What Addicts Need

Vaccines that would arm the immune system against addictive drugs and prevent them from making the user high are, potentially, the ultimate weapons against addiction. A cocaine vaccine is poised to enter its first large-scale clinical trial in humans this year, and vaccines against nicotine, heroin and methamphetamine are also in development. In theory, these addiction vaccines work the same way as the traditional vaccines used to treat infectious diseases like measles and meningitis. But instead of targeting bacteria and viruses, the new vaccines zero in on addictive chemicals. Each of the proposed vaccines consists of drug molecules that have been attached to proteins from bacteria; it's the bacterial protein that sets off the immune reaction. Once a person has been vaccinated, the next time the drug is ingested, antibodies will latch onto it and prevent it from crossing from the bloodstream into the brain. Nabi Biopharmaceuticals, a small biotech company in Maryland, has engineered a nicotine vaccine that is in late-stage clinical trials. Earlier studies showed that it was twice as effective as a placebo in helping people quit smoking. The cocaine vaccine, developed by Thomas Kosten of Baylor College of Medicine, could be on the market as early as 2010. It would have to be given three or four times a year, but presumably not for life, says Kosten. While the vaccine is being studied in people who are already addicted to cocaine, it could eventually be used on others. "You could vaccinate high-risk teens until they matured to an age of better decision-making," Kosten says. He acknowledges the obvious civil-liberties issues this raises. "Lawyers certainly want to argue with us on the ethics of it," he says, "but parent groups and pediatricians have been receptive to the idea."

The revolution these new drugs promise will have a huge impact on the addiction-treatment industry (or, as it prefers to think of itself, the "recovery movement"), which runs the gamut from locked psychiatric wards in big-city hospitals to spalike mansions in the Malibu Hills of California. And the reaction there is guarded; the people who run them have seen panaceas come and go over the years, and the same addicts return with the same problems. They also, of course, have a large investment in their own programs, which typically rely on intensive therapy and counseling based on the 12-Step model. "We need four or five more years to see how [Vivitrol] does," says staff psychiatrist Garrett O'Connor at the Betty Ford Center, in Rancho Mirage, Calif. "And we need to be very cautious, because a failed treatment will set a person back." The Ford Center and the Hazelden Foundation, in Minnesota, use drugs sparingly, and mostly just in the first days or weeks of recovery, the "detox" phase. "Hazelden will never turn its back on pharmaceutical solutions, but a pill all by itself is not the cure," says William Moyers, Hazelden's vice president of external affairs. "We're afraid that people are seeking a medical route that says treatment is the end, not the beginning." As for Alcoholics Anonymous and its imitators, they mostly do not forbid members to use medication but there are strong institutional biases against it. "I'm not judging others, but for myself, using something like Vivitrol or Campral feels like a crutch," says one longtime AA member, who, following the organization's practice, asked not to be named. "It's not true sobriety."

The competing view is that of Lisa Torres, a New York lawyer who has been in recovery from heroin addiction for nearly 20 years, and continues to take methadone, which she regards as medication for a chronic condition, analogous to blood-pressure or cholesterol-lowering drugs. "It's a paradox that some of addicts' biggest advocates have been the most resistant to new treatments," she says. "But a lot of them come to the field after recovering from their own addictions, and they can be very stubborn about what works and what doesn't." More pointedly, she adds, "some people feel recovery from addiction should not be easy or convenient."

So for this new paradigm to take hold, a lot of long-held prejudices will have to change. Doctors (and insurance companies) will have to get used to the idea of medicating their addicted patients, rather than handing them a brochure for AA, which a study published in 2005 in The New England Journal of Medicine found was the most common form of "treatment" offered. "If you have hypertension and it flares up, you go to a specialist," says psychologist Thomas McLellan of the University of Pennsylvania. "The specialist doesn't discharge you to a church basement. If he did, we would call it malpractice." Addicts, he adds, are by no means unique in their propensity to relapse. In a study comparing alcoholics and drug addicts to patients with diabetes, asthma and hypertension, McLellan found nearly identical rates of noncompliance and relapse; between 30 and 40 percent of each group failed to follow even half their doctors' guidelines.

Where doctors go, drug companies are likely to follow. Most of the research on addiction treatments has been done by NIDA (total 2007 budget: $994 million) or small pharmaceutical companies. "I have been imploring the bigger companies to work on this," says Volkow. "Their scientists get it, but the business people are tough to persuade." Companies with billion-dollar stakes in selling drugs for osteoporosis or cholesterol don't want their names on a product used by heroin addicts, says Leshner. Even the relatively unknown Nabi, according to CEO Raafat Fahim, decided to focus on a vaccine for nicotine "because it's not illicit and it's not something you can overdose on" (and afterward sue the company that made the drug that didn't stop you from taking it). But Steven Paul, the head of research for Eli Lilly, believes the landscape is changing. There used to be a stigma attached to depression, too, he says, but the development of Prozac put an end to that. "Anything that has a large unmet need," says Paul, "is ultimately going to succeed commercially."

And addicts may need to change their thinking, too. For nearly 75 years, that thinking has been dominated by the principles laid down by Bill W., the founder of Alcoholics Anonymous. The amount of good AA has done in the world is incalculable; most people reading this article probably can think of someone they know who owes his or her life to it. Some readers themselves have surely benefited. But in 1935 AA was, essentially, the only legitimate option. There were "cures" of various sorts, including gold chloride injections, but there was virtually no modern neuroscience or psychopharmacology. Many people are now living in society with mental illnesses like schizophrenia and bipolar disorder that would have required institutionalization back then. Addicts, like the rest of the public, need to recognize the fact that we are entering a new era in addiction treatment. Viewing her condition as a chronic, recurring disease that could be treated was precisely what Dyess needed to return to sobriety. "In the past, when I would relapse," she says, "the thinking from 12-Step or from family was that I had failed. Now I know that if it happens, it happens, and I can pick myself up and move on, instead of assuming it's all over so I might as well keep drinking." The 12 Steps begin with a confession of powerlessness over addiction. But there's hope that science may some day help put that power within the reach of anyone who needs it. And then who would choose not to grasp it, and begin the long war for sobriety—a war without end, but one worth the fighting.

With Raina Kelley

© 2008