A Vaccine for Drug Addiction

I guess that an addicted person will trigger a huge inflammatory process every time it uses (that) drug. Furthermore if the same person change the inoculation method, it may destroy it's own body (kidneys for instance)

@ Rafael - I don't think there would be massive inflammation - the mode of action for these vaccines is to trigger an antibody response so that a huge amount of the drug will be neutralized and excluded from entering the brain, reducing the high associated with it.

While definitely laudable research, I would have significant reservations about it's usage. Would this be a strictly voluntary administration? Could a judge order/coerce someone to have this forcibly administered? Could a psychiatrist declare that the addict isn't competent and have it administered? Would parents immunize their kids to prevent them from becoming addicts? What are the moral implications of forcibly administering a drug that permanently alters a persons biochemistry?

Also what happens down the road? Person A gets over their addiction, but then get's in a car wreck and is in agony? Or the accident causes permanent, painful nerve damage? There are other drugs that could pinch hit (mainly by just heavily sedating the person), but they've got their own drawbacks, many just as bad or worse, and aren't as effective at dealing with the pain in long term pain management scenarios.

"the mode of action for these vaccines is to trigger an antibody response so that a huge amount of the drug will be neutralized and excluded from entering the brain, reducing the high associated with it."
So you end up with a higher tolerance for the drug. Wouldn't that drive addicts to compensate by using higher doses?

@ Sven - Excellent points. To be honest, those implications didn't even occur to me, but I agree that they are serious ethical issues. The more we learn to manipulate our genes, our biochemistry and the rest of what makes us living, the more we will have to grapple with issues like this. Unfortunately, I don't have the answers.

@ hibob -

So you end up with a higher tolerance for the drug. Wouldn't that drive addicts to compensate by using higher doses?

Possibly, though high affinity antibodies can neutralize enormous numbers of molecules in relatively short order. I imagine the goal is to get the titers high enough that acquiring enough of the drug would be impossible.

Vaccines have already been tested for nicotine addiction, so I'm not surprised that they are looking at other addictions. From what I've read, the nicotine vaccines were quite successful in animal models, and didn't result in increased self-administration (in a tolerance-type effect), it simply blocked the development of self-administration, and in addicted animals reduced or eliminated self-administration.

People are a little more complicated, though, and trials in people were
not as successful. It might be that heroin is a simpler addiction, with less of a social/behavioural component, but I suspect that like smoking, it may be more complex, and resistant to such an approach.

@ Epinephrine - That's pretty interesting. I wonder if it has anything to do with route of administration. A drug inhaled into the lungs can basically go straight to the brain, whereas intravenous injection needs is going to take a longer path. Or maybe, as you said, there's a stronger social component.

In either case the antibodies need to react fast - and the non-clinical data shows that the nicotine vaccine has enough time to bind nicotine before getting to the brain (1). I looked around, and found the an article comparing arterial kinetics of inhaled vs injected nicotine, and they were quite comaparable (2). Of course, just because arterial kinetics are the same doesn't mean that there isn't some interaction with the lungs that is important to addiction.

It's certainly looking to be an interesting while in the world of vaccines.

(1) Cerny EH, Lévy R, Mauel J, et al. Preclinical development of a vaccine 'against smoking.' Onkologie. 2002; 25(5):406â11.
(2) Rose JE, Behm FM, Westman EC, Coleman RE (1999). Arterial nicotine kinetics during cigarette smoking and intravenous nicotine administration: implications for addiction. Drug Alcohol Depend 56: 99â107.

"I don't think it's a good idea to use opioids as pain relievers in addicts anyway"

As a health care provider, I've witnessed scores of residents in nursing homes suffering in the final years of their lives because their doctors felt the same way. Patients were not given the benefit of the doubt, and doctors were more concerned about not supporting or creating an addiction than helping a human being in pain.

In our criminal justice system, presuming a person's innocence (at least in theory) will result in letting actual criminals go free more often than would presuming a person's guilt. What we are doing by judging people we label "addicts" is presuming they are guilty, so a great many more "innocent" people in pain (even pain caused by not having a drug they are addicted to in some cases) go to jail than would otherwise.

A history of abusing drugs - such as Oxycodone - should not automatically disqualify one from receiving that drug (especially in a setting where medication is dispensed by health care professionals). Labels - especially those related to mental health - stick, and doctors who apply them are not always right, which leads to sub-optimal health care decisions by providers for the rest of that person's life. People misdiagnosed have enough to deal with; they don't need to be potentially forced to endure pain for the rest of their lives on top of that.

If a person says they are in pain and that a particular drug relieves that pain, who is anyone else to deny them that drug, because they are - according to someone else - an addict?

You might think I'm overreacting, it wasn't the main point of your post. I hope you do not, because these are real people I'm talking about.

One final note: a former boss, a nurse by training and the compliance officer of a large health care organization, was driven to the ER by her husband after she collapsed at home due to the pain from kidney stones, the first time she'd ever experienced such a thing. She did not, nor does she now, take drugs or even drink alcohol for that matter. She thinks she has an abnormally high tolerance for pain.

