GENES AND ADDICTION—AN UPDATE

INTRODUCTION AND TERMINOLOGY:

1. Addiction: Loss of control over drug use typically manifested
as compulsive seeking and taking of drugs despite adverse
consequences. Cessation of the drug produces an
abstinence (withdrawal) syndrome.
2. Gene: In genetics, a unit inferred from the pattern of
inheritance.
In molecular biology, defined narrowly as a section of DNA that
is expressed as RNA or, more widely, as a coding sequence of
DNA and associated regulatory sequences.
3. Gene locus: the specific place on a chromosome where a gene
is located.
4. Heritability: the proportion of phenotypic variance that can be
attributed to additive genetic variance.
5. Polygenic: a trait arising from more than one genes
6. Allele: one member of a pair of homologous genes in diploid
cell; an individual with identical alleles at genetic locus is a
homozygote; one with non-identical allele is a heterozygote. In
a case in which one alleles leads to an observable gene product
and the other has no phenotype, the functional allele is said to
be dominant and the non-functional allele recessive.
7. Genotype: the genetic make-up of any organism. All of it may
not find expression in phenotype.
8. Phenotype: the outward physical manifestation of the cell or
individual due to actual expression of the alleles that are
present.
9. Polymorphism: the occurrence of something in several forms
e.g. the occurrence in a population of two or more alleles of a
gene at a single genetic locus.
10. Linkage: the more-frequent –than-random occurrence of two
traits together due to the proximity of their corresponding
genes on the same chromosome. The likelihood of
recombination event separating the two genes decreases with
their increasing proximity on the chromosome.
11. Linkage study: these studies use multiply- affected families to
examine traits that are inherited together. The concept is based
on the fact that genes that are located close to one another will
be more likely to be inherited together from one parent than two
genes located farther apart.
12. Candidate gene: genes with perceived relevance to the trait in
question, which can be used to compare allele frequencies
between affected and non-affected groups.
MODEL OF DRUG DEPENDANCE
Figure 1

DRUG AND NEURO TRANSMITTERS: IN DRUG DEPENDENCE

Figure 2, Figure 3, Figure 4
SUBSTANCE IN NEUROTRANSMISSION
Figure 5
Genetic alterations in various combinations of genes for NT and
receptors (i.e. 5HT, NE, GABA, Glutamate and opioid) that modify
dopamine neuron function may put individuals at risk for
dependence.
GENETIC EPIDEMIOLOGY:
 1. Prevalence of most psychiatric disorders is much higher than
that of mendalian disorders.
2. High disease prevalence associated with small gene effects
since evolutionary forces would rapidly eliminate large gene
effects. (Pablo et al. 1998)
3. Adoption studies, twin studies and family studies
• Adoption studies attempt to separate genetic, prenatal,
and perinatal events from postnatal environment is
contributors to illness. Adoption studies are
considered by some to discriminate better than twin
studies between the effects of genes and environment. This
is because MZ twins might share more similarity in their
environment that DZ twins.
• Francis Galton was the first to realize the importance of
twins for the study of genetic traits (Galton 1875). In
twin studies, differences between identical or monozygotic
(MZ) twins are attributed to the environment, and the
differences between franternal or dizygotic (DZ) twins
to both hereditary and environmental factors. This is
appropriate because MZ twins have 100% gene
identical by decent (IBD), but DZ twins have only 50%
genes IBD just as with nontwin siblings. the concordance
rate, which is the probability that a second twin will develop
a disorder if the proband (first examined) twin has the
disorder, is commonly used to determine relative
contributions of genes and environment in a disease.
The concordance rate of MZ versus DZ twins are then
compared.
 GENE AND ENVIRONMENT IN ADDICTION:
Fig 6 , 7 and 8

STRATEGY TO FIND SUSCEPTIBILITY GENE( Tasmen )

