Double standards, politics, and drug treatment research

My mom, like millions of others in the U.S., has been a smoker for decades. She's tried to quit a few times, but it's been hard for her. The thing that's helped the most so far? The nicotine patch.

While the patch is not a universal cure - see the Mayo Clinic's analysis here - physicians back them because, well, the long-term cost of remaining a smoker is too high (for the smoker, the smoker's family, and society). We all know smokers, and love them, and want to help them quit. Right?

But there's a huge double standard in the media, and in society in general, when it comes to drug abuse treatment. I spent two years as a AAAS Fellow at the National Institute on Drug Abuse, and it was both depressing and inspiring: I was deeply impressed with the dedication of the staff, and horrified by the immensity of the problem of addiction in this country. That's why it upsets me that while research to help smokers quit is generally portrayed as necessary and important, increasingly, I'm seeing politicians complain that research to help other drug addicts quit is a waste of money.

Maybe it's because these other addicts are meth addicts, or potheads, or heroin addicts - probably not people you relate to or approve of. That makes it pretty easy for the media to take cheap shots at crack, etc. addicts, and question whether we should waste money trying to help them. But we should get angry about these cheap shots. A crack addict will die faster than a smoker. A crack addict can rarely hold down a job or be a parent. His/her illegal addiction poses a bigger danger to society than a smoker's does. Most importantly, a crack addict, like a smoker, can quit. Tobacco is still a significant public health problem, and I want to do all we can to help smokers (like my mom) quit, but crack, meth, etc. utterly destroys families and communities. We should be leveraging scientific research every way we can to help these people - not throwing them away or taking shots at them because they're "bad," or because we can't relate to them. They're real people. They have families.

Nevertheless, people routinely and cynically use drug treatment research as a political football. In just the latest example of this, today's Louisville Courier-Journal has an article on a small pharma company that's developing a THC patch - the equivalent of a nicotine patch, only for marijuana users. You'd expect that for those people who oppose any kind of drug use, including marijuana use, any new addiction treatment (especially one made by a smaller company) would be a good thing. You'd be wrong.

What are the folks at Health and Human Services smoking?" said Jim Waters, policy director for the fiscally conservative Bluegrass Institute in Bowling Green. "Why are we spending $2 million on a company to make patches for pot smokers when we have schools that are crumbling and roads that are breaking and unemployment payments which are skyrocketing?" Waters said. "Seriously, somebody's been smoking something."

Uh-huh. Who cares about potheads?

But here's an even easier target than pot smokers: drug-using Thai transgendered prostitutes! Earlier this year, an NIH study to understand the spread of HIV among Thai prostitutes, and the role played by drugs in the spread of the virus, was absolutely excoriated in the media. The clear implication is the U.S. shouldn't waste its money on these people. But of course there are scientific reasons for doing a study like this - the results are generalizable to other people who aren't Thai prostitutes.

The NIH responded:

The research is easy to ridicule if it is taken out of its public health context. The fact is, we need to explore a range of research avenues in vulnerable populations around the world to learn the best ways to control the transmission of HIV. ...

The toll from illnesses associated with sexual behavior is enormous. The epidemiological bridge for the spread of HIV and other sexually transmitted infections to persons at-risk involves multiple routes, including drug abuse and prostitution. Understanding the risk factors posed by prostitution and illicit drug use remain critical to controlling the HIV/AIDS epidemic in the United States and worldwide. The transgender community -- which certainly exists in the U.S. -- is complex, and has been understudied. It is urgent we understand more about social behaviors and HIV risk for all populations, including transgender individuals.

As much as some people may hate to admit it, there actually are prostitutes, transgendered people, and people with HIV in the US. They deserve treatment just like anyone else. But that's not even the point. Drugs seem to contribute to the spread of HIV, maybe through promoting unprotected sex, maybe through other mechanisms - especially among young heterosexuals who don't think they're at risk. There's a general public health problem here, and it's important to understand it. The Thai cohort is a model system for studying a much bigger problem - one that certainly does affect the US.

