NIAAA: Researching Alcohol in America

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1 NIAAA: Researching Alcohol in America Patricia Powell, Ph.D. Deputy Director National Institute on Alcohol Abuse and Alcoholism The NABCA Administrators Conference October 24, 2017

2 The National Institutes of Health NIH is the steward of medical and behavioral research for the United States. Its mission is science in pursuit of fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to extend healthy life and reduce the burdens of illness and disability.

3 The National Institute on Alcohol Abuse and Alcoholism (NIAAA) NIAAA is one of the 27 Institutes and Centers of the National Institutes of Health The Institute focuses on alcohol and its impact on health and development The FY 2017 appropriation for NIAAA provided $483.4 million Just over 82% went to support research at extramural institutions

4 Cost and Scope of Alcohol Related Problems Prevalence of disorder/disease Millions in the US Alcohol Illicit drugs Tobacco Cancer HIV/AIDS Cost to society Alcohol Illicit drugs Tobacco Cancer HIV/AIDS Billions of dollars ~ 88,000 people die annually from alcoholrelated causes in the U.S. ~ 50% of all liver disease attributable to alcohol misuse in the U.S. Increase in Emergency Department visits and hospitalizations related to alcohol in last 10 years <20% of people with AUD get any treatment for AUD; <10% get a medication Sources: Prevalence NSDUH (2015) ages 12+ 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

5 NIAAA: The Source for Credible Research Information on Alcohol & Health

6 Surgeon General s Report on Alcohol, Drugs, and Health First ever SGR addressing alcohol, other substance misuse, and SUDs Under SAMHSA s lead, NIAAA and NIDA played key roles in report development Presents state-of-the-science, with focus on: Neurobiology co-authored by Drs. Koob and Volkow Prevention Treatment Recovery Delivery of care Outlines future directions and recommendations for action

7 HBO Documentary on Risky Drinking Produced in conjunction with NIAAA and featuring NIAAA experts Described as a no-holds-barred look at AUD through the intimate stories of four people whose drinking dramatically affects their relationships Aims to provoke conversation about how to identify risky drinking and to suggest alternatives to a one-size-fitsall approach for treating it Opportunity for screenings and discussion panels Premiered December 19, 2016

8 Alcohol Policy Information System 35 Policy Topics, 1998-present: Alcohol control systems Alcohol beverage taxes DWI laws BAC limits (adults, youths) Health insurance parity Insurers liability for losses due to intoxication (UPPL) Vehicular insurance exclusions Underage drinking policies Keg registration Beverage server training Hours/Days sale Alcohol and pregnancy Recreational marijuana Open container laws (

9 APIS Coverage Taxation Underage Restrictions Driving Under the Influence Cultivation Restrictions Retail Outlets On Premises Consumption Product Types Permitted Pricing Controls Local Authority Primary State Agency

10 NIAAA Strategic Plan: Strategic Priorities Identify Mechanisms of Alcohol Action, Alcohol-Related Pathology, and Recovery Improve Diagnosis and Tracking of Alcohol Misuse, Alcohol Use Disorder, and Alcohol-Related Consequences Develop and Improve Strategies to Prevent Alcohol Misuse, Alcohol Use Disorder, and Alcohol-Related Consequences Develop and Improve Treatments for Alcohol Misuse, Alcohol Use Disorder, Co-occurring Conditions, and Alcohol-Related Consequences Enhance the Public Health Impact of NIAAA-Supported Research

11 Alcohol Issues Across the Lifespan NIAAA supports research to study how alcohol can affect health and wellbeing at various stages of life. Alcohol Lifespan Transcending Themes Neurobiology Metabolism Genetics Epigenetics Epidemiology Health Services Research Alcoholic Family Environment Alcohol Dependence Medication Interactions Prenatal Alcohol Exposure Binge Drinking Organ Damage

12 Some Specific Areas of Interest Fetal alcohol spectrum disorders Alcohol and the developing adolescent brain Extreme binge drinking Interventions for alcohol misuse and consequences by college students Alcohol use by women and girls Alcohol and aging Alcohol and marijuana use and consequences Alcohol involvement in opioid overdoses Navigating alcohol treatment Long term recovery Medications development The effects of moderate alcohol consumption on cardiovascular health

13 Fetal Alcohol Spectrum Disorders Research Characterize biological mechanisms underlying FASD and biological and environmental factors contributing to it Identify biomarkers of prenatal alcohol exposure Improve FASD diagnosis Advance 3-D facial imaging technology to detect FASD in a broader range of people and settings Distinguish individuals with FASD from those with other neurodevelopmental conditions Establish more precise FASD prevalence estimates Develop interventions to prevent and reduce alcohol misuse during pregnancy

