Brad Girtz responds cautiously to my article on emerging vaccine therapies for cocaine addiction:
The harmful effect of cocaine is about more than its addictive properties…even recreational and occasional users of the drug put themselves at a higher risk of a heart attack or stroke due to its effect on blood pressure, the artery walls and the nervous system.
He is quite correct that the development of a widely-effective cocaine vaccine, like any other new treatment for addiction, would do nothing to reduce the health damage experienced by non-addicted users. And as Sally Satel and I have pointed out, this damage can be enormous both at the individual and population level. There is however a fascinating new medication being developed for the acute toxic effects of cocaine that could benefit non-addicted users as well as those who are addicted.
Around the roots of the coca plant is a bacteria which contains a remarkable esterase that breaks down cocaine with astonishing speed. Professor James Woods of the University of Michigan has sequenced the bacteria and can produce it in the lab. Rats injected with the esterase are unaffected by even lethal doses of cocaine.
The esterase doesn’t survive long in the body, so it isn’t intended as an addiction treatment. Rather, like naloxone (aka Narcan) for heroin overdose it has the potential to be life saving in crisis situations (e.g., the ambulance arrives to find some in acute cocaine overdose). The beneficiaries could include casual users who overdose as well as addicted people who for example are on an anti-stimulant vaccine and tried to override it with a massive dose of cocaine.
Unfortunately, as with cocaine and methamphetamine vaccines, private industry has shown only tepid interest in the esterase, leading the development process, in Dr. Woods’ word, to be “as slow as the dickens”. The life-saving possibilities of this esterase are another reason why we should use public policy to increase private investment in medication development for stimulant drug users.
I wonder if eventually one might consider transgenically inserting the esterase gene into someone’s lung epithelia or hematopoetic lineages (not trivial) or into their endogenous bacteria (pretty trivial to do, but would likely be lost over time, and given the way cocaine is delivered probably wouldn’t be effective). Voila: they can’t use cocaine again.
ow big is the problem? Does it work with crack?
John Beaty: Crack is still cocaine at root and I presume the esterase eould work just as well for it as for powder form.
How good is compliance with the treatment plan? It is hard to get patients to take medicine that is good for them if it does not make them feel better. If it deprives them of some pleasure they like, you may not be able to get them to take it at all. They will rather suggest you take it yourself, and they will suggest which route.
They don’t take it themselves any more than a heroin overdose patient takes naloxone. It’s something the medical team does to reverse potentially fatal acute effects of a drug in some who has ODd, is unconscious and dying, or is having the equivalent of a heart attack. And it’s not on ongoing medication so compliance is not the issue.
Let’s game out a treatment scenario here. Once cocaine induces a possibly-fatal arrhythmia, my (admittedly dated) understanding is that you don’t really need more cocaine to keep the heart in state that will kill the victim. Sure, it’s not great to have around, but is getting rid of the cocaine going to make a substantial difference in survival versus, say, improving response times for EMTs or other measures for treating arrhythmias?
(And of course, unless you can guarantee that the transplant won’t die out, as so many genetically-engineered additions to cells apparently do, putting it into addicts’ bodies is pretty much a recipe for death by overdose.) I wonder whether — assuming it’s otherwise safe — the place for the esterase might be as a surface coating on manufactured plastic containers.
Paul — I am not a cardiologist so can’t respond with any authority. I do know that cocaine greatly increases heart rate and blood pressure, so to the extent that that makes any cardiac event more dangerous, rapid cocalysis would be good.
On your transplant question, it’s not a gene therapy, it doesn’t make any enduring change and it isn’t supposed to. It’s like naloxone (or anti-venom for snakebite), a medication administered to counter the lethal acute effects of the drug. After that it gets metabolized and is gone from the body.
I was not clear; I was referring to the immune therapy referred to in your WSJ article, which seems to depend on patients agreeing to multiple shots of the vaccine; in the 2009 randomized trial, they had five vaccinations of placebo or the cholera toxin subunit linked active vaccine. The esterase, which seems to be only in preclinical trials, was clearly analogous to Narcan, and was not the focus of my question. But the vaccine looks like something that people would have to agree to receive on repeated occasions, and the compliance issue could be a major one there.
Ed Whitney: OK, I get you now. If people have to come back every few weeks (which seems likely regardless of which vaccine is ultimately available) then there are possible compliance limits. This is of course true with every chronic disease thar requires behavioral management, diabetes, hypertension, addiction etc. Relative to other addiction treatments, e.g., oral naltrexone or buprenorphine, weekely counslling sessions, the compliance challenge of a vaccine is actually less because you don’t have to do something every day/week.
We need to create an alternative to sexual reproduction (maybe involving the harvesting of eggs) so that we can castrate and remove the genitals of infants. This will ensure that the scourge of STD’s will stop, and nobody will suffer any of the significant and lasting emotional and physical effects of sexual intercourse, including rape victims who see their lives ruined, sex addicts, and everyone else who suffers harm.
Of course, this will also interfere with the ability of these children to experience sexual pleasure as adults. But it is a serious and technocratic preventative health measure.
My proposal is NO different from medically intervening to defeat the pleasure centers of the brain with respect to narcotics. The only difference is that Keith Humphreys likes to have sex but thinks that hippie drug addicts are a bunch of immoral sloths and a menace to society.
This is NOT medicine. This is morality dressed up as medicine, and this sort of thinking is a far greater menace to a free society than the drug problem.
Shit, you’re right! Wanna get some baseball bats and go bust up some government-funded methadone clinics? We gonna smash those junkies free of their false consciousness, MAAAAAAAAAAAAAAANNNNNNNNNNNNN!!!!!!!!!!!!!!
Methadone is a treatment. Treatments are fine. Vaccines to numb the brain to pleasure should be a bright line no., because there are too many puritans who would like to medicalize their moral beliefs.
OK, Dilan, suppose that cocaine gives you an intense pleasurable high for which you cannot control the craving, leading you to feel the need to steal from your own children’s college funds, but you get more gratification, with less intensity, out of being calm and relaxed so that you can be with your friends and family and live comfortably on what you earn. Suppose that the treatment which blocks the extreme high gives you the ability to enjoy the more mellow, though less intense, gratification. Does this rob you of anything? Or does it give you something?
It doesn’t matter, as long as there are too many policymakers who consider it immoral to use drugs for pleasure. Manipulation of the pleasure centers of the brain is a loaded weapon for them.
Ed, don’t even bother, buddy. Dilan prefers to live in a world of science fiction rather than social reality. The menace of nazi docs like Keith Humphreys fiendishly plotting forced immunization campaigns to crush pleasure under calumny makes it incredibly easy to concoct arbitrary bright lines. Notice how twice in a row he rationalizes this line based on the supposed existence of boogeymen for whom he harbors a special grudge. Who cares whether such a TREATMENT would be useful and efficacious for those whose lives (and the lives of their families) are being torn apart by addiction? These miserable little lives are but dust compared to the calamity we risk by letting the technocrats anywhere near the button! I guess we better ban Vivitrol right quick… once you get on that SLIPP-AH-REE SLOPE, ALL YOU GAH TAH DO IZ MAKE ONE WRONG MOVE AND YOU GONNNNA SLIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIDE!