Drugs are bad, m’kay.

A recent paper by Donny and Dierker entitled “The absence of DSM-IV nicotine dependence in moderate-to-heavy daily smokers” and the recent update of the Monitoring the Future (MtF) survey of drug use and attitudes seemingly have little in common. Stick with me.

The essential point of Donny and Dierker is captured by this from the abstract:

RESULTS: Approximately 39.4% of daily smokers never reached nicotine dependence. While the probability of remaining non-dependent decreased with smoking quantity and duration since the onset of daily smoking, a substantial portion of individuals (37.7%) who reported smoking >/=10 cigarettes per day and began smoking daily >/=10 years prior, remained never nicotine dependent.

The overwhelming majority of animal research in the area is based on the self-administration and drug-discrimination paradigms- each of which focus on the animal equivalent of “how (good) does this drug make me feel right after I take it?”. On a design basis, the vast, vast majority of studies are predicated on the notion that what is important is the group result derived from the mean of the whole subject population. I’ve often wondered how can this be relevant to issues of drug dependence? The people smoking 10 cigs a day in the Donny sample are certainly getting some acute reinforcement from the nicotine yet this “drug liking” doesn’t really explain dependence. This paper shows that what is important is distinguishing individual traits or liabilities that dictate which of the population exposed to a given drug will go on to develop dependence.

This also shows what is so hard about convincing people that addictive drugs are going to suck them into a cycle of destructive use…because they are generally NOT going to do so. I.e., for the majority of people who get “acute reinforcement” (aka, pleasure) from using a given drug. (Not to mention their college chums “My friend Joe used to snort cocaine every day in college but got a job and never used again after graduating…” . Everyone has similar anecdotes.) Wouldn’t we do a lot better at convincing people to be wary of drug use if we pursued models that addressed questions related to who will become addicted rather than questions related to “how good does this drug make me feel”?

Ah, says the scientist. I don’t have to worry myself with some sort of PR mission to convince people. I’ll just publish my great papers and eventually this will solve the drug use problem. Ha. The single biggest contributor to population drug exposure is…..PR. (Loathe as I am to acknowledge this.)

From the recent MtF 2006 overview section on Ecstasy:

The figures on the facing page show little change in 12th graders’ perceived risk of ecstasy until
2001, when it jumped by eight percentage points…

…Significant increases in perceived risk occurred again in 2003 for all three grades. This very sharp rise likely explains both the deceleration and the turnaround in use, as we had predicted it would. In 2004 and 2005, perceived risk continued to increase among 12th graders, though at a much decelerated rate. The 10th grade has shown a leveling in perceived risk, while 8th grade has shown a slight decline—perhaps an early sign of generational forgetting. In 2006 the 8th graders’ perceived risk of using ecstasy dropped sharply (down seven percentage points).

Is attitude everything? Does a “scared straight” approach really work best? Examine the data in the MtF 2005 full report and you will find that, in general, attitudes toward health risks of a given recreational drug are remarkably stable, even across decades. (You will also find that drug use follows broad trends unlikely to be explained by specific events. This is a caveat to my main thesis.) There is one other notable case in which the perceived risk for a drug (e.g., for “trying it once or twice”) was initially low in comparison with most other drugs and underwent a rapid increase in the proportion of people thinking it “risky”. For cocaine between 1986 and 1987. Unsurprisingly, the shift in attitudes led to a drop from about 20% of 20-somethings endorsing annual use in the early-mid eighties to about 7-8% in the early nineties. The “why” is material. Two words, Len Bias. It also seems very likely that MSM publicity surrounding the entirety of The Ricaurte Affair explains the Ecstasy use data. I would suggest that in each case the existing scientific evidence played a minor role, that is, the totality of evidence before and after Len Bias’ death and before and after the publication/retraction of Ricaurte’s Science paper was essentially unchanged. The scientific interpretation of risk should have been essentially unchanged. What differed, was the scope of reach of the information. I would so argue anyway.

Is there a point here for drug abuse science? That depends. Do you really want to have a “translational impact”? Do you really want to serve the public health mission by helping to avoid or ameliorate the detrimental impact drugs of abuse have on the public? Then perhaps scientific paradigms that are relevant and understandable to the public should be prioritized. Stop asking which drugs feel good and how good they feel. We know this. Ask rather, what is special about the circumstances of that subset of your sample that is most likely to develop compulsive drug use…