Unfortunately, the American public, and especially our politicians, have a tenuous grasp of model systems and how small scientific studies are generalizable to a bigger public health context. Remember Sarah Palin's comment about the uselessness of "French" fruit fly research, when we should be doing something about real problems like autism? Any geneticist could have told her that the fruit fly model system is used to identify proteins that are involved in human disease - including autism! But scientific illiteracy, combined with a knee-jerk lack of sympathy for drug addicts (or the French, as the case may be), makes it easy to take cheap shots (pot shots?) at these kinds of studies.

This is politics, and it's absolutely nothing new. Back in 2003, there was a very close call in the House on a vote to de-fund four NIH studies that some members of Congress found distasteful. (It didn't happen; you can read the debate here, and an article on it here.) Earlier this year, Darrell Issa (R-CA) succeeded in stripping the grant money for several studies involving Thai prostitutes from the NIH funding bill. Just a month ago, Joe Barton (R-TX) and Greg Walden (R-OR) complained about four more specific NIH grants, including one to study drug use among native Americans. You can find the letter at Walden's website.

I know a lot of you are scientists, biologists, doctors, teachers, etc. I hope that you believe drug abuse treatment is important - even for people that aren't much like you. So I'd like to ask that if this kind of thing is as frustrating to you as it is to me, say something about it. That's why I'm writing this post, even though I fully expect to get a lot of angry comments. . . because I haven't seen many science blog posts out there on this - even though it touches on peer review, parity, and so many other issues important to the scientific/medical community. (Some Scibling exceptions: DrugMonkey's post on Barton and Walden; Orac on Issa.)

I don't see how the heck we are going to get better drug abuse treatments unless we let doctors and scientists actually study drug abuse and test treatments out in the real world. Personally, I happen to think research works - not perfectly, but it works. What do you think?

I leave you with this Fox News interview with Walden. . . see if you're okay with the way the studies (and their subjects) are described. "Eye-opening" indeed.


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As far as I'm concerned, if there were magnificent treatments that let people actually walk away from those kinds of choices the world would be a better place immediately. If there's even a 1% chance that any of the studies ridiculed by Fox "News" then they're cheap at twice the price.
Frankly, if someone can lobby to send billions to bailout bankers who, given the evidence, don't appear to understand how math works, let alone economics, then is it so much to ask for a couple of million to make a shotgun effect on studies in the reasonable hopes that something new will be learned about how to make society less impacted by drugs? I don't think it is wasted.
So you may yet get angry posts about wasted money, but given the effluvium from our government for things that benefit mostly a select few board members/stockholders for corporations so large no one is really sure if they aren't actually doing evil; that somewhere in a corporate headquarters in a hidden conference room, golden chalices of children's blood await ghastly owners and their toasts of success in bringing about the downfall of life. It probably isn't true, but sometimes when viewing things like this:
you do have to wonder how someone could actually not have at least some shred of human decency enough to say, no, arbitration is for things like working conditions, overtime pay, etc. A felony is, you know, kinda' different, FFS? So if billions can be provided for that kind of wretchedness, why not millions for something with a more hopeful intent?

By Mylasticus (not verified) on 03 Nov 2009 #permalink

Yes, if someone can lobby to send billions to bailout bankers who, given the evidence, don't appear to understand how math works, let alone economics, then is it so much to ask for a couple of million to make a shotgun effect on studies in the reasonable hopes that something new will be learned about how to make society less impacted by drugs? I don't think it is wasted.

A very large and vocal swath of America views illegal drug use as a moral failing. These same people nearly always believe that those with moral failings deserve to suffer. In their eyes, anything that reduces the suffering of those with moral failings is evil. These people view sex outside of marriage, and much more so, being a prostitute, as moral failings as well. Being transgendered is also viewed as a moral failing by them.

The problems you have described are a direct result of our culture's long standing tradition of framing undesirable behaviors as moral failings.

Thanks so much for this informative and thoughtful post. I am in complete agreement with you.

Addiction runs in our family. As far as I can see a lack of addiction is more luck than virtue. People often seem to forget the toll it takes not only on the people with the disease but also their children, parents, siblings and society.

By micheleinmichigan (not verified) on 04 Nov 2009 #permalink

regarding the news clip, it is not "congress" that wants to know. it is a limited number of social conservative scientific no-nothings who are making political hay firing up their political base by saying "Thai prostitutes" and "Mongol alcoholics". The sentiments are not general to all of Congress. Start here:……

By DrugMonkey (not verified) on 04 Nov 2009 #permalink

I agree 100%. We need to stop avoiding (either directly or indirectly, through lack of funding) research subjects that make us uncomfortable, whether it's addiction treatments, the spread of STDs in sex workers, or the social and health effects of teenage sexual activity.

If getting to do the research in the first place is hard enough, then getting politicians to listen to you is still a problem. In the UK David Nutt has been sacked from Advisory Council on the Misuse of Drugs because he insisted on evidence-base assignment of drugs to harm categories. *sigh*

This is ridiculous. We definitely need to have more funding to help figure out better ways to stop addictions. The cost to the addict, families, and society itself is outrageous and needs to be acknowledged. Not only "drug" addicts but self injury addicts, food addicts, gambling, etc. Every addict needs help!

By S.I. Addict (not verified) on 04 Nov 2009 #permalink

I think part of the issue may be a misunderstanding of what 'legitimate medical research' is. That when someone thinks medical research they imagine something having to do with hospitalization, medical devices, or pharmaceuticals. All of the studies mentioned here are things which might be cost effective means of improving human health, but none of them have anything to do with what is conceptualized as 'medicine'.

By Timothy Underwood (not verified) on 04 Nov 2009 #permalink

Brilliant post, BioE! You have hit the nail on the head. It's very sad that so many people still think of drug addiction as a "moral failing", even though there are studies showing clear neurobiological changes. I hope that, the more know about the neurobio, perhaps the more they will understand. :)

I wish people made more of the brain aspects of dependence. Most people understand that depression is an imbalance of neurotransmitters or receptors in the brain; dependence is no different, merely different receptors that all lead to dopamine. And, by the time that someone is dependent, that person has no control over his or her situation and could not longer stop a drug habit any more than stop eating or drinking.

Excellent comments - llewelly, I totally agree with your point on moral failings. It's interesting how moral failings are always in the eye of the beholder - and how we are willing to forgive some addictions but not others. Unfortunately, our society can't seem to acclimate to the physiological aspects of addiction as a chronic disease.

The cultural group-think about drugs is prevalent in many of the medical staff I must interact with. I was a pedestrian struck by a car (driven by a hit & run drunk) moving about 35mph. My body was severely mangled. After several long hospitalizations and forty surgeries I am left in a massive amount of continuous pain.

I am prescribed a large amount of morphine, for which I am run through an expensive and degrading procedure each month to ensure I am not a 'drug seeker.'

I was prescribed marinol, marijuana in pill form, by an understanding physician for about two years and benefited greatly from it. I was able to reduce the amount of the addictive medicine, morphine, by using a non-addicting med, marijuana.

Sadly the physician retired and I was forced to go to physicians who were 'pain specialists.' The first physician I tried refused to take me because I was using morphine - a true #%*&ing humanitarian.

The second doctor took me in, but immediately denied me the morphine, instead placing me on a low dose of methadone (she acted as if the use of morphine and marinol were sins against her god). Twelve hours after starting methadone I went into deep withdrawal - a condition no one should have to experience.

After two months of suffering with Dr. GOD, I switched to a physician who put me back on the level of morphine I needed, however, he absolutely refuses to prescribe marinol.

I suppose I could buy marijuana, but its' illegal, I don't like the effects on my lungs that smoking it causes and, since I am unable to leave my house much, I worry about putting an intermediary in harms way from drug dealers or police.