14 National Consortium on Alcohol and Neurodevelopment in Adolescence (N-CANDA) Ongoing multisite longitudinal study of more than 800 youth ages using advanced brain images and other tools Objectives: To elucidate the short- and long-tem 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 that the much larger Alcohol Brain Cognitive Development (ABCD) Study could be done successfully

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16 Abnormal gray matter volume loss in heavy versus light drinking college students Gray matter volumes decreased more over 2 years in sustained heavy drinking (average 48 drinks/month) compared to sustained light drinking (average 2 drinks/month) college students beginning at average age 18.5 This pattern of greater gray matter decline in heavy users occurred largely in regions responsible for emotion, memory, mental flexibility, and decision making, all of which might have a direct impact on student college success. - Meda et al (2017) Source: Meda SA et al (2017) Heavy drinking in college students is associated with accelerated gray matter volumetric decline over a 2 year period. Frontiers Behav Neurosci 11:176: Gray matter volume loss in heavy versus light drinkers Less More

17 Binge drinking during adolescence reduces the integrity of white matter tracts in the corpus callosum Binge drinking teens aged 16-19, average 15 drinks per month, with no history of alcohol use disorder had lower functional anisotropy (FA; a measure of white matter integrity) in 18 white matter areas including the corpus callosum (above). Lower FA in 6 of the areas was linked to greater lifetime hangover symptoms and/or higher estimated peak blood alcohol concentrations in the last three months. Source: McQueeny et al (2009). Altered white matter integrity in adolescent binge drinkers. Alcoholism: Clinical and Experimental Research, 33(7):

18 Binge drinking during adolescence reduces the integrity of white matter tracts in several brain areas Binge drinking teens aged 16-19, average 15 drinks per month, with no history of alcohol use disorders had lower functional anisotropy (FA; a measure of white matter integrity) in 18 white matter areas including the corpus callosum and corona radiata (below). Lower FA was linked to greater lifetime hangover symptoms and/or higher estimated peak blood alcohol concentrations in the last three months. White matter Allows for fast and efficient communication between brain areas Source: McQueeny et al (2009). Altered white matter integrity in adolescent binge drinkers. ACER 33(7):

19 Model of epigenetic reprogramming by alcohol during adolescence Model suggests binge alcohol exposure during adolescence can produce persistent effects on chromatin remodeling, synaptic plasticity, and brain function into adulthood, increasing the likelihood of alcohol use disorder (AUD) (Source: Kyzar et al., 2016)

20 College Binge Drinking and Blackout: Prevalent Among College Students Past month binge drinking among college students: 1 Overall: 37.9% Male: 39.4% Female: 36.5% Blackouts are common: A 2012 survey of 26,000+ college students found that 32% experience a blackout each year (34% male, 31% female) 2 Blackout frequency predicts other alcohol-related consequences 17% of males and 22% of females blacked out Source: Hingson et al., 2016, ACER 1 National Survey of Drug Use and Health, SAMHSA, 2016; 2 American College Health Association, 2012

21 Young Adult Alcohol-Related Emergency Department Visits On the Rise Number of visits Alcohol related ED visits among year olds Male Female Source: Nationwide Emergency Department Sample, HCUP; ICD-9 codes: 980 (toxic effect of alcohol), E860 (accidental poisoning alcohol), (acute alcoholic intoxication), (nondependent alcohol abuse), (excessive blood alcohol level)

22 And, There was a 67% Increase In Hospitalizations Related To Alcohol Overdoses In Year Olds Between ~ ½ alcohol only (up 25%) ~ ½ alcohol + other drugs (up 76%) From: White, AM et al. (2011). Hospitalizations for Alcohol and Drug Overdoses in Young Adults Aged in the United States, : Results from the Nationwide Inpatient Sample. J Studies Alcohol Drugs, 72(5):

23 Available Interventions Can Address Harmful and Underage Drinking among College Students NIAAA-supported research has shown that individual and environmental interventions can be effective in preventing and reducing harmful and underage college student drinking. In response to a request from NIAAA s College Presidents Working Group, NIAAA commissioned a group of researchers to develop an interactive, user-friendly decision support system to help colleges and universities navigate existing strategies and select those appropriate for their school. The Presidents specifically pointed to the need for a clear, easy-tounderstand tool to facilitate decisions about alcohol interventions to help compare a range of strategies, understand costs and effectiveness, and select a mix that best meets each schools needs.

24 Resources for Colleges and Universities CollegeAIM Alcohol Intervention Matrix is a guide and interactive website to help schools address harmful and underage student drinking. While there are numerous options for addressing college drinking, they are not all equally effective. The centerpiece of the guide is a user-friendly, matrix-based tool developed with input from leading college alcohol researchers, along with college student life and alcohol and other drug (AOD) program staff.

