Tuesday, December 18, 2012

Why Don't We Have New Treatments for Addiction?

I just got back from a meeting of the American Academy of Addiction Psychiatry, and one of the most striking things was the lack of anything new in the treatment of addiction. There was a lot of tweaks of existing modalities, both behavioral and pharmaceutical, but nothing groundbreaking. As a clinician, I encounter this every day. We have a handfull of psychotherapeutic and pharmaceutical treatments available, but it is no where near enough.

Far too many patients respond modestly or not at all to available treatments of all kinds. Don't drink the Kool-Aid of 12-Step programs that tell you that their approach is 100% effective among those who truly want sobriety and work the program. It's simply not true, and most older AA'ers will admit that. There are very few treatments that even approach that level of efficacy. In most of medicine, we are simply slowing the rate of deterioration, if that.

I believe that talking therapy approaches have reached the point where further refinement of them will not improve outcomes, or at least not much. There are two areas of research that may eventually transform care: more direct approaches to reprogram the preconscious or unconscious mind, and pharmacotherapy. I'll leave the former for a later blog, but today I'd like to address concerns about the lack of medications in the medication development pipeline.

This is not a problem that only afflicts addiction treatment. It's true throughout health care. With a few notable exceptions, very little progress has been made in the past 10 years on developing new medications for our most vexing and common disorders: heart disease, depression, addiction, high blood pressure, cancer, arthritis, pain. And the pipeline looks so dry it's almost scary.

It's not because Big Pharma isn't investing in R&D either. According to Phrma.org, the industry website, industry investment in R&D has not dropped, either as real dollars or as percentage of revenue.  For example, in 1990, Pharma spent $8.4 billion on R&D, but in the past few years, it's been hovering around $50 billion. And yet, as this chart in an article by Scannell et al. (Nature Reviews Drug Discovery 11, 191-200) shows, the number of new drug approvals as a function of R&D investment has been dropping for 60 years. Why? Tune in tomorrow for the next blog!


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