New Thinking About Addiction: NIAAA

Update

George F. Koob, Ph.D.

Director
National Institute on Alcohol Abuse and Alcoholism

National Press Foundation

April 11, 2018
Cost and Scope of Alcohol-Related Problems in US

Prevalence of disorder/disease
• In 2016, 6% (14.6 million) of
Millions in the US
people 18+ reached criteria for
0 20 40
alcohol use disorder (AUD)
Alcohol 14.6
Illicit drugs 6.6 • ~ 88,000 people die annually
Tobacco 28.6 from alcohol-related causes
Cancer 14.5
HIV/AIDS 1.2 • ~ 50% of all liver disease deaths
attributable to alcohol misuse

Cost to society • Increase in the intensity of

Billions of dollars binge drinking, ED visits and
0 200 400 hospitalizations in last 10 years
Alcohol 249
Illicit drugs 193 • <10% of people with AUD get
Tobacco 295 any treatment and fewer than
Cancer 217 4% receive pharmacotherapy
HIV/AIDS 36

Sources: Prevalence – NSDUH (2016) ages 18+ using DSM-IV criteria, NCI (2014), CDC (2016); Cost – CDC (2015), National Drug Intelligence
Center - National Drug Threat Assessment (2011), 2014 Surgeon General’s Report, NHLBI (2012), Hutchinson et al, 2006, Hingson et al, 2017
National Institute on Alcohol Abuse and Alcoholism
• NIAAA is the largest funder of alcohol research in the world

• Mission: Generate and disseminate fundamental knowledge about

the effects of alcohol on health and well-being, and
apply that knowledge to improve the diagnosis,
prevention, and treatment of alcohol-
related problems, including alcohol use
disorder (AUD) across the lifespan

Alcohol
• Budget:
• FY 2017 appropriation $483.4 million
• $16.7 million or a 3.4% increase over the FY 2016
• 686 Research Project Grants, 20 Centers, 109 Research
Careers, 305 Training Grants
• 5 divisions (Epidemiology and Prevention, Treatment and
Recovery, Neuroscience and Behavior, Metabolism and Health
Effects, Medications Development)
 Flow of Talk

1. Prenatal Alcohol Exposure

2. Adolescent Alcohol Exposure

3. Emerging Issues in Alcohol Misuse

4. Role of Alcohol in Opioid Epidemic

Prenatal Alcohol Exposure
 Research Update –FASD Research
Fetal alcohol spectrum disorders (FASD) – A broad range of health effects
caused by prenatal alcohol exposure: Red indicates
where facial
features are
•Fetal alcohol syndrome (FAS) contracted;
•Partial FAS blue where
they are
•Alcohol-Related Neurodevelopmental Disorder expanded, and
green where
•Alcohol-Related Birth Defects they are
similar in the
individual with
Most profound effects are brain damage and the resulting FAS compared
to age-
impairments in behavioral and cognitive functioning. matched
controls

A new NIAAA-supported study determined the prevalence of FASD ranged

from 1.1 – 5% among four U.S. communities
• > 6,600 first grade children examined using comprehensive criteria based
on facial features, growth, and neurodevelopmental performance
• Communities in the Midwest, Rocky Mountain, Southeast and Pacific
Southwest selected to be more reflective of U.S. community populations
• Further evidence that FASD is a significant public health problem and
strategies to expand screening, diagnosis, prevention, and treatment in
communities are needed
The Hand-Held 3-D Camera

Red indicates
where facial
features are
contracted; blue
where they are
expanded, and
green where they
are similar in the
individual with
FAS compared to
age-matched
controls

NIAAA funded researchers developed 3-D photography and image analysis

techniques to enhance detection of alcohol-induced facial features in children
prenatally exposed to alcohol.
Adolescent Alcohol Exposure
 The Science: Frontal Lobe Changes During
Adolescence

• Planning, decision-making, impulse control,

memory, language, processing social cues
• Gray matter goes down, white matter goes
up, overall size stays about the same

