New Treatments for Addiction Behavioral, Ethical, Legal, and Social Questions (2004) / Chapter Skim
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Appendix H: Anticipating Unintended Consequences of Vaccine-Like Immunotherapies for Addictive Drug Use
Appendix H: Anticipating Unintended Consequences of Vaccine-Like Immunotherapies for Addictive Drug Use
Pages 241-275
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programs that would prevent addiction or relapse to such drugs as tobacco or cocaine are largely unprecedented. These interventions differ in important respects from other pharmacological treatments for drug addiction and, for that matter, from vaccines used to prevent viral diseases.
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Overdose treatment appears to be less susceptible than the other two categories to unintended consequences created by behavioral responses to the intervention, at least with respect to the mechanisms considered here. And to the extent that overdose treatment might operate via those mechanisms, its effects are likely to be similar to those of a relapse prevention program, only weaker.
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If effective, it should increase the flow of heavy users into nonuse and reduce the flow of nonusers back into use. An addiction protection program would target some fraction of light users and perhaps (not shown)
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It will be more effective to target heavy users when the doseresponse curve for various harms rises slowly at low doses and when the statistical distribution of consumption is heavily skewed. Relapse prevention I/DMs would disproportionately target right-tail users; addiction protection I/DMs would presumably include individuals from the whole range of the use distribution (even including some who would never use anyway)
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Although the distinction between voluntary and mandatory programs has legal and political relevance, it may have less clinical and behavioral relevance. Many experts contend that mandatory treatment is as effective as voluntary treatment,3 and that conclusion seems even more plausible for these pharmacological interventions than for more traditional psychotherapeutic modalities.
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the program has no direct effect on the behavior of nonparticipants, and any indirect effects are benign. Under these conditions, a successful psychopharmacological relapse or addiction prevention program ought to shift the demand curve downward, such that less cocaine (or tobacco)
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Ceteris paribus, a downward shift in the demand curve ought to produce a reduction in the quantity supplied and a drop in the equilibrium price of the drug.4 In the short run, this reduced price should not in itself lead to increased use; by definition, the equilibrium price and quantity already reflect consumer and supplier preferences. But in the long run, reduced prices pose a risk of increased consumption, for two reasons.
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. This increase is not fully understood, but it appears that the shift in the demand curve may have been accompanied by a shift in the supply curve, due to increased advertising expenses, tort litigation expenses, and other factors (personal communication to the author from Frank Chaloupka, University of Illinois at Chicago, 18 November 2003)
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but is important to consider because it has implications for the effect of a downward shift in the demand curve. Figure H-3 indicates that with a downsloping supply curve a downward shift in the demand curve would still produce a reduction in the quantity supplied, but prices would actually rise.
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In the Drug Abuse Treatment Outcome Study, a nationwide naturalistic examination of nonexperimental treatment settings, median retention in treatment ranged from 29 to 177 days across 18 long-term residential programs and from 42 to 144 days for 16 outpatient drug-free programs (Joe, Simpson, and Broome, 1998)
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23) suggest that "proactive recruitment and population-based studies demonstrate no-show rates approaching 50 percent." Pharmacological Treatment of Cocaine Dependence Table H-1 summarizes data from 45 clinical trial arms on the effects of 15 different pharmacological interventions for cocaine dependence, computed from data presented in a recent metanalysis by Silva de Lima et al.
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range from 13 to 80 percent, with a mean of 43 percent and a median of 46 percent. As might be expected, dropout rates are lower in programs with higher daily methadone doses (see Figure H-4)
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High treatment dropout rates probably have less to do with treatment management than with the inherent difficulty of changing addictive behaviors (De Leon, 1998; Joe et al., 1998)
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Positive urine tests for illicit opiates are found in methadone maintenance clinical trials in anywhere from 16 to 71 percent of the clients, with a median rate of 53 percent (Farre et al., 2002)
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Moreover, a traditional extinction account may fail to capture important subtleties of addictive drug use. Both classical conditioning and operant conditioning have long been implicated in drug addiction, but they do not account for many aspects of the phenomenon (Robinson and Berridge, 2003)
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DRUG SUBSTITUTION Another major concern is whether a pharmacological relapse prevention or addiction protection program would inadvertently motivate participants to increase their use of other drugs -- a substitution effect. Note that the substitute drug may have either more or less harmful physical and behavioral effects than the targeted drug.
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. Second, some of the econometric studies of substitution operationalize "price" using proxies like drug enforcement risk, marijuana eradication, and variations in state drinking ages, all of which involve reduced availability to the consumer.
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Model interpreted this as evidence for a substitution effect, in which users shifted from harder drugs to marijuana after its legal risks decreased. A laboratory study of hypothetical drug purchase choices by heroin addicts also suggests that marijuana and heroin are substitutes (Petry and Bickel, 1998)
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. does not induce a novel set of subjective effects, nor is it more reinforcing than either drug alone." Effects of Methadone Maintenance on Use of Other Drugs Methadone maintenance provides a partial analogy to the pharmacological treatments at issue here.
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. Naturally, there is a concern that use of these other drugs reflects a substitution effect of the methadone maintenance regimen.
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In many settings, technological risk reduction provides little evidence that behavioral responses produce net increases in harm or even the constant level of harm predicted by Wilde's (1982) "homeostatic" version of the theory.
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Immunotherapies or depot medications for drug dependence are potentially vulnerable to compensatory behavioral responses. The decision to take risks is influenced by the expected outcome of an activity but also by perceived worst-case scenarios (March and Shapira, 1992; Slovic, Fischhoff, and Lichtenstein, 1979)
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Still, this line of reasoning bolsters the concern that I/ DMs might well encourage drug use by reducing the perceived risks. UNINTENDED EFFECTS ON DRUG MARKETING Putting aside the unintended consequences discussed thus far, assume again for the sake of argument that a successful pharmacological intervention is widely implemented and reduces the prevalence and 12 Caulkins et al.
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The Pharmaceutical Industry For manufacturers of immunotherapeuties or depot medications, the largest market will involve addiction protection rather than relapse prevention simply because the population of potential clients is so much larger. There are many more potential addicts than actual addicts, especially if "at risk" is defined broadly.
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14 According to the National Household Survey on Drug Abuse, in 2001 there were 7 million current users of illicit drugs other than marijuana versus 66.5 million current users of a tobacco product. See http://www.samhsa.gov/oas/nhsda.htm#NHSDAinfo.
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. CONCLUSIONS This appendix raises a number of potential unintended consequences of a depot medication or immunotherapy program for addiction, including increased use of the target drug by some program clients (if the treatment is only partially effective and fails to reduce drug motivation, increased use of other drugs by program clients (a substitution effect)
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. Treatment of drug abuse.
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Predicting substance use at 1-year follow-up. American Journal of Drug and Alcohol Abuse, 19, 465-474.
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. The effects of prices and policies on the demand for marijuana: Evidence from the National Household Surveys on Drug Abuse.
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. Contingent access to methadone maintenance treat ment: Effects on cocaine use of mixed opiate-cocaine abusers.
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. Cannabis versus other illicit drug use among methadone maintenance patients.
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. Treatment retention and follow-up out comes in the Drug Abuse Treatment Outcome Study (DATOS)
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Substance Abuse, 19, 49-59. Wilde, G.J.S.
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