When this 40 year old woman arrived at the ER - after telling her husband in the car that the pain was at a level that she would probably pass out, so if she vomited to make sure her airway was clear - the staff refused to give her pain medicine because - for reasons that were unclear (since the hospital ordered the staff to keep quiet after realizing their serious and potentially expensive error).

Her husband - not knowing what to do - grabbed a doctor and physically threatened him if he did not do anything to help his wife, who was now on the floor. The doctor relented, told her to get up on the gurney (which was a laughable request). She said "what?" and as he bent down to tell her again, she reached for his tie to pull him closer to give him a mouthful, but instead accidentally vomited all over him.

She woke up two days later, kidney stones removed. :)

@ satanfornoreason - Probably should have been "I don't think it's generally a good idea to use opioids as pain relievers in addicts..." It makes sense that there would be extenuating circumstances, and Sven's points about other potential ethical dilemas are well taken.

After reading #9 a couple of things occurred to me. 1) Virtually all those who assess drug and alcohol issues in our hospitals are either in recovery themselves or advocating a 12 step method of recovery. It is one of the few issues you can encounter where it is taken for gospel that the best folks to identify alkies/addicts and treat them are other alkies/addicts. Initially, this may not sound bad, but do we have cancer survivors being treated as cancer care providers? Are those who suffer from mental illness seen as valid care providers for the mentally ill. I have a tendency as well, to believe that in such a situation those assessing others tend to assume the worst and see issues that are actually non-existent. Basically, it can become a situation of either a person being evaluated is told to "accept his disease or live in denial." and the disease is not something a blood test, a Genetic analysis or any other screen is going to give a clear cut diagnosis one way or the other. It is all opinion. 2) Having said that, I do believe that there are addicts in the world. Some of whom use for some unknown reason. Generally, the live in poverty and spending hours upon hours finding out what motivates each and everyone to use doesn't seem to be a task anyone is likely to take on. My point being, give them the vaccine. Then what? I may not like 12 steppers, but they do have a point about being clean is only part of the process. 3) While I was in the Navy working at the hospital a couple of things became clear: a) officers: doctors and nurses, had a tendency to assume nastier explanations for medical issues when it involved enlisted sailors or marines. Enlisted medical personnel tended to give different service and assume different motivations when treating non-medical enlisted personnel. My life experience has been that if you are seen as being outside the system, or somehow different from those within the system, your treatment, diagnosis' and personal observations are given a whole different view than if you are seen as an equal. I've experienced both and there is a world of difference. All it takes is one fool out to push a situation and you're done. I've seen it happen to others when they had done nothing.

I'm not sure the premise that "virtually all those who assess drug and alcohol issues in our hospitals are either in recovery themselves or advocating a 12 step method of recovery" is correct.

The first part is not, as there are definitely people who assess and treat addiction who have not themselves had an addiction.

I will say that what IS treated as gospel is the 12-step recovery method. It is helpful to many people and keeps people away from substances that would otherwise destroy their lives.

BUT: many people who are diagnosed as having an addiction can later indulge in whatever substance was the issue, without problem or disruption in their life, without going to excess.

Hopefully this isn't an epiphany to anyone reading this, but just because someone is labeled as an addict, doesn't mean they have a problem. True, some - perhaps many - people give drugs and alcohol a bad name, but that doesn't mean everyone has a problem. Some people can choose to do these things responsibly, and some irresponsibly in a way where the irresponsible part only affects that person (so it's no one else's business anyway).

The stigma of addiction and the fact that we put people in jail for doing drugs is disgusting, and I can only hope that - like we see slavery today - that we speed up that day when all people see the way that we treat this issue today is terribly unjust.

"I don't think it's generally a good idea to use opioids as pain relievers in addicts..."

You might as well write: I do not think it is generally a good idea to administer medically indicated treatments to people whose other choices in life I consider that I should sit in judgment of; so much so, indeed, that my disapproval alone of those decisions is sufficient to force that person to suffer needlessly.

Sorry, Kevin, there's no way to parse what you've said except to say that you think it's okay to withhold a medically indicated treatment from someone just because that person isn't the ideal candidate to have as a patient - and only on account of your estimation of that person's suitability.

I'm sure that those with puritanical beliefs about what others should and shouldn't do with their bodies can come up with some justification as to why they should be entitled by law to be the morality police for everyone else. We have people who think like you where I live, and here's what it's like to go to the local store to pick up cold medicine for a sick kid.

Go to store.

Wait in line.

Hand over my ID to a clerk.

Wait for the ID to be checked against a list.

Sign a statement that I do not intend to use the 12 tablets I may or may not be able to buy in the manufacture of methamphetamine, with the understanding that said list is routinely turned over to a state law enforcement agency for random background review.

Wait for the high school student behind the counter to decide if I look enough like I'm not a meth addict to complete the transaction.

Walk out with my 6 or 12 tablets of child-strength cold medicine to give to my kid when I finally get back home.

