the IPN on nicotine-taking behavior is the largest ever seen in Dr. Kenny’s laboratory. 

In summary, when a person smokes a cigarette, the nicotine activates the alpha-5 receptors in the habenula and the NTS. The habenula releases glutamate into the IPN, which activated  GABAergic neurons. Through a process that is still not fully understood, this causes a marked satiety-like response to nicotine that serves to reduce the motivation to consume nicotine. If the ventral tegmental area (VTA) to accumbens circuit is what’s driving nicotine use, the habenula-IPN circuit is doing the opposite. Furthermore, activation of alpha-5 receptors on GLP-1 neurons in the NTS serves to further enhance the habenula response to nicotine, meaning that the habenula-IPN-NTS is a broad network that serves to oppose the consumption of nicotine. Experiments are ongoing to investigate where alcohol fits into the circuit.  

When GLP-1 receptors are activated by GLP-1 or exendin 4, there is an increase in beta-catenin activity, which translocates the nuclear and dimerizes a transcription factor called TCF-7L2. The researchers found that there is dense expression of TCF-7L2 in the medial habenula. Thus, the researchers believe that TCF may be an important factor regulating the effects of GLP in the habenula. They made a knock-out rat removing the TCF and again examined nicotine self-administration in knock-out rats compared to their wild type counterparts; the knock-out rat consumed significantly more nicotine, indicating that TCF signaling is involved in regulating the motivational property of nicotine. To confirm this hypothesis, they knocked down TCF in the habenula of rats by infusing siRNAs into the medial habenula. Twenty-four hours later, they recorded a persistent increase in nicotine self-administration in the knock-out animals. This suggests TCF-7L2 plays a role in regulating nicotine intake. 

To further investigate the role that GLP-1 and TCF-7L2 play in regulating nicotine intake, Dr. Kenny and his colleagues measured nicotinic receptor function in the habenula after modulating the TCF signaling. They found that no change in the wild-type animal compared to the knock-outs when they activated them with nicotine. They also desensitized the same way, i.e., nicotine was able to turn on and turn off the receptors in both types of animals. However, the receptors in the wild-type animals recovered back to baseline after the nicotine was taken off, but the knock-out animals did not. Thus, this study provided an example of a potential gene by environmental interaction that the researchers intend to continue investigating in the laboratory. 

GLP-1 agonists are a good way of turning on insulin transmission, and thus are used as diabetes medications. Nicotine is known to be one of the major causes of diabetes. TCF-7L2 is the gene that is most associated with risk for Type 2 diabetes. Therefore, Dr. Kenny and his colleagues wondered if the results reported above occurred because their animals were diabetic, which might be influencing their nicotine intake, and thereby confounding the research. To test this possibility, they injected rats with nicotine and then measured their blood sugar. They found a huge dose-dependent increase in blood sugar when they injected regular wild type rats that had been food-restricted. However, the increase might be stress-related from being picked up and injected. Further investigation indicated that at the standard dose used in self-administration in these experiments, there was no effect of nicotine on the rats’ blood sugar. However, if the dose of nicotine was more comparable to what human smokers actually consume, it activated the habenula and the animals became profoundly diabetic. Thus, an unexpected role for the habenula is controlling blood glucose levels. The researchers believe that the habenula, in concert with the NTS, is regulating the autonomic nervous transmission, i.e. communicating with organs outside the brain, including the pancreas. This could explain why smoking is a major cause of diabetes. Further research on that hypothesis in the patient population at Mt. Sinai is currently underway. 

Discussion: Dr. Koob observed that tobacco smokers, particularly women, smoke to control weight. He inquired if Dr. Kenny had looked at both males and females in his research. Dr. Kenny responded that the research includes both males and females. Females are slightly more sensitive; one can observe the effects of the knock-out at even lower doses of nicotine. 

Council Member Presentation: Characterizing the Cells Making Up the Brain: How Important is Distinctness (Variation)? 

Dr. Koob introduced Dr. James Eberwine, Elmer Holmes Bobst Professor of Systems Pharmacology and Experimental Therapeutics and AMD Co-Director of the Penn Program in Single Cell Biology at the University of Pennsylvania. Dr. Eberwine began his presentation by explaining that no two cells are exactly the same. There are an estimated 10 to the 12th number of neurons in the brain and perhaps ten times more glia. The neurons form synaptic connections with one another, and the glia and neurons work together to form functioning circuits as well. Dr. Eberwine’s laboratory is trying to sort through this vast complexity with the assistance of Junyhong Kim, Ph.D., a computational biologist at the University of Pennsylvania. 

Dr. Eberwine traced the history of the study of cells, from Robert Hook’s “Micrographia” (1665) to the development of modern cell theory 150 years later. Today, initiatives to understand single cells includes the Single Cell Analysis Program (SCAP); the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative; the European Blue Project; the Riken Marmoset Cell Census; the China Nonhuman Primate Cell Census; the Chan-Zuckerberg Initiative; and the International Cell Census. Recently, NIH announced the Human BioMolecular Atlas Program (HuBMAP) to facilitate research on single cells within tissues, as well as variability in normal tissue organization at the level of individual cells. 

Among the new research addressed in these initiatives are sequencing the DNA from an individual cell; chromatin dynamics to detect chromatin in individual cells; single cell epigenetics; single-cell transcriptomics; single-cell mRNA translation; single cell peptidomics and proteomics; single cell enzymology; and single cell metabolomics. Multi-modal analysis is a combination of these different procedures; a cellular phenotype is a transcriptome of a cell that emerges from such analysis. 

