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?


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