Tuesday, October 18, 2011

NIH Funding Success Rate at Historic Low

As expected, recent figures release by the National Institutes of Health (NIH) show a dismal 17.4% success rate for scientists applying for research funding. NIH is the largest funder of biomedical research in the world, and has two institutes devoted to addiction: The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA.) It's only through NIH supported research that progress is made on understanding addiction and improving treatment outcomes. Yes, we need more access to treatment but we also need better treatments, and that can only come through scientific research. Anyone who care about addiction and its treatment needs to contact their representatives and let them know we support and need research on addiction. Advocacy matters! Why do you think research funding for breast cancer, HIV/AIDS, and autism has gone up so much! Advocacy! Please support research and urge others to as well. MW NIH Grants Funding Drops; The success rate of the government agency’s grant applications has hit an all-time low. By Jef Akst TheScientist.com Oct. 17, 2011 Grant proposals submitted to the National Institutes of Health (NIH) are less likely to be funded than ever before, according to a sneak peak at this year’s success rates obtained by ScienceInsider last week. According to the new estimate put out by the NIH’s Office of Extramural Research (OER), the fiscal year that ended on September 30 saw the funding of just 17.4 percent of research grant applications—a historic low, according to a comment from NIH Director Francis Collins. The numbers are still “preliminary,” and may rebound slightly in the final release of the data next month, OER chief Sally Rockey told ScienceInsider. Still, it’s a significant drop from the 32 percent of grants the agency was funding around the turn of the millennium, and the first time in NIH history that the success rate has dipped below 20 percent. And the drop in grant funding could get even worse: just last month, the Senate approved a 1 percent drop in the NIH budget. If finalized, it would mark only the second time since 1970 that the agency’s budget has gone down instead of up.

Sunday, October 9, 2011

No More Unsupportable Claims!

I had a conversation this past week with another professional who is offering alternatives to 12-step rehab. I had examined his website and had some concerns I wanted to discuss with him. The most important was that on his site, he made claims that I didn't think were scientifically supportable. He claimed, for example, that his program yielded a 70% response (read: cure) rate. So we had a talk. It wasn't easy. I expressed my concern that those of us offering alternatives would be best served by sticking as close as possible to scientifically supportable claims or assertions. I also said that I was concerned that if we acted like current providers in making unsupportable claims that we would hurt our cause. He said that his program is extremely selective in who they take. They accept only "highly motivated" individuals who apparently have little in the way of significant coexisting problems. Among this group, he claimed a 70% rate of success "as the client defined it." He also said some things about accepting only clients with "abuse" rather than "dependence." Finally, he said that a prominent 12-step program had only a 3-5% success rate (compared to his 70%.) Well, as you can imagine, this didn't sit especially well with me. Even with great selection, I have yet to see a credible outcome study demonstrating a 70% rate of remission. Improvement, yes, remission no. Even the worst program in the world is going to have a success rate above 5%, since an evaluation alone yields a success rate of 20-30%. We had a brief discussion about what "abuse" and "dependence" meant in DSM IV (ICD-9 doesn't have an abuse category.) I quoted various studies. None of this mattered. He "respectfully" disagreed. He said he would "take my input under advisement," obviously meaning forget about it as soon as he could get me off the phone. True to form, I received a follow up email saying he'd "appreciated my input" but also that he basically didn't want anything to do with me, since they didn't fit my "model" nor would they be likely to in the future. Since the only "model" I discussed was adhering to scientifically supportable assertions, I have to conclude he decided that no, he didn't want to be held to that standard. In other words, he wanted to say whatever he wanted to, whether it was scientifically supportable or not. What mattered was not the truth, but rather his "model." "Model" and "Philosophy" are two of the most destructive concepts in addiction treatment today. I'll have more to say about this in a future blog. There are so many "programs" out there that provide "miraculous cures" for addiction already. We don't need more. Nutrition therapy, yoga, SPECT scans, yada, yada, yada! Miraculous pharmacotherapy (remember PROMETA anyone?) 12-step programs engage in a more subtle form of this, providing the same treatment over and over again even when it has been proved ineffective. We don't need yet another one. What's needed is straight talk about what we know works, how well (or not) it works, and how best to provide it. We don't need 12-step alternatives that are based on someone's "model" or "philosophy." We need consumer choice based on science and professionalism. The fact is, our treatments for addiction are only partially effective. In many cases they don't work at all. This is how it is in medicine and virtually all other human affairs. Let's face up to this. What's needed is more research, not more unsupportable claims. MW

Tuesday, October 4, 2011

More NIDA Hype: Vaccines for Addictions (NYT, 10/4/11)

The New York Times today published a story about research on vaccines to prevent or treat substance addictions. The tantalizing title: "An Addiction Vaccine, Tantalizingly Close." The problem? It's not only not close, it's looking more and more unlikely as time goes on. The article details the research career of Kim Janda, an immunologist at the Scripps Institute. Unfortunately, his dedicated quest to develop an effective vaccine for nicotine, alcohol, cocaine, methamphetamine or even obesity have all been dead ends. Often, research in rodents is tantalizing but then human studies are inevitably disappointing. Yet, he is said to be at the "vanguard of addiction research." No less a luminary than the inevitably quoted Drug War General and Director of the National Institute on Drug Abuse (NIDA) Nora Volkow naturally endorses this research, which they funded. Ummmhhh. What am I missing here? I wish that this research offered more promise than it appears to, but I'm afraid I see it on the back burner more than the vanguard.