From: Ball W et al with the Brain Development Cooperative Group (2012). Total and regional brain volumes
in a population-based normative sample from 4 to 18 years: the NIH MRI Study of Normal Brain
Development. Cerebral Cortex, 22(1):1-12.
 The Science: National Consortium on
Alcohol and Neurodevelopment in
Adolescence (N-CANDA)
• Ongoing multisite longitudinal study of more than 800 youth ages
12-21 using advanced brain images and other tools
• Objectives:
– To elucidate the short- and long-term effects of alcohol exposure
on the developing brain
– To identify brain structural and functional anomalies that result
from alcohol exposure as well as predict onset of AUD and other
psychopathology
• N-CANDA has already generated a number of important research
findings including evidence that youth who drink heavily show
structural abnormalities in the frontal cortex of the brain
• N-CANDA’s success demonstrated the much larger Alcohol Brain
Cognitive Development (ABCD) Study could be done successfully
 The Science: Research Update – NCANDA
National Consortium on Alcohol and Neurodevelopment in Adolescence

Brain regions where heavy drinking adolescents have steeper reductions

in gray matter volume than no/low drinking adolescents

Source: Pfefferbaum et al. Am J Psychiatry 2017

Adolescent Brain Cognitive Development (ABCD)
Study

Time

More than 8,000 children enrolled to date

 Prevention: Screening and Brief Intervention
• Research indicates adolescent alcohol screening and brief
intervention can be effective
• 6 studies are evaluating NIAAA’s Alcohol Screening and Brief
Interventions for Youth: A Practitioners Guide in:
– primary care
– emergency departments
– with children with a chronic medical illness
– schools
– juvenile justice settings
• School-based universal SBI grounded in the NIAAA youth
screening guide, as well as a community-based intervention,
both reduced overall alcohol use among American Indian and
other youth in rural areas. Komro et. al. Am J Public Health, 2017

Opportunity for CADCA Coalitions – Encourage health care

providers to screen for youth alcohol misuse in their practices.
 Prevention: Underage Drinking
Any successful approach must consider many factors, including:

• Genetics • Level of risk

• Personality • Social factors
• Rate of maturation and • Environmental factors
development

Evidence-based approaches can prevent and reduce youth alcohol misuse:

• Environmental interventions
• Limit access to alcohol, e.g. enforcing the minimum drinking age of 21
• Zero-tolerance laws - outlaw driving after any amount of drinking for
youth
• Individual-level interventions - change the way young people think about
alcohol, so they are better able to resist pressures to drink
• School-based interventions - provide students with the knowledge, skills,
motivation, and opportunities they need to remain alcohol free
• Family-based interventions - empower parents to set and enforce clear
rules against drinking, as well as improve communication between
children and parents about alcohol
 Prevention: The Case for Screening and Brief
Intervention
• 2012: U.S. Preventive Services Task Force recommends
alcohol screening and brief intervention for adults in
primary care

• Alcohol screening and brief intervention recognized as

one of the highest ranking preventive services among 28
effective services. Maciosek et al., Annuals of Family Medicine, 2017

• Similar score as screening for:

- cervical cancer
- colorectal cancer
• NIAAA provides a Clinician’s Guide to
facilitate alcohol screening in adults.
Emerging Issues in Alcohol Misuse
 More women in the United States are
drinking and they are drinking more often

White A, Castle IJ, Chen CM, Shirley M, Roach D, Hingson R. (2015) Converging Patterns of Alcohol Use and Related
Outcomes Among Females and Males in the United States, 2002 to 2012. Alcohol Clin Exp Res, 39(9):1712-26.
 Emerging Issues – Alcohol and Women’s Health

• Gaps between women and men are narrowing for

prevalence, frequency and intensity of drinking, early onset
drinking, having AUD, drunk driving, and self-reported
consequences (Slade et al., 2016; White et al, 2017)

• Women more likely to experience blackouts, liver

inflammation, brain atrophy, cognitive deficits, certain
cancers, and to experience negative affect during
withdrawal and stress or anxiety-induced relapse (Becker and
Koob, 2016)

• But we still know very little about why

• Out of 230 structural neuroimaging studies on substance

use over 23 years only 26% evaluated sex differences (Lind et
al., 2017)
Sources – Lind K et al (2017) Drug Alc Dependence; Slade T et al (2016) BMJ Open; White A et al (2015) ACER
 Emerging Issues – More People Aged 65+ Are
Drinking and Binge Drinking

Source – Breslow R, et al (2017) Trends in Alcohol Consumption Among Older Americans:

National Health Interview Surveys, 1997 to 2014. ACER, 41, 976-986
Emerging Issues – Increase in Alcohol-Related
Emergency Department Visits

The rate of ED visits involving alcohol in the U.S. population aged ≥12 increased
47% between 2006 and 2014, yet per capita consumption increased <2% during
the same time period. The number of alcohol-related ED visits increased from
3,080,214 to 4,976,136. Increases were larger for women.
Source: White, A. et al 2018, Alcohol Clin Exp Res
 Emerging Issues – Extreme Binge Drinking

Binge drinking – 4+ drinks for women, 5+ drinks for men, on an occasion

Extreme binge drinking – consuming 2 or more times these thresholds
• Nearly 32 million adults engaged in extreme binge drinking

(Hingson, R. et. al. 2017, Am. J. Prev. Med.)