1. The performance of genome wide linkage or association scans,
which don’t require an a priori knowledge of the
pathophysiology of the disease (methods of mapping are
linkage and association).
The key biological phenomenon in linkage analysis is meiotic
recombination or crossing over during which both the maternally-
and paternally-derived chromosomes lie in close proximity and
undergo exchange of genetic material between the homologues
chromosomes (e.g., between a paternally derived chromosome and
its maternally derived counterpart). The change of crossing over
between two loci is referred to as the recombination fraction. Genes
and other genetics markers that are close together are less likely to
be separated by this process than those that are farther apart
(genetic markers are DNA sequence variations known as
polymorphism). They allow the differentiation of different forms of a
gene of chromosomal region. Therefore, they are usually inherited
together by the progeny cells and are said to e genetically linked.
2. The study of candidate genes, i.e genes that encode proteins
thought to be involved in the pathogenesis of addictive disorders.
Association studies are based on linkage disequilibrium (LD).
This means that in illness gene mutation was initially associated
with specific alleles of nearby polymorphic loci (polymorphism are
nucleotide sequence changes in a DNA sequence among
individuals). The markers most commonly used for the study of LD
are single nucleotide polymorphism (SNPs), which are the most
 common and easy to score DNA polymorphism. Essentially there
are two types of association study, direct and indirect. In the
former, association is sought between any variants that can alter
the structure, function of expression of a gene or genes. In
contrast, indirect studies seek association between markers and
disease that are due to linkage disequilibrium between the
markers and susceptibility variants.
3. The investigation of cytogenetic abnormalities.
4. Cytogenetic anomalies can lead to direct disruption of a gene of
genes, indirect disruption of the function of neighboring genes
by a so-called position effect, or an alteration of gene dosage in
the case of deletions duplications and unbalanced
translocations.
GENETICS AND SPECIFIC SUBSTANCE ABUSE :
• Unlike single gene disorder, rare and 1 in 10000 people, complex
disorders, such as substance dependence, are common often
affecting 1 in 100 or more people.
• Exposure to psychoactive substance could have a much greater
effect on somebody who carries a genetic vulnerability to substance
dependance, than on someone who does not.
• It is the combination of the presence of several distinct genes or
alleles, may be important, rather than a single gene. However, one
overwhelming finding from genetic studies of psychoactive
substances is that the heritablity (i..e genetic contribution) of
dependence for one substance correlates highly with dependence
for other substance.

NICOTINE:
Heritability of tobacco dependence
• evidence of significant heritability among different populations, sexes
and ages.
• Family and twin studies demonstrated a genetic effect on
“ever”smoking (or lifetime smoking i.e. having smoked a cigarrete at
least once)
( McGue, Elkins & Lacono, 2000).
• “never” smoking or intensity of smoking, showed a genetic
contribution in males, which was not clear in females (Edwards et
al., 1995).
• One set of genetic factors was found to play a significant etiological
role in both initiation and dependance, while another set of familial
factors, probably in part genetic, soley influenced dependence
(Kendler et al., 1999).
• Once smoking is initiated , genetic factors determine to a large
extent (86%) the quantity that is smoked (Kaprio et al., 1982;
Koopmans et al., 1999).
• A study in adolescents demonstrated heritability estimates over 80%
for susceptibility to lifetime smoking and current use (Maes et al.,
1999). Other aspects of smoking are also influenced by genetics ,
such as weight gain following cessation (Swan & Carmelli , 1995).
• It is evident that there are different genetic contributions to different
aspects of smoking behaviour, such as initiation, amount used,
development of compulsive use, withdrawal symptoms, and
development of tolerance.
 • Tobacco dependence and linkage studies
• There is some evidence that smoking behaviour is associated with
at least 14 different chromosomal locations
(Bergen et al., 1999 ; Duggirala , Almasy & Blangero, 1999;
Straub et al., 1999).
o One of the loci of interest is located on chromosome 5q near
the locus for dopamine D1 receptor, and this receptor has
been associated with smoking (Comings et al., 1997;
Duggirala , Almasy & Blangero , 1999).
Candidate genes for tobacco dependence
• Several types of evidence have suggested that a nicotine receptor
containing the β2- subunit is necessary for at least some of the
reinforcing properties of nicotine (Mihailescu & Druker – Colin,
2000).
• The results of one study of inbred mouse strains, selected on the
basis of their response to ethanol, suggest that the α4 nicotinic
receptor gene should be evaluated for its potential role in regulating
ethanol and tobacco use in humans (Tritto et al., 2001).
• Smoking is increased if the nicotine content in cigarettes is
decreased or if nicotine excretion is increased, and smoking is
decreased if nicotine is administered concurrently either
intravenously or with a patch. The genes involvement in nicotine
metabolism may be important risk factors for smoking ; the extent of
variation is likely to be a major determinant of levels and
accumulation of nicotine in the brain.
• A significant impact of CYP2A6 genetic variance has been found on
the risk for tobacco dependence, age of starting smoking, the
amount and patterns of cigarette smoking, duration of smoking ,
 probability of quitting , and some aspects of risk of developing lung
cancer (Tyndale & Seller , 2002). However, not all studies agree with
these findings (Zhang et al., 2001).
• Among Caucasian smokers, those with genetically slow nicotine
metabolism require fewer cigarettes per day, reflected in lower
carbon monoxide levels, to maintain equal plasma nicotine levels,
while those with the CYP 2A6 gene duplication (Fast metabolizer)
smoked more , and those with atleast one decreased or inactive
allele were higher in non-smokers than in smokers (Tyndale et al.,
2002) indicating that slow nicotine inactivation modestly protects
people from becoming smokers.
• These data suggest that the CYP2A6 genotype is likely to alter the
risk for smoking and may alter the risk for smoking – related disease
(Bartsch et al., 2000)
ALCOHOL:
Heritability of alcohol dependence

