The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 launched the National Institute on Alcohol Abuse and Alcoholism, authorizing NIAAA “to develop and conduct comprehensive health, education, training, research, and planning programs for the prevention and treatment” of alcohol-related problems. Called the “Hughes Act,” after its champion, Iowa Senator Harold E. Hughes, the legislation highlighted alcohol misuse as a major public health issue. NIAAA’s launch was an important step in advancing America’s understanding that alcohol use disorder (AUD) is a preventable and treatable medical disorder. Today, AUD is recognized as a spectrum disorder, from mild to severe, mirroring other chronic diseases and demonstrating that distinct symptoms of AUD can vary among individuals.
Tracking Patterns and Trends in Alcohol Misuse
Alcohol epidemiological surveys are useful tools for understanding the scope and outcomes associated with alcohol misuse. The findings of such surveys are instrumental in informing prevention and treatment of alcohol-related problems. In addition to supporting extramural epidemiological studies, NIAAA advanced alcohol epidemiology by conducting two major surveys of adults: the National Longitudinal Alcohol Epidemiologic Survey (NLAES) and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). NLAES and NESARC represent the largest, most comprehensive alcohol surveys ever conducted in the United States. Both collected critical data about alcohol consumption, family history of AUD, treatment, and co-occurring psychiatric conditions such as major depressive disorder. More recently, NIAAA established a DNA repository of more than 23,000 samples collected as part of the last NESARC survey, NESARC-III, to facilitate research on the contributions of gene-environment interactions to AUD and co-occurring disorders. NLAES and NESARC have had an substantial impact on the work of the wider alcohol research community, including informing the development of the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) and the Global Burden of Disease Project.
A New Challenge: Fetal Alcohol Spectrum Disorders
Soon after NIAAA’s establishment, groundbreaking reports about “fetal alcohol syndrome” demonstrated alcohol’s negative effects on prenatal development. NIAAA quickly marshalled resources, funding new grants to investigate birth defects associated with prenatal alcohol exposure. Experts now use the term “fetal alcohol spectrum disorders” (FASD) to reflect the broad range of lifelong effects associated with prenatal alcohol exposure. Early scientific evidence generated by NIAAA-supported studies informed legislation in 1988 requiring government warning labels on alcohol beverage containers. In 1996, NIAAA established the Interagency Coordinating Committee on Fetal Alcohol Spectrum Disorders (ICCFASD) to improve communication and collaboration on issues related to prenatal alcohol exposure. More recently, methodological advances have enabled initiatives such as the Collaboration on FASD Prevalence to more accurately estimate the prevalence of FASD in U.S. communities, demonstrating rates on par with autism spectrum disorders. Today, basic, translational, and clinical research programs including the Collaborative Initiative on Fetal Alcohol Spectrum Disorders continue to provide valuable insight into the trajectory, underlying mechanisms, prevention, screening, early diagnosis, and treatment of FASD.
Defining Binge Drinking
To advance scientific consensus across the alcohol research community, NIAAA convened a multidisciplinary task force of experts in neurobiology, physiology, psychology, and sociocultural research to determine the factors that distinguish binge drinking from other patterns of alcohol misuse. In 2004, NIAAA’s National Advisory Council approved the experts’ recommended definition: A “binge” is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gram percent or above. For the typical adult, this pattern corresponds to consuming 5 or more drinks (male), or 4 or more drinks (female), in about 2 hours. Binge drinking is clearly dangerous for the drinker and for society. Today, this definition of binge drinking is widely used by researchers, policymakers, and the general public.
Advancing Wearable Alcohol Biosensor Technology
The ability to monitor a patient’s drinking in real-time can be an invaluable tool for improving the success of AUD treatment. In 2015, NIAAA launched the Wearable Alcohol Biosensor Challenge, an innovative competition to encourage the design of a discreet, wearable device capable of measuring blood alcohol levels in near real-time. Such a device could aid researchers, clinicians, therapists, and individuals by providing more accurate data on how much a person is drinking. The challenge culminated in a 1st Prize of $200,000 awarded to BACtrack Inc., and a 2nd Prize of $100,000 to Milo Inc., for their successful production of working prototypes that measure blood alcohol levels in near real-time, and stimulated interest in a new generation of alcohol biosensor devices.
Providing Scientific Evidence for U.S. Surgeon General Reports
In addition to contributing scientific evidence for the U.S. Surgeon General’s warnings about prenatal alcohol exposure in 1981 and 1989, NIAAA-supported research provided much of the scientific foundation for two landmark publications. In 2007, The Surgeon General's Call to Action to Prevent and Reduce Underage Drinking focused national attention on underage alcohol use, including the potential vulnerability of the developing adolescent brain to negative consequences from alcohol use. In 2016, the release of Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health marked the first such report focused on alcohol and other substance misuse and substance use disorders.