 Emerging Issues: Urgent Need to Grow the
Addiction Medicine Workforce
• Many providers do not perform screening, are not aware of evidence-
based treatments or where to refer people

• A study of 54 primary care clinics found 88% had no policies or

requirements to ask patients about alcohol use, and those with
policies had no consistent evidence-based methods for screening
or referral (Mertens et al., 2015)

• Goals:
• Improve physician training in substance use
prevention and treatment at all levels, from
undergraduate and graduate medical education
through residency, fellowship, and beyond

• Integrate prevention, early intervention, and

treatment into routine medical care
 Increasing Participation of Under-Represented
Minorities in Clinical Trials

• As the diversity of the US population increases, so should the

participation of under-represented groups in NIAAA-sponsored
clinical research.
• The availability of research measures in non-English
languages is one way to help enhance participation
by underserved populations.
• NIAAA has launched an effort to create a database
of alcohol measures in Spanish and Asian languages to:
• Increase minority research participation
• Encourage investigators to include underserved
populations
• Lower overall costs to engage linguistic minorities in
clinical research
Role of Alcohol in the Opioid Epidemic
Alcohol and Opioids: A Dangerous Combination
Increase in Emergency Department Visits

Alcohol involved in ~15% of cases each year

Alcohol and Opioids: A Dangerous Combination
Increase in Prescription Opioid Overdose Deaths
18,000 Alcohol involved in ~15% of cases 3,000

# opioid analgesic deaths involving alcohol

16,000
2,500
14,000
12,000 2,000
# opioid analgesic deaths

10,000
1,500
8,000
6,000 1,000
4,000
500
2,000
0 0

Opioid analgesic deaths Opioid analgesic deaths involving alcohol

Source: CDC-WONDER, Multiple Cause of Death Data

Neural Circuits of the Withdrawal/Negative
Affect Stage

Key Neurochemical Systems

• CRF
• dynorphin
• norepinephrine
• vasopressin
• hypocretin (orexin)
• neuroimmune

Adapted from: George O, Koob GF. Proc Natl Acad Sci USA, 2013, 110:4165-4166.
Neurobiological Circuitry of the Overlap of
Pain and Addiction
 Martha Woodroof: Alcohol Provided Relief from
My Emotional Pain

I grew up professionally focused and personally adrift.

There's a long history of depression in my family, and my
childhood home was dominated by my mother's mental
illness that was not recognized, let alone treated.
Sometime in my mid-thirties I started using alcohol to
provide relief from the pain of childhood damage and
organic depression. Bourbon was the only thing that
would make the loop tape of despair in my head pipe
down.
- Martha Woodroof, former public radio
journalist and late-blooming novelist
 Alcohol Reduces Pain Sensitivity at Doses that
Exceed Low- Risk Drinking
Highlights
• Meta-analysis of 18 controlled
experiments comparing pain in people
given alcohol versus no-alcohol
• Findings support the pain reducing
effects of alcohol
• A mean BAC of ~0.08% (legal driving
limit) produced a small elevation in
pain threshold and a significant
reduction in pain intensity
• Higher BAC is associated with greater
pain insensitivity
• These effects could explain alcohol
misuse in those with persistent pain
despite its potential consequences for
long-term health
Source: Thomspon et al (2017) The Journal of Pain, 18, 499-510.
Increased Pain Sensitivity in Alcohol
Withdrawal

Source: Jochum T, Boettger MK, Burkhardt C, Juckel G, Bar KJ. Eur J Pain, 2010, 14:713-718.
 NIAAA
Your source for credible,
evidence-based
information about alcohol
and health.

www.niaaa.nih.gov
 Brand New – NIAAA Treatment Navigator

• To assist people in finding AUD treatment, NIAAA has

developed the NIAAA Alcohol Treatment Navigator℠

• One-of-a kind resource that:

 Outlines the features of
evidence-based AUD
treatment
 Describes the varied
routes to recovery
 Provides a strategy for
locating qualified
treatment specialists

• Launched October 3, 2017

AlcoholTreatment.niaaa.nih.gov