So here I am in a state that allows for legal medical marijuana use, but cannot get it prescribed because I live in an area populated by conservative physicians who see marijuana as some type of evil instead of another tool in the palliative tool box.

Please forgive my wordiness, I am frustrated and embittered by the death-grip the religious right have on drug policy.

By Gilgamesh (not verified) on 04 Nov 2009 #permalink

If you see addiction as a moral failure you not only want addicts to be miserable and hopeless, you also want them to be seen as such, since that way, any children who might be tempted to try an addictive substance will be that much less likely to do so. Healing addicts hurts children! (of non-addicts). Won't anybody think of the children??

A "meta"-problem here is that the politicians and commentators who raise these issues have no interest in having a debate. We are not their intended audience. Their audience is ready and willing to hear about "waste in Washington" and "corrupt liberal scientists" and are not about to search out other opinions.

One in five?!

So, if they're saying the government should not these fund studies or initiatives, does this mean they then condone> or actively support: binge-drinking among college students, depressed parents, cigarette smoking, sedentary old people, self-medicating by heroin, Latino adolescents getting high, traffic accidents and poor hygeine in low-income families?

Even some prominent liberals think that in place of meth treatment for probationers/parolees we should first try 2 day jail sentences upon random drug test failures. While I find it promising that it seems to be radically effective for stopping meth use in that population, I wonder if we'll eventually find it acceptable to put our grandparents in jail for smoking once that's illegal. In a war on drugs, users are co-conspirators with the enemy.

I hate to say this but the guy talking about the THC patch is probably right. The company will sell millions and people like me will just use them recreationally. I think the rest of what you say is spot on though.

To Gilgamesh: If you don't have one, you could buy a vaporizer. They are better for your lungs and the experience will be a lot less harsh than just burning the stuff, particularly if you wouldn't smoke it if not for the pain. Mine cost around $600 but it was well worth it.

Last thing: don't be stingy, pay for the good stuff because then you can get more relief per gram and have to inhale less. Iâm just a recreational user, but I hope something I said here helps you.

Josh: the whole point of the THC patch is that it's a controlled low-level release. Which means it would be about as satisfactory to a pot smoker as a nicotine patch is to a tobacco smoker - better than withdrawal, but not so enjoyable. One could speculate, though, that while it won't get you high, it could have potential medical applications for users of medical marijuana, who are more interested in the analgesic effects.

Awesome post :)

And would people use pot-patches recreationally? Noone I know uses nicotine patches as a substitute for ciggerettes unless their trying to get off the things (or are addicted and have a long distance flight ahead). As far as I understand (and I may be completely wrong here) they fulfil the bodies desire without actually fulfilling most of the physiological desire for simple having a cigerette.

Well, if the general public was more accepting that every person is driven to the behavior that best modifies their brain chemical balance, we could identify with every one's addictive behavior. Myself, I am addicted to driving fast, hitting that perfect tennis shot, being in love, creating something. Some of my addictions have been great, some cause me problems to this day. If we take a truthful look at chemical addiction, about 5,000 people die each year from illegal drugs, tobacco is thought to kill 600,000. Perception is the defining factor we need to address if there is any hope to intelligently design effective solutions. Pick an addiction you can live with.

By greg zurbay (not verified) on 11 Nov 2009 #permalink

I suppose I could buy marijuana, but its' illegal, I don't like the effects on my lungs that smoking it causes and, since I am unable to leave my house much, I worry about putting an intermediary in harms way from drug dealers or police.

Thank you for this eye-opening post. I am well aware of anti-intellectualism and mistrust of science that is spreading from the right in this country affecting many areas. But, I realize I was naive about this subject, since I interned as an undergraduate in a brain-research lab funded by the US drug-control agency. I took it as something anyone could obviously see, that money spent on discovering the mechanisms of addiction in order to decrease the demand among users would go farther in the war on drugs than money spent indefinitely prosecuting users and chasing down dealers. How sadly wrong I was, alas.