Why? Because methamphetamine is a problem in some counties in this state (not the one I live in notably), but this is statewide now. Oh, it's worth noting that shutting down the supply of Sudafed in the market does nothing whatever to hinder the manufacture of methamphetamine; it just changes the chemicals people will use to make it. Now, matches are all the rage. And lithium batteries too.

So, if you're a person whose name is similar to someone else's name who has an active warrant out for his or her arrest, you may or may not be visited by the police to serve that warrant on you, whereat you'll be detained until such time as the police can determine that you are, in fact, not the person named in the warrant.

I'm sure that like you the people who came up with this scheme are well-meaning. Self-entitled and convinced of their moralizing so that it doesn't matter how many people are inconvenienced or have to suffer because of it, but well-meaning nevertheless.

Clearly, I'm not a fan of that particular line of reasoning you've espoused.

@ Justicar - I feel like you've parsed my statement in a way that removes all nuance and delved into a bit of reductio ad absurdem. This might be appropriate had I stuck with a categorical statement like "addicts should never be given opiods," (which was implied by my statement in the original post), as opposed to my later comment that you quoted, that it's not generally a good idea. For someone with a history of addiction to opioids, treating pain with a medication that could exacerbate that addiction is often not medically indicated. I think Sven's and Satanfornoreason's points about circumstances requiring opioid use, even in people with a history of addiction are really important.

I don't think a general rule taking people's past behavior into account when determining treatment is unwarranted. We have a right to own guns in this country, but I think it's reasonable to say that someone with a history of violent crime should have to pass a much higher bar before they're allowed to exercise that right. A closer analogy to this medical issue might be - if someone has a demonstrated allergy to penicillin, it's a bad idea to give the patient penicillin, even if it's the medically indicated treatment for a particular infection. The treatment has the potential to do more harm than good.

I agree with Satanfornoreason's point:

A history of abusing drugs - such as Oxycodone - should not automatically disqualify one from receiving that drug (especially in a setting where medication is dispensed by health care professionals).

You said:

Sorry, Kevin, there's no way to parse what you've said except to say that you think it's okay to withhold a medically indicated treatment from someone just because that person isn't the ideal candidate to have as a patient - and only on account of your estimation of that person's suitability.

I disagree. I think medical professionals should (and I believe they generally do) take many things into consideration, including someone's past behavior, when determining the medically indicated treatment.

Hrm, Kevin. I'm afraid I can't accept the charge, for it is the case that a medically indicated treatment is one that does not include prescribing to someone a contraindicated medication. Put another way, severe allergy to a medication alone makes that treatment contraindicated. A history of substance abuse/addiction/whatever is not a contraindication to the management of pain even if that entails using the precise same drug to which someone has previously had chemical dependence.

On my reading of what you've said, you've argued that previous chemical dependence is itself sufficient to contraindicate the use of a certain class of available, effective and indicated means. Of course prescribers take many things into consideration - after all, it's people who are to be treated, not the condition in a vacuum.

My little example about the hoops and hurdles mandated by law in my state to buy 6 over the counter nasal decongestants is the logical terminus of denying to people what is a perfectly normal and indicated medication because of, in this case, what is imagined to possibly be someone's potential previous or future uses thereof. In other words, the dispensing of sudafed is no longer determined by whether it is a medically indicated therapy, but rather on the presumption that any given patient may not use it for its intended purpose.

No huge deal there; it is after all only a stuffy nose. The issue is far more sensitive when considering that the denial of an otherwise medically indicated treatment is that a given patient must suffer. And suffer for no reason other than some physician's ideological guesswork about whether a patient is suffering quite enough to warrant demonstrably effective remedies.

Yes, drug addicts present potential future issues that an opiate naive patient does not. This says nothing whatever about what is happening in the present. A physician can easily enough deal with the immediate issue and work out some treatment plan with a patient that is appropriate to both a.) resolving the pain, and b.) mitigating risk of dependence.

And I quite frankly don't care one iota if in this system some people game the system for a free high anymore than I care that some guilty people are acquitted. It's a quite small consequence in comparison to its negation (in both cases, and for the same reason): not prescribing effective remedies to someone who is legitimately in pain because some doctor guesses wrong, or letting rot in prison an innocent person.

There are just certain presumptions that should be folded into the system to stand as a bulwark against torturing the innocent, even if that entails rewarding the guilty. And the same as any other case, a presumption can be overcome by sufficiently weighty facts to the contrary.

Your system, such as I understand it, would allow for quite a lot of people to really, really for reals suffer quite needlessly by making them forever unworthy of intervention and treatment until they hit some magical (ever changing and not defined) threshold simply on account of previous decisions they've made that some physician objects to. I realize you're going to take refuge in the 'not automatically disqualify' bit, but I don't see that as a positive angle unless it in some sense is on par with: we don't automatically imprison people; we do so after an extremely high bar of proof of its necessity has been reached.

For a doctor to withhold treatment from someone, that doctor should have to meet some reasonably high standard of evidence that the patient is actively lying, and that to a medical certainty demonstrate that the patient is, in fact, not in pain. But I do not think this is a system you endorse. Which is why I am unable to parse what you've said as being a distinction with a difference of much (if any real) import.