Fostering Innovative Research—The Alcohol Research Centers
In 1976, Congress passed a law to establish the National Alcohol Research Centers Program, the goal of which was to provide stable, long-term support for alcohol research and serve as a platform for research training and dissemination. The Alcohol Research Centers are research programs at institutions across the nation that serve as an incubator for interdisciplinary, collaborative research and research training on a wide range of topics that are important to the NIAAA mission. The Centers program has grown from five Centers in 1977 to more than twenty Centers today, and has made significant contributions towards our understanding of the causes, consequences, diagnosis, prevention, and treatment of alcohol-related problems.
Harnessing Neuroscience to Advance Alcohol Research
At the time NIAAA was established, little was known about how alcohol influenced brain function. Over the past five decades, NIAAA-supported basic, translational, and clinical research has made major strides in shedding light on the neurotransmitter systems and neurobiological mechanisms that are altered by alcohol misuse. In addition to conducting cutting-edge neuroscience research in the NIAAA Intramural Research Program and supporting an extensive portfolio of innovative extramural research projects, the Institute established several research consortia to examine alcohol’s effects on the brain and behavior across the lifespan. For example, in 2001, NIAAA established and later expanded the Integrative Neuroscience Initiative on Alcoholism (INIA), a translational, multidisciplinary, and collaborative research effort studying brain mechanisms that underlie alcohol misuse and their relationships with AUD, stress, and anxiety. In 2012, NIAAA launched the National Consortium on Alcohol and Neurodevelopment in Adolescence (NCANDA), a longitudinal study of approximately 800 youth to identify the brain precursors and consequences of adolescent alcohol use. NCANDA would go on the lay the methodological foundation for NIH’s Adolescent Brain Cognitive Development (ABCD) study, the largest long-term study of brain development and child health in the United States. The advances contributed through NIAAA’s research programs in neuroscience and behavior have helped to establish a heuristic framework for understanding the brain circuitry mediating AUD, enabled a deeper understanding of the pathological mechanisms of alcohol misuse and co-occurring conditions, and revealed a wide range of targets for prevention and treatment.
Understanding the Role of Genetics in Alcohol Use Disorder
By the 1970s, many studies had clearly demonstrated an association between family history of alcohol problems and AUD, although the exact contribution of family history remained unclear. NIAAA has built upon this evidence base, supporting family-based studies, such as the Collaborative Study on the Genetics of Alcoholism (COGA) launched in 1989, and numerous extramural and intramural studies. These research efforts have established that genetic factors account for about half of an individual’s risk for developing AUD. Additional studies have revealed that a wide range of genes are involved in the physiological, behavioral, and neurobiological processes that play a role in AUD. Further research has demonstrated that AUD risk is influenced by the complex interplay between genetic and environmental influences, contributing to the vast heterogeneity seen among individuals with the disorder. Today, methodological and technological innovations in genomics and big data are enabling researchers to integrate genetic, neurobiological, and other key behavioral and biological information to enhance understanding of the key mechanisms that contribute to AUD and to help guide AUD prevention and treatment.
Investigating Alcohol-Related Organ Damage
NIAAA-funded scientists first linked alcohol misuse directly to liver disease in 1975. In the decades since, research has helped clarify the mechanisms involved in alcohol-associated liver disease (ALD) and expanded our understanding of alcohol’s effects on other organs and systems. For example, it is well-established that alcohol misuse compromises the immune system, increasing the risk of infections. Research has also yielded important discoveries about the role of gut permeability in ALD and the central role of inflammation as a mechanism of alcohol-related organ pathology, including the lung and acute respiratory distress syndrome. The development of animal models of liver injury as well as studies on the cellular and molecular mechanisms of alcohol-induced organ damage have also enabled the identification of potential therapeutic targets for ALD. The research efforts described above as well as many other extramural and intramural studies have paved the way for advancing research on mechanisms and potential therapies for alcohol-related organ damage, such as the work being conducted by the Alcoholic Hepatitis Network (AlcHepNet), a network of basic, translational, and clinical research sites aimed at accelerating the development of effective treatments for alcohol-associated hepatitis, a severe and potentially life-threatening form of ALD.
Developing Medications for Alcohol Use Disorder
The introduction of disulfiram, a drug approved in 1951 by the Food and Drug Administration (FDA), spotlighted the potential of pharmacological approaches for treating AUD. Decades later, pivotal scientific evidence from NIAAA-supported studies helped achieve FDA approval of two new medications: naltrexone, approved in 1994, and acamprosate, approved in 2004. NIAAA-supported studies also provided the foundation for the FDA’s more recent change in AUD clinical trial endpoints, opening the door for potential regulatory approval of more candidate AUD medications. In addition to supporting a vast range of preclinical and clinical studies, in 2007, the Institute established the NIAAA Clinical Investigations Group (NCIG), a network of sites established to accelerate phase 2 clinical trials of promising compounds, and later expanded NCIG to include early human laboratory studies. Today, NIAAA maintains a very robust medications development program comprising extramural and intramural research and spanning the medications development pipeline.
