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[IPp] Some Gene Research Just Isn't Worth the Money

 http://www.nytimes.com/2005/01/18/health/18essa.htmlSome Gene Research Just

Published: January 18, 2005

 ow 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

 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

 Rachel - "I would rather live my life as if there is a God, and die to find out
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