The Addicted Brain (27 page)

The idea of using vaccines to treat drug abusers has some important, novel aspects. To see this more clearly, let us look at more traditional, non-vaccine treatment medications, such as methadone or naltrexone, which are used to treat opiate addicts. These medications are both active but in different ways. The first one stimulates opiate receptors and the second one blocks them. In both cases, the medication is doing something to the brain’s process of neurotransmission, and these medications have to get into the brain to work. Although in the brain, they produce useful changes that benefit the drug user. However, they are also having other effects—side effects
²
that can’t be avoided. For example, long-term use of methadone can result in changes in blood proteins and prolactin—and there is still the danger of overdose.
All
of the drugs used in psychiatry have to get into the brain to work, and they all have at least some side effects and dangers. But, and this is the interesting part, antibodies don’t get into the brain. They don’t have to. They don’t do anything to neurotransmission. Rather, they reside in the blood and prevent the dangerous drugs from getting into the brain. In the clinical trial mentioned at the end of the last paragraph, the antibodies against cocaine prevented the drug from entering the brain and thus prevented the drug-induced reward. Without a reward, there is no incentive to take the drug. The use of vaccines to treat drug abuse will be an interesting adventure in treatment. It is a new approach, but will it be useful in the long run, or will prohibitive problems develop? We can only try it, and wait and see. But everyone is hopeful.

As we have seen, new medications are needed. Because there are no medications for psychostimulant (including cocaine, amphetamine, and methamphetamine) addicts, this is one area where help is important. As an example, let us consider one possible candidate for a medication, RTI-336.
³
For the sake of discussion, let us look at it as a medication for cocaine users, although it can be used for any psychostimulant drug (see
Figure 14-2
).

Figure 14-2. Chemical structure of cocaine and RTI-336. One can see at a glance that RTI-336 and cocaine are similar in some ways and different in others. The similarity of the two is why RTI-336 acts like cocaine and can be a substitute medication for the drug. The differences, however, are key. RTI-336 is more specific and selective acting than cocaine, gets into the brain more slowly, and seems to lack prohibitive toxicity. The compound was synthesized by Dr. Ivy Carroll and colleagues at the Research Triangle Institute (RTI). (The drawing was provided by Dr. Ivy Carroll.)

RTI-336 is the result of an effort of a diverse group of scientists with complementary skills who were searching for a substitute medication for cocaine.
⁴
What are the properties that we would want in such a medication?
First
, it should be less toxic than cocaine. Cocaine acts at many sites in the brain, and a medication that acts only at the
addicting
site for cocaine would be desirable so that other unrelated actions (side effects) would be avoided.
⁵
Next
, cocaine gets into the brain quickly and, depending on how it is taken, can impart the much sought after “rush” of feelings that addicts like. A medication is best if it enters the brain more slowly so as to be less emotionally disruptive and less addicting. (It is thought that drugs entering the brain quickly are more addicting than those entering more slowly.) Cocaine’s duration of action is about one and half hours, which is short and is presumably why cocaine users binge, or repeatedly take the drug over a several hour period. A medication should have a longer duration of action so as to have a continued therapeutic effect and so that it doesn’t have to be taken often. Medications that have to be taken often are less successful because people forget to take them as often as needed. Finally, a realistic laboratory test is that an injection of the candidate medication into an animal that is self-administering cocaine should produce a reduction in cocaine self-administration.

It turns out that RTI-336 (see
Figure 14-2
) is an ideal medication candidate for many reasons. It is selective for the dopamine transporter, which is responsible for the addicting properties of cocaine, it enters the brain more slowly than cocaine, and it has a duration of
action that is longer than cocaine’s. In addition, it reduces the self-administration of cocaine by animals after injection. Preclinical toxicity studies show that RTI-336 has very little toxicity, and in early phase human clinical trials it also had low toxicity. But, more clinical trials with drug users are needed to show that it works effectively in psychostimulant addicts.

Are there drawbacks or concerns? Yes, as there is with every new, potential medication. Will previously unknown side effects be discovered? Will it continue to be effective or will tolerance develop? Will the fact that it is a substitute medication
⁶
create controversy? These are issues that must be considered by regulatory agencies and doctors with any and every new medication candidate.

Drug use and addiction are stigmatized. It means that drug users are often looked down upon, and not seen as fully equal or acceptable to
us. They are seen as perhaps less than fully functional or capable. Would we consider them for a job that was important to us? We would worry about their reliability and their performance. We know their problem is long lasting and we would wonder how long is long enough without relapse. When they have a prison record related to drugs, many feel that that is just too much—they are stigmatized even further.

Drug users are usually aware of all this, and they might think about these issues themselves. This can contribute to self-loathing, adding a self-esteem problem to an already huge drug problem. Their motivation is blunted: “Why should I finish school? They won’t give me a job anyway with my police record.” Having tried to stop using drugs only to relapse, they might lack confidence in their ability to stop using. They might feel trapped and truly hopeless. Some would rather use drugs than face the stigma of being labeled as an addict—why deal with that? Because drug use is sometimes more or less secret, going into treatment is akin to making it public and official. If seeking treatment creates more trouble for users, they might prefer to deal with the drug use on their own. Families that normally help out when an illness occurs might go into denial or be afraid of stigmatizing themselves or everyone in the family when the illness is drug addiction. Overall, the stigma can be debilitating.