Expanding Evidence-Based Treatment Options
NIAAA-supported research has generated an extensive evidence base supporting the effectiveness of AUD behavioral treatments that are commonly used today. This evidence has also informed the treatment of other substance use disorders. Building on the findings of alcohol treatment research at the time, NIAAA initiated Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity, conducted 1989-1996) and the Combined Pharmacotherapies and Behavioral Intervention (COMBINE) study (conducted 2001-2003), two of the largest multisite alcohol clinical trials ever conducted. These studies made significant contributions to our understanding of AUD treatment effectiveness and laid the foundation for research on alcohol-related mechanisms of behavior change. In 2007, NIAAA developed Rethinking Drinking, a website and booklet that draws upon principles of behavioral treatment and behavior change, to help individuals assess their relationship with alcohol. To date, over 1.6 million copies of the booklet have been distributed. Behavioral therapies continue to be a key component of AUD treatment and the growth of mobile health technologies have greatly improved accessibility of these therapies for patients.
Closing the Treatment Gap
NIAAA has a long tradition of developing strategies to close the treatment gap. NIAAA produced Helping Patients Who Drink Too Much: A Clinician's Guide, as well as Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide to assist clinicians in conducting alcohol screening and brief interventions (SBI) for adults and people aged 9-18, respectively. The evidence base supporting alcohol SBI also contributed substantially to the U.S. Preventive Services Task Force’s recommendation of alcohol SBI for adults in primary care, a service that has been ranked among the top cost-saving preventive services. NIAAA support has helped to pave the way for the integration of addiction medicine into graduate medical education and lay the groundwork for addiction medicine being recognized as a medical subspecialty. NIAAA and the Substance Abuse and Mental Health Services Administration jointly convened a consensus panel to review the current evidence on the effectiveness of AUD medications and develop guidance for their use in clinical practice, resulting in the 2015 publication Medication for the Treatment of Alcohol Use Disorder: A Brief Guide. In response to many appeals from the public seeking AUD treatment, NIAAA launched the NIAAA Alcohol Treatment Navigator®, a comprehensive, easy-to-use resource to help individuals in understanding and finding treatment for alcohol problems. In 2019, NIAAA added a clinician’s portal to the Alcohol Treatment Navigator to assist health professionals in making treatment referrals for their patients.
Preventing and Reducing Underage Drinking and Alcohol-Related Consequences—The Leadership to Keep Children Alcohol Free
Historically, preventing and reducing alcohol misuse and related consequences has been a major research priority for NIAAA. One example involves the prevention of underage drinking—an important public health issue that NIAAA has addressed on multiple fronts—and these efforts have helped to contribute to a steady decline in underage drinking over the past two decades. Seminal research funded by NIAAA demonstrated that young people who begin drinking before age 15 are four times more likely to report symptoms of AUD at some point in their lives compared to those who wait until they are 21 or older. NIAAA research also helped provide much of the evidence concerning the effectiveness of the minimum legal drinking age (MLDA) of 21—a key public health strategy that has helped to save lives. In addition to public policy research, NIAAA has collaborated on underage drinking prevention programs with important stakeholders such as The Leadership to Keep Children Alcohol Free. This non-partisan, public-private coalition led by the Governors’ spouses partnered with the U.S. Surgeon General’s office, the American Academy of Pediatrics, and other health organizations, as well as with federal, state and local government representatives. The Leadership developed educational resources used by communities, schools, and families across the country. At the same time, NIAAA has continued to work broadly on underage drinking issues through scientific collaboration. One such effort was the NIAAA Underage Drinking Research Initiative that was established in 2004 with the goal of understanding and addressing underage drinking within the context of overall development and improving prevention and treatment interventions.
Addressing the Problem of College Drinking
In 1976, NIAAA issued its first report on college drinking. This report was followed by research that expanded our understanding of the factors that influence college drinking and resulted in the development of strategies for preventing and reducing alcohol misuse among college students. In 1998, NIAAA convened the Task Force on College Drinking that culminated in A Call to Action: Changing the Culture of Drinking at U.S. Colleges published in 2002. This landmark report gave national visibility to the importance of reducing binge drinking and alcohol-related consequences among college students. NIAAA continued to support pivotal research on individual and environmental college interventions and, in 2015, based on input from NIAAA’s College President’s Working Group, developed CollegeAIM—the College Alcohol Intervention Matrix, a resource to guide college and university officials in reducing student drinking and related problems on their campuses. Today, thanks to the efforts of NIAAA, researchers, colleges and universities, and numerous other stakeholders, current drinking and binge drinking among college students are at the lowest rates observed in this population.
Reaching Broad Audiences—Partnerships with HBO
In 2016 NIAAA experts collaborated with HBO Documentary Films on an acclaimed documentary, Risky Drinking. This 85-minute film spotlights alcohol’s impact on the lives of four individuals and features commentary by NIAAA Director George F. Koob, Ph.D., and NIAAA Medical Project Officer Deidra Roach, M.D. Previously, NIAAA worked together with HBO, the National Institute on Drug Abuse (NIDA), and others to produce Addiction, a documentary that won an Emmy-award in 2007. Such public-private collaborations underscore NIAAA’s commitment to disseminate research findings to broad audiences.