• It is not clear if genetic risk is major factor in the initiation of driniking

or drinking during adolescence (Han et al., 1999; Maes et al., 1999;
Stallings et al., 1999). It may be that environmental effects explain
most of the variation in initiation of drinking but genetic factors are
more important in explaining the frequency of intoxication (Viken et
al., 1999). Genetic factors contribute to the stability over time (68-
80%) in frequency and in the quantity of alcohol consumed per
drinking occasion (Kaprio et al., 1992; Carmelli et al., 1993).
• Estimated habitability of early alcohol use was significantly greater in
boys (55%) than girls (11%) (Rose et al., 2001). Men (but not
 women) who are at increased genetic risk of alcohol dependence
exhibited reduced sensitivity to alcohol (Health et al., 1999).
• The genetic risk for alcohol dependence was increased in those
reporting a history of conduct disorder or major depression and in
those with high neuroticism, social non-conformity, “tough-
mindedness”, novelty-seeking or (in women only) extraversion
scores (Health et al., 1997).
• Specific genes are also likely to influence the heritability for alcohol
withdrawal syndrome (reviewed in Schuckit , 2000).
• Genetic influences also alter treatment seeking (41%) for alcohol
dependence, with shared environment explaining a further 40% of
the variance (True et al., 1996).
• Although it is clear that there is a genetic component to many
aspects of alcohol drinking (e.g. initiation, frequency, quantity and
response to alcohol), the relationship between genes and alcohol
drinking behaviour is not a simple one.
Alcohol Dependence and linkage studies
• On chromosome 4q, one location identified was very close to the
region of the alcohol dehydrogenase (ADH) genes (Long et al.,
1998; Reich et al., 1998; Saccone et al., 2000); Linkage to
chromosome 4q has also been seen near the β1 GABA receptor
gene (Long et al., 1998).
• The strongest suggestions of linkage with susceptablity loci for
alcohol dependance are on chromosomes 1 and 7 , and more
modest evidence for a locus on chromosome 2 (Reich et al., 1998).
Candidates gene for alcohol dependence
• ALDH2 is found on chromosome 4q which has been linked to
alcohol dependence in Asian and Europeans. ALDH2-I is very active
 form found at high frequency among most ethnic populations, while
the ALDH-2 is inactive (or has very low activity) and is found at high
frequency among Asians (e.g. Chinese , Japanese and Korean
people).
• Genetic variation in ALDH-2 in multiple ethnic groups alters the
amount of ethanol consumed (Sun et al., 1999; Okamoto et al.,
2001) and risk for binge drinking (Luczak et al ., 2001)
• CYP2E1, a hepatic enzyme, metabolizes ethanol to acetaldehyde;
activity varies by 15-fold, genetically polymorphic. The rare 2E1
variant alleles are associated with altered ethanol metabolism
(Yoshihara et al., 2000a) Nicotine increases hepatic CYP2E1 in
animal models. Smokers have higher CYP2E1 activity than non-
smokers (Benowitz et al . 1999)
• Twin study suggests that smoking may contribute to tolerance to the
effect of alcohol and diminished sense of intoxication (Martin 1997)
suggesting that smoking induces increased alcohol metabolism.
• Chronic ethanol consumption results in the induction of CYP2E1,
which is believed to play an important role in the pathogenesis of
alcohol-induced liver disease and is responsible for the increased
rates of ethanol metabolism observed in those consuming relatively
high amounts of alcohol (Oneta et al., 2002). Genetic variants of
CYP2E1 can alter the relative inducibiility , which may alter the
impact on risk for alcohol dependence, or resulting hepatic damage
(lucas et al, 1995)
Genetics of opioid dependence :
Heritability of opoids dependance
Heritability is high (70%) (Tsuang et al., 2001).
Twin study suggest higher concordance of monzygotic than dizygotic
twins. Genetic risk for dependence can be divided into a common or
shared vulnerability across different classes of drugs, and a genetic
vulnerability to the specifc drug in question; opioids have lowest extent of
common vulnerability to substance dependance.
Opioid dependence and linkage study
No family – based genetic linkage studies of opioid dependance in
human.
Candidate genes for opioid dependance
Data from genetic epidemiology ; highest genetic contribution is from
unique genetic effects – i.e. those not connected with dependence on
other drugs- pointing to components of endogenous opioids system as
good candidate genes. All three known receptors (mu, delta, and kappa) ,
and genes coding for opoids ligands have been screened for genetic
variation (Mayer & Hollt, 2001)
Mu opoid receptor :
Primary target of morphine and the mediator of the reinforcement and
reward effects of opioids, which makes the mu opioid receptor gene the
outstanding candidate for genetic vulnerability; not consistently associated
with opioid dependence: persons expressing a mu opioid receptor variant
have altered hypothalamic – pituitary – adrenal axis function and altered
responses to other physiological processes regulated through activation of
the mu receptor (Wand et al., 2002).
Kappa opioid receptor
Seven allelic variants discovered but no evidence that allele are functional.
Dopamine D4 receptor
Shown some evidence or association with opioid dependence (Frank et al.,
2000)
CYP2D6
 The most significant finding is the association found between oral
codeine dependence and the metabolizing enzyme CYP2D6.
4-10% of Caucasians lack CYP2D6 activity due to inheritance of two
non-functional alleles.
In contrast with 4% of people in non-dependent group being poor
metabolizers of CYP2D6, suggesting that the CYP2D6 variant genotype
offers protection against oral opioid dependence (Mikus et al., 1998).
SUMMARY:
Substance Heritabiliity Linkage Candidate genes
estimates (%)
Nicotine 60-80 Chromosome 5q CYP2A6 Dopamine D4
near D1 receptor receptor
loci` Dopamine Beta hydroxylase
Alcohol 52-63 Loci on ALDH2
chromosomes 4q , ADH
6,1,7,.2,11q, 10q CYP2E1
GABAA , α6, β1, β3, γ2
Dopamine D4 receptor
COMT (catechol-O
methytransferase)
Serotonin 2A receptor
Opioids 70 None identical CYP2D6
Combined 50-80 Loci on Dopamine D1 receptor
risk for chromosome 15 Dompamine D2 receptor
substance 19q 12-13 Dompamine D4 receptor
dependance Monoamine Oxidase A
in general