25 Development Process Phase I: involved identifying the interventions to be included in CollegeAIM and the factors by which they would be evaluated. Phase II: involved analyzing the substantial research literature on college alcohol interventions and rating each of the interventions according to those factors. Ultimately, the development teams examined and rated nearly 60 interventions on their relative effectiveness, costs, barriers to implementation, and amount and quality of research, among other variables.

26 Intervention Characteristics Relative Effectiveness insufficient, not effective, limited, moderate, higher Amount /Quality of Research 0, +, ++, +++, ++++ Relative Monetary Costs for Program and Staff for Adoption and Implementation/ Maintenance lower, mid-range, higher Relative Magnitude of Barriers higher, moderate, lower Staffing Expertise policy advocate, coordinator, health professional Strategy Level federal, state, local, college Public Health Reach broad vs. limited Targeted Population underage, all students, individuals, small groups Research Population college vs. general Short/Long-term Effects (individual-level only) short-term effects (yes/no), long-term effects (yes/no), not assessed Primary Modality (individual-level only) individual, group, online

27 Development Process In the next phase, an additional 10 college alcohol researchers reviewed the analysis, applied their knowledge and professional judgment, and provided detailed feedback for refinements. Through multiple rounds of reviews and revisions, this consensus process distilled the results of decades of research and hundreds of studies into a user-friendly decision tool.

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29 Click on strategies to print for reference or discussion.

30 Select a strategy to see ratings, references, and potential resources.

31 Campuses are encouraged to use to: Review the individual and environmental-level interventions to learn how their current strategies compare to other alternatives. Find new evidence-based options to consider. Select a combination of approaches that best meets the needs of their campus and their budget.

32 More Women in the US Are Drinking and 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 Alcohol Clin Exp Res, 39(9):

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34 More Older Americans Are Drinking Upward trend in prevalence of drinking among adults 60+ years old, particularly women, between Breslow RA, Castle I JP, Chen CM, Graubard BI. Alcohol Clin Exp Res, March 2017

35 Alcohol Screening is an Effective Prevention Strategy Alcohol screening in primary care reduces alcohol misuse among adults Adult screening recommended by U.S. Preventive Services Task Force Mounting evidence that screening is effective for preventing and reducing youth alcohol misuse NIAAA supports research to evaluate youth alcohol screening in primary care and other settings NIAAA s 2-question youth alcohol screener is effective for identifying alcohol use and AUD among rural youth and youth with chronic health conditions

36 Integrating Addiction Medicine into Medical Education NIAAA grant to SUNY Buffalo to translate addiction into clinical practice in collaboration with American Board of Addiction Medicine Paved the way for integrating addiction medicine into postgraduate medical education at 37 academic medical centers Provided model for residency training in addiction medicine Laid groundwork for recognizing addiction medicine as a subspecialty by American Board of Medical Specialties NIAAA and other federal agencies engaged with White House on a national effort to grow the addiction medicine workforce Next steps: Identify medical school curriculum needs and enhance addiction medicine questions on medical board exams

37 NIAAA Treatment Navigator To assist people in finding AUD treatment, NIAAA 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 tools for locating the most qualified addiction specialists

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47 Promoting Recovery Research Program Announcement: Understanding Processes of Recovery in the Treatment of AUD Operationally define recovery and develop measures that reflect it Identify factors that facilitate or prevent relapse and promote resilience Identify novel biomarkers of relapse risk Evaluate the effectiveness of mutual help groups and recovery systems of care Explore the optimal timing and dose of AUD interventions needed to maximize recovery Gray Matter Volume Deficits Predict Time to Relapse in Alcohol-Dependent Patients Rando et al (2011)

48 Wearable Alcohol Biosensor Challenge Winning prototype: BACtrack Skyn submitted by BACtrack Worn on the wrist Detects alcohol in sweat Continuous BAC monitoring Stores data to a smartphone via Bluetooth Expected to be marketed later this year Second place winner, Milo, launched Kickstarter campaign marketing their alcohol biosensor PROOF ; research package in development Both first and second prize winners are commercializing their products Devices being made available to alcohol researchers for use and validation

49 Alcohol and Opioids: A Dangerous Combination Increase in Emergency Department Visits Alcohol involved in ~15% of cases each year

50 Alcohol and Opioids: A Dangerous Combination Increase in Hospitalizations Alcohol involved in ~20% of cases each year

51 Alcohol and Opioids: A Dangerous Combination Increase in Deaths Deaths due to opioids Number involving alcohol Alcohol involved in ~15% of cases each year

52 NIAAA: The Source for Credible Research Information on Alcohol & Health