[Paleopsych] NYT: Some Gene Research Just Isn't Worth the Money

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Essay: Some Gene Research Just Isn't Worth the Money
NYT January 18, 2005
By KEITH HUMPHREYS and SALLY SATEL

How should we set priorities in medical research? Officials
at the National Institutes of Health will grapple with this
question as they allocate billions of dollars from the
agency's budget this year.

Two geneticists, Dr. Kathleen Merikangas of the National
Institute of Mental Health and Dr. Neil Risch of Stanford
University, have taken on this challenge by introducing an
intriguing framework for setting priorities for genetic
research.

The best candidates for genetic research, they believe, are
disorders whose emergence and course cannot be derailed by
changes in personal habits or manipulation of the
environment. Examples are autism, Type 1 diabetes and
Alzheimer's disease.

In contrast, lower priority on the genetic research
hierarchy should go to conditions like Type 2 diabetes or
alcohol or nicotine addiction, they argue. Type 2 diabetes,
after all, can be largely avoided through exercise and
weight loss, and teenagers will buy less beer if taxes on
alcohol are high enough. Similarly, a combination of
smoking bans, social pressure and taxes have had an impact
on smoking.

Not surprisingly, the geneticists' proposal, published in
Science, drew fire from their colleagues who study
addiction, including Dr. Nora Volkow, director of the
National Institute on Drug Abuse. In a published rebuttal
last June, they insisted that addiction deserved a much
higher ranking for genetic-research money, noting that the
health and social costs of alcohol and drug addiction
exceed $500 billion a year.

No one can dispute addiction's high cost. But is genetic
research the best way to reduce it? Probably not.

Environmental approaches may not be as sexy as high-tech
gene-based solutions, but they work. In the past 20 years,
California has reduced smoking to 16 percent of adults from
26 percent through higher cigarette taxes, closer
monitoring of sales outlets, restrictions of smoking in
public places, endorsement of antismoking attitudes in the
general public and better decisions about health by current
and prospective smokers.

"Californizing" the country in a public health sense would
reduce smoking to a much greater extent than a comparable
investment in genetics research. Within a generation, most
of those who continued to smoke despite every environmental
barrier would be those at high genetic risk; the rest would
be a small cohort who are not interested in quitting. At
that point, investigating smokers' genes might warrant a
greater investment because they would be a more highly
genetically determined group. But for now, resources could
be better directed toward diseases where society has no
similarly potent environmental tools.

Could genetic screening prevent addiction? Ideally, people
of legal age could refuse cigarettes or alcohol if they
knew that their genes put them at higher risk for
progressing from casual to compulsive use. But screening
can backfire: fraternity members, for example, might be
more likely to go on a drinking binge if they knew their
genetic risk for alcoholism was low.

In its defense, genetic research may one day improve
addiction treatment. In response to Dr. Merikangas and Dr.
Risch, addiction genetics researchers noted that
therapeutic response of alcoholic patients to the
medication naltrexone, an agent first developed for heroin
users, might be associated with a variant of a gene that
codes for a specific brain receptor. If replicated, this
finding might allow clinicians to use genetic information
to decide whether to offer naltrexone to a particular
patient.

But future improvements in treatment from genetics research
are unlikely to have much effect because, research shows,
most addicts who recover do so without formal treatment. A
survey by the National Institute of Alcohol Abuse and
Alcoholism, for example, found that three-quarters of
adults who had once been alcohol-dependent but no longer
have alcohol problems never received treatment.

As Dr. Merikangas and Dr. Risch emphasize, addiction is
malleable under the right circumstances. Only 12 percent of
American soldiers addicted to heroin in Vietnam maintained
the heroin habit after returning home. That is a striking
example of a physiological process (drug dependence)
interrupted by psychological and environmental processes -
less need to manage the anxiety or boredom of a war zone,
reduced availability of inexpensive heroin and increased
recognition of the personal cost of continued drug use.
Less startling examples of environments' changing addictive
behavior abound: when is the last time you saw a heavy
smoker light up at a religious service?

Finally, much of the harm to public health from drug and
alcohol use has nothing to do with addiction. In 1986, Len
Bias, the basketball star, died not because he was addicted
but because cocaine can induce sudden cardiovascular death.
Improved treatments for alcoholism would not make our
highways safe: of the 32.3 million Americans who
acknowledge driving drunk in the last year, most were
nonaddicted people who made bad choices after drinking too
much.

Genetic research on addiction could have benefits. There is
a distant possibility of improving treatment, and it might
help in understanding related traits, like impulse control
and anxiety. But unlike benefits from research into more
intractable diseases, major cuts in drug- and
alcohol-related harm depend not on genes but on choices by
policy makers and individual citizens.

Keith Humphreys is an associate professor of psychiatry at
Stanford. Sally Satel is a resident scholar at the American
Enterprise Institute and an unpaid advisory board member
for the Substance Abuse and Mental Health Services
Administration.

http://www.nytimes.com/2005/01/18/health/18essa.html