CONFOUNDING ISSUES I LINKAGE AND CANDIDATE GENE STUDIES

1. Environment
 • Recent developments in genetics raise the possibility of sorting out
the complex interactions between genotype and environment that
determine the development of the individual behavioural phenotype.
This is clearly a direction that needs much attention.
2. Genetic heterogeneity
• Many psychiatric disorders likely to be caused by multiple genes that
interact with each other (Cooper, 2001). This suggests that one
predisposing allele does not imply high risk; in fact, the majority f
carriers are not expected to express the disorder (Stolenberg and
Burmeister, 2000).
• Issues of genetic heterogeneity create complexity for linkage
studies, as well as for studies that examine only gene, or allelic
variant at a time.
3. Phenotype
• Clearly defining the endpoint (e.g. relative risk for drinking over 8
drinks per day. Alcohol withdrawal, relative risk for initiation of
smoking, initial tolerance) may improve the ability to identify specific
gene involved.
4. Comorbidity
• Comorbidity among disorder will be understood only with increased
knowledge of the underlying neurobiology of the disorders.
Behavioural genetic approaches will allow investigators to directly
test causes of each disorder as well as the comorbidity, and to
estimate the size of the effect of each contributing factor.
METHODICAL ISSUES
• Candidate gene studies have often found conflicting results. The
reasons for differences in findings include:
 o Inconsistencies in the definitions of “smokers” (i.e over vs.
never, former, > 100 cigarettes in lifetime, dependence) and
“smoking behaviour” (i.e. initiation, maintenance, quitting,
cessation, relapse);
o Issues concerning functionless polymorphisms, methodology
(e.g. erroneous genotyping techniques) and statistical power;
o Ethnic ancestry.
Differences in definitions of “smokers”, “drinkers” and “ethnic
ancestry”
ETHICS AND GENETIC RESEARCH
• As long as participants are not intoxicated or suffering acute
withdrawal symptoms at the time they given consent, there is no
compelling reason for believing that persons who are substance
dependent cannot give free and informed consent. The risks of
administration of drugs, and the use of neuroimaging methods in
these experiments, generally do not pose a serous risk to
participant.
• Free ad informed consent, an acceptable risk benefit ratio, and
protection of participant privacy and confidentiality.
• The risks of stigmatization and discrimination that are raised by any
preventive intervention that identified high – risk subjects will need to
e dealt with.
FUTURE DIRECTIONS
Once genes are identified and the functional understand how the
genes interact with the environment this will allow a rational exploration of
biochemical underpinnings of the actions substances so that a link
between behavioural change, genetic predisposition and biochemical
action will be established which will help in prevention, initiation, amount of
intake, maintenance, cessation of substances and personalize treatment
approaches.
CONCLUSIONS
1. Genes are implicated in addiction
2. Polygenic pattern are involved
3. Some genes have been identified, but still intensive researches
are needed to locate more
4. Genes and environment interaction are to be studied in more
depth.
5. Ethical aspects are to be kept in mind