But the world has many recovered addicts, and recovery
is
possible. It is possible to stop using drugs and begin to lead a normal life. Sometimes it is a long road, so it is best to start as soon as possible. There are many who are willing to help recovering addicts and they can make a big difference. Because there are many ways of helping, people need to be available and attuned to the possibilities. Because of the fear of stigmatization, discretion is vital in any helper. A supportive conversation, or suggestions on how to get help, can be done best with a promise of discretion. But we all need to look at and into ourselves—can we accept recovering drug users? Can we extend ourselves to help them and put aside our own judgments? These things are necessary for them and for us.

The illicit drug problem is a frustrating one. Trying to stop illicit drugs from entering our country, or from being made here, has not been successful. There are highly publicized victories in the form of seizures of drugs or military victories in source countries—but the problem continues. Drug addicts continue using these drugs in spite of the serious problems they cause, and drug-related crime has far from gone away. Addicts and their families complain about the illegal status of many drugs because it compounds the problem. For example, just the possession of a drug can be illegal and result in expensive litigation or confinement. These can interfere with finding appropriate treatment. Under these kinds of circumstances, helping an arrested addict can even create legal risks for the helpers. For these reasons, many people have proposed that some illegal drugs be legalized. It is claimed that this would reduce the prices of these drugs, perhaps provide revenue through taxation, reduce society’s costs of law enforcement, and save drug users from the additional stigma of breaking the law. A prison record can be a significant hindrance to full recovery and working in society. Legalization sounds interesting and good to some, but is it really a good idea?

If we view drug abuse solely as a criminal or legal problem, then legalization would be a focus and could be discussed, although it is not simple by any means. But, drug abuse is a
different
problem; it is a brain disorder, and in this sense legalization will not help, but, in fact, will likely make drug use worse. The reason it will make it worse is because legalization will increase the availability of drugs. If drugs are more readily available, then there will be more people dependent on drugs, and that dependence is well known to create problems for users. Some straightforward evidence for this was shown in
Figure 1-1
and its legend. The legal drugs, alcohol and nicotine, are much more widely and frequently used than the illegal drugs by maybe a factor of ten. Imagine what would happen if the illicit drugs were made legal. Heroin, cocaine, and amphetamine are not less addicting
than alcohol and nicotine. A public health perspective says that legalization, as a blanket, unrestricted policy, will not help but will most likely hurt because there will be more drug users. But, it is possible that reductions in some penalties (decriminalization) could be useful in some cases. There is a difference between legalization and decriminalization.

On June 17, 2011, the 40
^th
anniversary of the “war on drugs,” President Jimmy Carter wrote an op-ed piece in the
New York Times
(p. A31) entitled “Call off the Global Drug War.” He cites surveys showing that the “war” has failed. In the last ten years, drug consumption has significantly increased: 34.5 percent for opiates, 27 percent for cocaine, and 8.5 percent for cannabis. Moreover, current policies have contributed to the burgeoning prison population in this country—more than 3 percent of American adults are either in prison, on probation, or on parole! This is a higher proportion than any other industrialized country. The “war on drugs” seems more harmful than the drug problem itself. He notes that the Global Commission on Drug Policy recommends that the focus on low-level, non-violent drug users should be deemphasized, and international, violent criminal organizations should be targeted. Treatment should be the focus for the average drug user.

Dr. Avram Goldstein, a leader in the field of drug addiction, thinks that neither total prohibition nor total legalization are good ideas, and that each drug is unique and requires its own consideration and level of control.
⁷
He has made a number of suggestions. Tobacco and alcohol are too readily available and a variety of steps could be taken to reduce their availability. Opiate drugs such as heroin and psychostimulants (for example, cocaine) are currently regulated and they should remain so because they are dangerous. Marijuana is not harmless, but perhaps some penalties associated with its use and possession could be reduced. Other drugs like inhalants are toxic and are used often by children; they need to be targeted for abuse prevention. Many of these ideas have been discussed among public health
professionals, and their implementation has been tried in various ways. Dr. Griffith Edwards, an expert from the UK, has also commented on the alcohol problem and has made relatively similar suggestions.
⁸
In any case, drug addiction is a serious illness with many consequences for the user, and any policy or action must take this into account.

Some reasonable recommendations
⁹
for combating drug abuse are as follows. Treat drug abuse as a public health problem and support reducing drug use by treatment and prevention education. (This is not saying that drug users who break the law should not be held accountable.) Focus on the collateral damage caused by drugs. This includes the spread of infectious diseases such as HIV and STDs because of bad health practices and poor judgment due to drug use. Support prevention efforts because they are the least expensive way to reduce the costs of drug abuse to society. Prevent use in children, because people who do not use drugs from ages 10 to 20 years of age are unlikely to start using drugs in later life. Support increasing funding for research into the process of addiction, treatment, prevention, and drug policies. Finally, help prevent the stigmatization of drug abusers so that they can more readily get help.