Vaccines against drug abuse (NOT!)

A really bad idea about how to use a really promising technology.

What if someone who would like to quit smoking cigarettes or crack but finds it hard to do so could get an injection that would keep the molecules of the drug in question from getting from his bloodstream to his brain? If he took the drug, he would get little or no psychological effect from it; the behavior, like all unrewarded behaviors, would extinguish fairly quicly.

If such a treatment existed, some forms of drug dependency would suddenly become curable rather than merely treatable. (Here’s the fairly optimistic National Academy report on the topic, which includes my chapter on benefits and costs.)

The technology seems to be within reach; a nicotine therapy is well along in human trials, and a cocaine therapy shows promise, though it has yet to be subjected to the double-blind acid test. (Alcohol is a no-go for technical reasons, and there are so many opiates and opioids out there that there might not be much use in making one or two of them unusable by a given patient; the new treatments are molecule-specific.)

The idea is either to teach the body’s immune system to respond to the drug molecules as if they were pathogens (by making antibodies to them), or to make the antibodies in a factory and then inject them directly into the patient.

Since this is the same principle by which vaccination against infectious disease works, it seems natural to call the proposed therapies “vaccines.” But calling them vaccines would be profoundly misleading, since vaccines are used prophylactically, to prevent disease, while the new anti-drug treatments would be used therapeutically, to treat already established cases of drug abuse (or, perhaps, as secondary prevention in individuals — especially adolescents — who had started to use an abusable drug but not yet become diagnosably drug-abusing or dependent).

As a policy proposal, mass preventive immunization against the abuse of some drug just doesn’t pass the giggle test. The useful life of a treatment is likely to be three months or so, though it could be repeated. Each treatment is likely to cost hundreds of dollars, which is tiny compared to the cost of active cocaine addiction and small compared to the cost of active tobacco addiction but huge compared to the risk faced by a randomly-selected child of becoming dependent on any one drug within a three-month window.

That’s why those working on these new treatments prefer to call them “immunotherapies” rather than “vaccines”: to keep anyone from thinking that we can prevent cocaine abuse the way we prevent polio.

Apparently, it didn’t work. The Independent reports that the British government is seriously studying the idea of mass immunization.

There are three possibilities here: (1) The Independent has gotten the story entirely wrong; (2) Someone in Her Majesty’s Government has been smoking something; or (3) The story is satire. The fact that the primary person quoted is “Professor Nutt” argues for #3, but #2 still seems like the most likely interpretation. Sigh.

It just goes to show that, just when you thought you had a foolproof idea, someone comes along and invents a higher-performance fool.

Against J.S. Mill

Is there a defensible principle of autonomy that ought to rule out paternalistic legislation regardless of the facts? I doubt it.

Ignoring the context (quite interesting in its own terms), I’d like to reflect on a sentence from a post by Eugene Volokh:

Talk of autonomy and freedom of choice isn’t fully apt (and perhaps isn’t apt at all) when we’re dealing with people who lack the mental capacity to fully comprehend the nature and consequences of their choice.

Right. But of course none of us has the mental capacity to fully comprehend the nature and consequences of our choices.

Adults are closer to being able to do so than children, and normally competent adults than developmentally disabled adults, and those without severe mental disorders than those with severe mental disorders. But we’re all more or less feeling our way in the dark, trying to see by the (inadequate) light of our own reason, moving under the (largely random) impulse of our appetites and aversions, and listening to the (unreliable) voice of tradition to warn us of pitfalls.

So the argument for freedom and autonomy can’t be that a normal healthy adult human fully comprehends the consequences of his or her own actions. Rather, it has to be that a normal healthy adult human, in many cases, understands those consequences well enough so that any limitation on his or her choices (made by other imperfect humans through imperfect institutional mechanisms) is more likely to worsen outcomes than to improve them, especially when the value of learning from one’s own mistakes is factored in.

In the case of a child, or an adult with profound developmental disabilities, it will often be the case that even imperfectly administered interference will lead to better outcomes than full autonomy, partly because the people deciding on the interference will, in general, have better judgment than the person whose autonomy is being interfered with. That will less often be true in the case of a normal healthy adult.

But it won’t (if you’ll pardon my grammar) never be true. Offer a random sample of normal healthy American adults free access to cocaine, and (I claim) the benefit enjoyed by those who sample it, find that they like it, but never lose control of their cocaine-taking will be swamped by the loss incurred by the minority who sample it, find that they like it, and become addicted. That is true in part because people systematically underestimate the risks of losing control over their own behavior; putting a sign next to the cocaine machine warning of the dangers of addiction won’t cure the problem. So (I claim) we can improve the welfare of potential cocaine-takers by denying people the choice of taking cocaine (or, rather, denying them the choice of taking it legally).