 Dr. Janda commented that because there is so little available to help some of these addicts, people are desperate to hear something that gives them hope. I am sympathetic to the suffering of individuals with addiction and their loved ones, and I understand their desperation. I see it every day in my practice. Indeed as a physician I experience it, having to give them some pretty bad news about the dearth of highly effective treatments for stimulant addictions. (Note: contingency management, where patients are given rewards for staying abstinent and attending sessions is effective at improving engagement and retention. Whether those effects last very long is still unclear. Also high quality cognitive behavior therapy given to better prognosis addicts is beneficial. However, neither of these treatments is available in the community. The 12-step rehab widely available in the community probably has little if any long term effectiveness.) My interpretation is that non-treatment factors (legal sanctions, accumulating adverse consequences, pressure from others, growing up) are more important than treatment of any kind in determining whether a person will stop.

 Just to be clear, none of this is to say that funding basic and clinical research which has not yet yielded much in the way of clinical breakthroughs is not unique to addiction, and not a reason to decrease funding for it. For all of the billions of dollars put into research on treating solid cancers, for example, there is not much to show for it. In many cases, like cancer of the pancreas, brain or lung, there have been no significant advances at all. We still have no effective way to prevent or treat obesity or osteoarthritis. And yes, new treatments in these other areas that offer modest if any net benefit are also touted by a press looking for something big. So this type of thing seems pretty common in a society that looks to technological solutions for problems where changes in policy and regulation would arguably yield more. But I am concerned when the importance of research findings for treating addiction are exaggerated. I think giving hope that something new may become available has its place here as it does in other diseases. But I also think we have to be careful so we don't lose credibility among a public that is not accustomed to looking to science for an answer for addiction since the most widespread treatment is based on a spiritual transformation.

 One more quick note: Dr. Janda also made the unfortunate comment about addicts needing to "want to stop." In my experience, all addicts want to stop because being addicted is so miserable. But breaking up with cocaine is hard to do. Changing behavior of any type is very hard to do. We aren't very good at it, and we are overall pretty poor at helping others change health behavior and maintain the change. It's possible, it happens more often than we might even expect, but when it doesn't happen it's just too easy to blame the victim as "not wanting to change." And it's too scary to realize that sometimes it's impossible to change even when your life depends on it. Just ask the smokers inhaling through their tracheostomy tubes after having treatment for throat cancer. How terrifying is it to watch yourself die of a behavioral disorder that you abhor and despise and want desperately to change?


Sunday, October 2, 2011

OK, So What's With the Hype About the "Drunk Protector" Drug?

Recently there have been some breathless reports about an experiment conducted by Mark Hutchinson, a scientist at the University of Adelaide, Australia. Hutchinson targeted a novel receptor, TLR4, that is involved in modulating the immune system. It is possible that this receptor is involved in some of the symptoms of drunkenness, like imbalance and slurred speech. Hutchinson gave alcohol to mice who were either normal mice ("wild type") or who had been genetically modified to lack genes encoding two different receptors involved in the TLR4 cascade. They also used a medication that blocked opioid receptors, naltrexone as a comparison group. In addition, they conducted some studies on cell cultures rather than live animals. One of the findings was that mice without these genes had shorter durations of imbalance on two difference measures when given alcohol, compared to mice who were genetically normal. This is what led to the media hype. So does this mean that we are close to a pill that allows people to drink and not get drunk, as media reports suggest? No, of course not. First, this is a very complex experiment that could only be understood by someone steeped in the neurobiology of brain transmission and alcohol's effects on various types of receptors and cells. Second, it has no current or near-term impact. It's meaning only be discerned by other neuroscientists, and it has not even been replicated by another investigator, let alone been translated into a treatment. So, don't get excited, college students! That said, the immune system is something of a trendy thing right now in just about every malady known to humankind, from diabetes to heart disease, stroke to depression. There's no question it is involved in and affected by alcohol consumption. Some effects might be positive, such as a reduced risk of diabetes or Alzheimer's Disease in moderate drinkers, and some might be negative, such liver fibrosis and dysfunctional brain neurotransmission. Here is the website for the original report, for those of you who are undaunted by lots of scientific jargon: http://onlinelibrary.wiley.com/doi/10.1111/j.1476-5381.2011.01572.x/pdf MW