Research from Dr. Eberwine’s laboratory addresses the question: is transcriptome variability important? One of the take-home messages is that there are few individual cell types with specific genomes. Additionally, there’s an evolutionary conservation to the variation created between the cells. That suggests there’s a functional rationale for having variation in cells, which is one of the drivers for science’s interest in trying to understand the variation that exists. 

At the University of Pennsylvania, the Institutional Review Board (IRB) has allowed half of the tissue resected during neurosurgery to be used for research; it appears in Dr. Eberwine’s laboratory within ten minutes after resection, enabling the creation of live human neuronal cell cultures. This research is not possible with adult mice or rats, whose cells die. The human cells, in contrast, live. The researchers are examining how cells respond to various types of drugs. They can isolate, amplify, and analyze the RNA of individual cells, combining the physiology with the transcriptome. One intriguing aspect of this work was finding human neurospheres, collections of cells that will migrate out upon proper stimulation and emerge as new neurons and new astrocytes, i.e., different types of cells. This suggests something about the ability of the human brain to regenerate.


Once the scientists were able to remove the neurons and put them into culture where they’re separate from everything else, they wanted to study the epigene expression in cells in their natural micro-environment. In collaboration with University of Pennsylvania chemist Ivan Dmochowski, Ph.D., Dr. Eberwine and his colleagues conducted studies using a methodology called TIVA (transcriptome in vivo analysis) that allows them to characterize RNA in single cells in live tissue. One study addressed single cell sequencing in mouse hippocampal cells. One of the findings from this research addressed the number of genes expressed in a cell removed from the brain (about 12,000) compared to a cell that’s present in the brain (about 9,000). The researchers believe that those 9,000 genes represent the total capacity of the cell to be a hippocampal cell, independent of where the cell is in the hippocampus. The neuronal connection inhibits gene expression and tries to push the cell towards a particular function; this finding is also true in humans. In another study using live human tissue, the researchers addressed the atrophy of dendrites and axons, the processes in which learning, and memory occur that characterizes neurodegenerative disorders. They were interested in what the RNAs are in these structures, and whether or not they’re regulated by the disease process. Using TIVA, they examined the individual cell soma and analyzed the RNA in a specific subcellular region in its natural micro-environment.

Dr. Eberwine also presented new data, currently under review, about sequencing the genomes of mitochondria in order to search for mutations in the mitochondrial DNA. Each mitochondrion may have between one and ten genomes within it. Mutations between mitochondria are called heteroplasmy. Heteroplasmy increases with age, and there are many types of diseases associated with mitochondrial dysfunction. Dr. Eberwine and his colleagues sequenced the mitochondria genomes independently of one another to identify different types of mutations, then confirmed their findings with RNA sequencing of the mitochondrial RNA in the cell. The next step is to learn the factors that contribute to the increase in mutations within and between cells, and determine if there are ways to potentially manipulate them in order to develop therapeutic modalities that will intervene with mitochondrial diseases. 

Looking to the future, new imaging techniques are being developed that will allow scientists to examine the dynamical states of cells as they develop and change over time; the ability to do this relies on the critically important live cells types of biology. 

Dr. Eberwine concluded his presentation with a quote from Canadian writer Alice Munro the reflects the nature of single-cell biology: “The complexity of things, the things within things, this seems to be eminent.” He pointed out that simple data generation is insufficient; what’s important is understanding the meaning of the data, putting into a biological context, and using it to take biomedical science where it needs to go. 

Discussion: Dr. Koob asked how long the cultures of human cells live. Are scientists creating remnants of human beings that live forever? Dr. Eberwine replied that this was an important question, and no one knows the answer. Such concerns led him to join the neuroethics group where the issues can be considered. David Goldman, M.D., inquired about Dr. Eberwine’s evaluation of the relevance of IPFF neurons derived from iPSCs. Dr. Eberwine responded that the problem with induced pluripotent stem cells (iPSCs) is the instability of cell lines that are created, resulting in various off-target effects. There are mutations in the DNA for many different types of cells after IPS generation. Thus, IPS is a useful type of cell to use to generate cells of interest, but scientists must be careful. Susan Smith, Ph.D., posed a question of cellular philosophy, grounded in her approach that cell function and action occurs through group consensus in that cells have individual responses, but what happens in biology is driven by mass action. She asked if cells are stochastically going to have somewhat different patterns of expression and that each one must compensate from the loss of neighbor cells providing what it needs. Dr. Eberwine responded that the transcriptome is the thesaurus of itself. The process is not stochastic but regulated, wherein groups of RNAs give rise to a specific function. 

Public Comments 

Sis Wenger, President and CEO of the National Association for Children of Addiction (NACoA) expressed gratitude to NIAAA for providing the scientific basis of the arguments that the organization uses to advance its mission. She shared an article that appeared in Counselor magazine (June 2017) written by Robert Dennison, Vice Chair of the NACoA Board of Directors, that criticized the absence of any information about children of addiction in Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. She encouraged NIAAA to speak up about the intergenerational impact of alcohol use. Dr. Koob observed that ABCD study will provide useful information to NACoA. 


The meeting adjourned at 3: 27 p.m. 


 I hereby certify that, to the best of my knowledge, the foregoing minutes are accurate and complete.


George F. Koob, Ph.D.
National Institute on Alcohol Abuse and Alcoholism
National Advisory Council on Alcohol Abuse and Alcoholism 
Abraham P. Bautista, Ph.D.
Office of Extramural Activities
Executive Secretary
National Advisory Council on Alcohol Abuse and Alcoholism  
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