Now perhaps that claim is false, or perhaps the damage from cocaine prohibition is high enough to swamp its benefits. I don’t think so, but those are a quasi-empirical questions. (Empirical because they concern partly matters of fact rather than purely questions of analysis or value, but only quasi-empirical because the relevant measurements cannot, in fact, be made.)

But since normal healthy adults lack the mental capacity to fully comprehend the nature and consequences of the choice to take cocaine (which involves taking the risk of becoming addicted to cocaine) the argument that drug prohibitions and other consumer-protection regulations ought to be ruled out because they violate a valid principle of freedom and autonomy cannot be sustained.

[See “Liberalism and Vice Control,” Journal of Policy Analysis and Management, Vol. 6, No. 2, Winter 1987. (Sorry, no link. If you’re curious, I can send an offprint.)]

What killed ADAM?

Why the most cost-effective element of the national drug data collection effort was the one we just stopped doing.

Some time ago, I complained in this space about the cancellation of the Arrestee Drug Abuse Monitoring program. Partly as a result, a respectable glossy magazine with a scientifically sophisticated readership asked me for a brief essay on the topic.

Here’s the draft. Comments solitcited. Warning: the piece lacks the spontaneous sparkle of my best blogging.

Preventing drinking by problem drinkers

Phil Leitzel on ankle bracelets to restrain dangerous drinkers.

Some time ago I offered some thoughts in this space about how to take the bottle away from dangerous drunks: from people who, under the influence, drive or commit assaults.

Jim Leitzel at Vice Squad reports on an alternative approach: an ankle bracelet that allows continuous remote monitoring of alcohol consumption by measuring the alcohol that transpires through the pores. Expensive ($12/day) but worth it in many cases. Presumably the price would come down in mass application.

Drugs and Violence in El Salvador

Report on my field trip to El Salvador, with a speech and a paper on reducing drug-related violence.

When not engaged in blogging, I sometimes teach, and do actual policy analysis. I just visited El Salvador for the second time (courtesy of the United Nations Devlopment Program’s Sociedad sin Violencia project to talk to officials and citizens there about how to modify drug policy to reduce the violence incident to drug trafficking and drug (especially alcohol) consumption.

It turns out that El Salvador has a big gang problem (apparently imported from Los Angeles). That I hadn’t known before my travels, so it’s not reflected in what I wrote. I’m hoping to go back this summer with a team including David Kennedy to plan an initiative to reduce gang violence, on the model of Boston’s Project Cease-Fire.

In the meantime, though, I thought I might as well show you what I’d been up to. Perhaps readers who know more of Salvadoran conditions than I do can provide some useful advice.

Controlling Drug-related Violence (Speech text from 2002

Reducing the Contribution of the Drug Problem to Violence in El Salvador (Report from 2004)

Is Rush being railroaded?

Don’t weep for Rush; in Florida, real pain patients who forge scripts do hard time.

Just in case you had, even for a moment, considered paying attention to Rush Limbaugh’s whining about how partisan Democratic prosecutors are mistreating him by not letting him walk on charges of illegally buying prescription drugs, here’s what happens to someone who’s (1) a genuine pain patient rather than someone feeding a habit and (2) not a politically powerful multimillionaire: a 25 year mandatory prison term.

Query: Can anyone tell me why the D.A. is bothering with doctor-shopping charges when he has Limbaugh on videotape buying diverted controlled drugs by the sackful?

Peter Jennings says “Yes” to MDMA

The Peter Jennings MDMA special
was, without a doubt, the most favorable story about an illegal drug ever to appear on network television. Most of it was right, but some of it wasn’t. MDMA is no longer spreading like wildfire — use rates have actually been dropping rather quickly for two years now — and there were heroes as well as villains at the National Institute on Drug Abuse.

The Peter Jennings MDMA special was, without a doubt, the most favorable account about an illegal drug ever to appear on network television.

The basic story line was: Here’s a drug with wonderful effects (and some risks, of course), invented and distributed by a bunch of smart, decent, creative, open-minded people, and banned and then lied about by a bunch of dishonest killjoys from the Federal government (with the collaboration of some truly whorish and incompetent scientists). But the efforts of the Bad Guys have completely failed to prevent the spread of the drug and have damaged the government’s credibility in the process.

Now, that’s a more accurate story than the war-on-drugs MDMA-rots-your-brain party line, which has been the staple of mass-media coverage of MDMA, but it’s certainly not the whole story. It’s not entirely accurate, and it’s far from complete.

