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April 23, 2019

An Interview with George F. Koob, PhD, from the National Institute on Alcohol Abuse and Alcoholism

Type: Announcements Tags: Interview, Alcohol Use Disorder, Newsletter

This month the NCIBH spoke with, Dr. George Koob an internationally-recognized expert on alcohol and stress, and the neurobiology of alcohol and drug addiction. He is the Director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), where he provides leadership in the national effort to reduce the public health burden associated with alcohol misuse.

Can you tell us a brief history about your interest and work in alcohol use disorder (AUD)? How did you first become interested in working in alcohol use disorder?

I was previously at the Salk Institute, one of the first alcohol research centers instituted in 1997. At the time there wasn’t much known about addiction as a disease and how alcohol affects the brain, but I became interested in alcohol use disorder (AUD) and how alcohol interfaces with emotion and well-being. I spent a large part of my career in the research domain and the more recent half focusing on stress, human awareness and its contribution to addiction. I wanted to apply what I learned as a researcher to the overall efforts of AUD diagnosis, prevention, and treatment which led me to the NIAAA.

Can you highlight some specific components of the NIAAA that are working to educate and train primary care providers on alcohol use disorder treatment and prevention?

The American College of Academic Addiction Medicine (ACAAM) has its roots in developing addiction medicine as a sub-specialty of preventive medicine, and a certification of that sub-specialty. They’ve started a program that we at NIAAA have supported for a long time, and they’re planning on having fellowship programs in every state to train and accredit 7,500 physicians by 2021. I call this the top-down approach in helping primary care doctors. It’s not a direct line, but I assume in the future, in internships and residencies, some of this information will filter down from the current fellows who will become the experts in major medical centers throughout the United States.

We do have another approach which I call the ‘bottom-up’ approach. We know that a major barrier to getting treatment is not knowing what to do or where to go. We have a broad range of efforts aimed at filling this gap. We have a program of research on screening, brief intervention, and referral to treatment (SBIRT), and SBI has been identified by the U.S. Preventive Services Task Force as an evidence-based way of identifying and addressing alcohol misuse including AUD. We’re currently working on validation studies to use this approach for detecting and addressing alcohol use in adolescents, and there is encouraging research to support this goal.

We have a website for both physicians and patients. The website, called Rethinking Drinking summarizes everything you need to know about alcohol in a concise way. It also offers research-based tips to help cut back on alcohol use or stop drinking if needed. In addition, NIAAA has also developed the Alcohol Treatment Navigator®, an easy-to-use online resource which helps people understand the range of available treatment options and locate good quality providers in their area. It links to directories of addiction specialists, offers signs of quality to look for, and suggests questions to ask a treatment provider and answers to listen for – all intended to help people make more informed choices about treatment options that will best meet their needs.

It is important for physicians and patients to understand that AUD can be viewed as a spectrum disorder – it has low, moderate and high severity, and so the right treatment is different for every individual. In other words, it doesn’t have to involve a 28-day rehab or Alcoholics Anonymous. We’re working on a companion website that we’re calling the Treatment Navigator for Clinicians to assist them in making better referrals to AUD treatment.  We hope it will help them better serve their patients by providing information on the full range of treatment options available in communities across the country.

What are emerging educational issues for educators in primary care who want to learn about alcohol use disorder?

We’ve toyed with the idea over the years of teaching addiction and alcohol use disorder in particular. I know that ACAAM has a curriculum committee they’re going to try implementing, but my experience over these past 40 years is that it doesn’t work simply because nobody adopts the curriculum and the curriculum becomes outdated. I’ll give you a very concrete example of what a primary care doc should know that I use in almost every lecture now: 10 years ago, the then-director of NIAAA and our current clinical director did a study where they looked at Asian-Americans – 30% of whom were missing the enzyme acetaldehyde dehydrogenase – this results in a “flush” reaction when consuming alcohol.  If those individuals drink past this reaction, they have a tenfold higher likelihood of developing esophageal cancer. Many primary care physicians might not know about that risk, so that’s the sort of thing that we want to bring attention to.

One thing the NIAAA is working on actively to educate providers is the NIAAA Clinician’s Core Resource. It’s generated a good bit of interest, and what we want to do is have a one stop shop with an emphasis on practical tools and essential information on what every clinician needs to know about alcohol, from presentation in primary care, its role in common conditions, diagnostic criteria, alcohol withdrawal syndrome, evidence-based therapies, etc.

What seem to be the biggest barriers and challenges in alcohol use disorder training and education?

I’ve been to many meetings around this subject since I’ve been at the NIAAA. The AAMC says that they’re teaching addiction, but when you ask the medical students themselves, it’s clear that they are not that knowledgeable. I think that the curriculums are crowded and it’s a catch-22: the curriculum committee says “it’s not on the exams so we won’t put it on the curriculum” and the exam committee says “it’s not on the curriculum so we won’t put it on the exams.” There’s an overwhelming amount of information that physicians have to process as is, and this just adds to it. But the problem with that view is that, if you go into any emergency room in the United States on a weekend night, many of the people are there because of alcohol related problems. So it’s time that we got our priorities straight.

Alcohol use disorder training is considered an add-on, but it shouldn’t be an add-on. It’s a critical part of what’s happening in the country, and half of liver disease cases in the US can be attributed to alcohol. My dream is to have an addiction medicine team in every emergency room in the country. The push for this, I think, will have to come from the medical community and especially the medical residents themselves.

This is a huge barrier we haven’t discussed much at NIAAA but I believe a growing challenge is finding a way to connect the communication between the different disciplines of medicine. It is important for all clinicians to have as complete a picture of their patients’ health issues as possible which includes information on alcohol use and misuse.


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