An Opioid Vaccine’s Promise—And Ethical Peril

    A multi-million dollar race to develop a vaccine that prevents the pleasurable and harmful effects of opioids has been quietly underway amongst military, hospital and university researchers in recent years—and 2019 has seen major advances to the therapy becoming a reality.

    Although promising to be another option to treat opioid use disorder and drive down increasingly-widespread fentanyl-involved overdoses, the prospect of a vaccine also raises numerous ethical concerns for harm reductionists.

    Since at least 2012, the National Institute of Health (NIH) has, according to Filter‘s review of press releases and federal grant tracking data, granted at least around $24 million to military organizations (like the Walter Reed Army Institute of Research), academic institutions (like Scripps Research Institute and the University of New Mexico), and hospitals (like Boston’s Children’s Hospital) to develop a vaccine that induces antibodies capable of binding to heroin or fentanyl molecules, preventing them from moving into the brain.

    Dr. Kim Janda, a lead researcher on the Scripps team, says that he is prioritizing a fentanyl vaccine due to the potent opioid’s role in driving fatal overdoses. For him, it will be one tool to complement others: “My vaccine is set up so you can use buprenorphine and naloxone with them. It’s not going to detract from them,” he told Filter.

    The vaccine is hoped to be beneficial for “a significant group” of people in treatment who “have tried multiple times to get into remission, and it hasn’t worked,” said Dr. Timothy Endy, an immunology researcher working on a vaccine at State University of New York, Upstate alongside military researchers.

    A September 2019 Government Accountability Office report expressed the concern that “Consent issues could arise for people who might receive an opioid vaccine,” suggesting that “some might question a parent’s right to compel their child to take a vaccine against a non-infectious agent, or an addicted person’s ability to understand potential long-term effects of an opioid vaccine.”

    Janda does not seem as concerned about this for his specific therapy. “We don’t view this as being used for children. The best value would be for someone with a substance use disorder,” he said, adding that his vaccine would only last three-to-four months before a patient needed a “reboost.”

    Since the reality of a vaccine remains years away, according to Dr. Kentner Singleton, a program officer working on opioid vaccines at NIH’s National Institute of Allergy and Infectious Diseases, some harm reduction experts believe that a vaccine raises more questions than answers.

    “In a public health context especially, whose choice will that be?” Dr. Ingrid Walker, a drug policy scholar at the University of Washington, Tacoma and Filter contributor, posed to Filter. “Will a vaccine be a requirement for someone with [substance use disorder] who seeks housing? Will drug courts mandate vaccines? Will systems of health care decide to offer it instead of more costly treatment options?”

    Janda is also working on another “immunopharmacotherapy,” as he calls it, that reverses overdoses involving carfentanil, an opioid 100 times stronger than fentanyl, and would be longer-lasting than naloxone. In addition to being used by people consuming an adulterated supply of illicit drugs, his carfentanil overdose reversal medication has security implications. “People don’t realize that synthetic opioids are terrorist threats,” said Janda. He referred to a 2002 case where Russian troops used aerosolized carfentanil to incapacitate armed militants taking hostages at a Moscow theater which resulted in 125 deaths, though he inaccurately stated the opioid was used by the Chechen rebels.

    But for Dr. Catherine McGowan, assistant professor at the London School of Hygiene and Tropical Medicine, “the solutions to fentanyl overdose reside in policy change, against prohibition and towards harm reduction.”

    Walker agrees that she’d rather see the millions of dollars being spent on developing a vaccine go instead towards harm reduction interventions that “do not require abstinence,” as a vaccine implicitly does. For these experts, the push for a vaccine overlooks the “systemic deficiencies and social inequities that people with SUD often experience, conditions that tend to influence and exacerbate SUD,” as described by Walker. Given the widespread prevalence of polydrug use, “will blocking the effects of one drug lead to struggles with other drugs for [people with substance use disorders]?”

    For her, what may seem like a “panacea” could yield more problems than solutions.

    Photograph of a scientist preparing a vaccine from 1993; by National Cancer Institute via Wikimedia Commons
    9/17/2019 Correction: A previous version of this article incorrectly stated that Chechen militants used carfentanil in a 2002 attack.
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