First and perhaps most annoying, though certainly not most important, Michael Clegg, who developed the multi-level-marketing scheme that made “E” a mass-market drug in the mid-1980s and then got it banned, was hardly a philanthropist. He was a cynical businessman, who gave the drug the name “Ecstasy” — which is actually a rather poor description of its typical effects — because the more descriptive “Empathy” didn’t sound like a big seller. When warned that his methods would get the drug banned, Clegg is said to have replied, “Yes, and then I’m going to get very rich.” Clegg is to MDMA as Leary is to LSD — with insensate greed thrown in on top of the spiritual arrogance — and neither is anything like a hero in my book.

Second, the claim that the ban and the subsequent campaign had no efficacy is almost certainly wrong. Yes, MDMA spread like wildfire in the mid-1990s, but that was a decade after the ban. If it had continued on the exponential growth curve generated by Clegg’s Amway scheme, it would have spread much further much faster. And the Peter Jennings report — mostly shot last summer — missed the data that came out in December showing a collapse in rates of MDMA use among high-school students.

It’s quite possible that MDMA will maintain its position as the second-most-widely used illicitly produced drug behind marijuana — it’s even possible that the reduction in use levels will prove to have been temporary, and that MDMA use in the future will exceed what now look like the peak levels of 2001 and 2002 — but it’s also possible that the drop in use will be as rapid as the increase, leaving people like me looking rather silly for thinking that a big new endemic (as opposed to epidemic) drug had suddenly appeared on the scene. (The 2002 National Survey on Drug Use and Health shows initiations down a little bit from 2001; it will be interesting to see if that trend continues when the 2003 data are released.)

Third, while it’s certainly true that NIDA under Alan Leshner disgraced itself by funding and hyping bad science, it’s also true that it was Leshner’s replacement, Nora Volkow, who started to purge the anti-MDMA b.s. from the NIDA website (and cancelled the hilariously fraudulent “Your Brain on Ecstasy” postcard campaign). Volkow also pressed Ricaurte to do the checking that eventually forced him to retract his “Parkinson’s” study and two others.

So the anti-government tone of the story was, while far from baseless, something less than balanced. (And I’m sad to say that the Democratic friend who emailed me with the comment “How come I’m not surprised that the government of George W. would be promoting phony drug data?” had it backwards: it was Clinton’s NIDA Director who did the dirty work, and Bush’s that tried to undo it.)

And the Peter Jennings report entirely ignored the responsibility of the journals, including Science, that published the (in some cases obviously) bad science and the media outlets (including ABC News that uncritically gobbled it up.

Fourth, the risks, though acknolwedged, were fairly heavily downplayed. No mention was made of the tendency of the drug’s pleasurable effects to go away with repeated use in a non-time-reversible, non-dose-reversible fashion, which does sound a great deal like something permanent is being changed at the cell-and-tissue level somewhere in the brain. The midweek depresssion Valerie Curran found in a substantial proportion of her sample of London weekend ravers also went unmentioned.

Still, not a bad job, all things considered. When you have 60 minutes minus 18 minutes of commercials to tell a complicated story, something’s going to get left out.

And I’m pleased to report that my 15 minutes of fame remain largely unused.

Here’s a tape of the show without the commercials (except for a rather hilarious ad for a pro-marijuana bookstore in Vancouver spliced on to the beginning.)

Peter Jennings on ecstasy

This coming Thursday, April 1, at 10pm, ABC will air a Peter Jennings special called “Ecstasy Rising,” which looks at both the actual drug problem around MDMA (the chemical people think they’re buying when they buy a pill called “ecstasy”) and the scandal around MDMA research funded by the National Institute on Drug Abuse.

I’m told that the program will take a noticeable bite out of my 15 minutes of fame.

Update: Well, my 15 minutes are still largely intact. And the show had some other good qualities as well. But it was too pro-MDMA, and too undiscriminatingly anti-government, for my taste. Not a bad job overall, though.

The promised crackdown on the pills

I’ve had some calls from reporters on the White House plan to make the abuse of diverted pharmaceuticals a major target for drug enforcement. The general tone of the reporters’ questions has been: “Why don’t they focus on something more important?”

Actually, this looks like a good move to me.

The surge in the abuse of prescription medications, and especiall the narcotic analgesics, over the past decade has been really astonishing, with survey-reported initiation rates at seven or eight times their early-90s levels. Diversion doesn’t usually carry with it the same level of organized criminal activity, disorder, or market-related violence as the street sale of cocaine, or the environmental damage of manufacturing methamphetamine. But the users can get just as hooked as those buying strictly illicit drugs.

Most importantly, though, there’s some low-hanging fruit in the diversion area. The internet pharmacies are certainly violating federal law, and just as certainly haven’t been getting any enforcement attention. A few well-publicized prosecutions will probably make most of them fold their tents.

There are some complicated issues around doctor-shopping and script-kiting, which are the other major sources of diverted pills. The trick is to make life harder for the scammers without making it harder for the legitimate patients.

But it’s good to see the drug czar’s office focusing, for once, on a real problem where there might be some real solutions.