Pushing Naltrexone as the Answer to Our Heroin Problems Is Unscientific and Unethical

May 02 2016

Pushing Naltrexone as the Answer to Our Heroin Problems Is Unscientific and Unethical

May 2nd, 2016

Recently the neuroscientist Marc Lewis, a friend of mine, gave Percy Menzies, president of treatment provider Assisted Recovery Centers of America, the chance to guest-post on his blog as part of a series on the “response to the heroin epidemic.” Menzies’s post suggested that naltrexone, an opioid antagonist, is a “highly favorable alternative” to opioid addiction.

I cannot accept this message. The promotion of naltrexone as a viable solution for heroin users is not based on data, and when it is promoted as an alternative to opioid substitution therapy (OST), it is dangerous, unethical and a violation of human rights. Here are the facts.

Opioid Substitution Therapy Works

The first and most important thing to note is that opioid substitution therapy works. For methadone we have 50 years of irrefutable proof that it works. We use buprenorphine because it is shown to compare favorably to methadone in some robust clinical trials (1). In some cases methadone is better, in some cases buprenorphine—the pharmacological action differs—but they both work effectively (2) and any risks are easily outweighed by the benefits.

OST is shown to reduce mortality by up to 75 percent, reduce crime, improve health, improve retention in treatment and allow people the space to resolve many of the other issues that have made drug use so meaningful to them, perhaps at the expense of other, more beneficial activities. OST also reduces the spread of HIV(3) and is cost-effective.

I feel it’s essential to add that some people use OST because they like opioids. They enjoy them and want to keep using them, but that basic human right has been removed by our ridiculous prohibitionist policies. So to mitigate the harms of uncertain dose, quality and arrest, they choose to use methadone for most of the time and heroin at other times. I have no problem with this, and neither should anyone else.

Some people also have limited access to medical services, and while the privileged access scripts and prescription medications, they use street analogues. This may not be the majority, but they exist and need to be acknowledged.

So Why Isn’t OST Alone Solving the Problem?

Heroin levels remain high, despite the existence of OST, for  three reasons: Firstly, OST is not widely available and secondly the manner in which it is offered is not welcoming to many heroin users. The third reason is that OST does not provide the same “high” as heroin and is not as attractive to those who would prefer to access diacetylmorphine, or pharmaceutical heroin. This should also be available, and the Swiss have demonstrated just how helpful it is.

Between 2003 and 2013 the use of OST as first-line treatment for people presenting with heroin use disorders declined from 33-27 percent in the US. While 45 percent of recipients were older than 45, only 22 percent were aged 20-34 (4). Just 3 percent of all US physicians are able to prescribe buprenorphine.

The lack of access to OST has been widely reported. For example, the Huffington Post ran a whole series called “Dying to be Free.” Disturbingly, US drug-court judges have even ordered people to stop their OST.

The Federal Guidelines for Opioid Treatment Programs (SAMHSA 2013) describe what are essentially abstinence-based, high-threshold programs with comprehensive admissions screening; they see OST as part of a “recovery orientated treatment plan,” and encourage “substance abuse” counseling, 12-step programs and mandatory continued drug testing through urinalysis (eight times per year minimum).

All of this discourages active heroin users from accessing OST services.

What Are Naltrexone and Extended-Release Naltrexone?

The website of Percy Menzies’ Assisted Recovery Centers of America (ARCA), describes their approach: Patients are detoxed “with the help of medications such as Suboxone® (buprenorphine) to relieve withdrawal symptoms. After this first step, you will be ready to begin taking the latest anti-craving medications, such as Vivitrol® (XR-NTX), or ReVia® (naltrexone) in our outpatient program and continue your daily life with few interruptions.”

What are these apparently miracle medications?

Naltrexone has been available since 1984 in pill form for treating opioid addiction; the extended-release injectable version has been available since 2010. Naltrexone is an opioid antagonist: In other words it has high affinity with the opioid receptor but unlike agonists (heroin or methadone) and partial agonists (buprenorphine), it has no effect.

Because of this high affinity, when an agonist like heroin is also ingested, the effect is blocked. The theory goes that if you are taking naltrexone, taking opioids is a pointless exercise. By blocking the normal functions of opioid use, the Pavlovian learning established through cue and reward dissipates over time.

In addition to this opioid-blocking function, ARCA describes the formulations of ReVia (in pill form) and Vivitrol (the 28-day injectable form) as anti-craving medications.

So, if promoters of naltrexone are to be believed, we have a medication that blocks the effects of opioids and relieves craving, and this should be offered far more widely in response to the US “heroin epidemic.”

But what does the data say?

The Data on Naltrexone

Various literature reviews show that naltrexone has little effect on levels of heroin use (5)  compared to placebo. Compliance and retention are cited as the reason for this lack of effect (6). As would be expected in early stages of resolving a heroin use disorder, attitudes and motivations towards abstinence fluctuate. Unless closely monitored, people may decide to skip doses, creating the opportunity for heroin use. Retention in treatment is often a measure of efficacy in and of itself, and based on this alone, naltrexone does not compare favorably with OST (7). A Cochrane review shows no increased treatment retention for psychosocial interventions by adding naltrexone (8).

The longer acting version of naltrexone was developed in order to address these issues of compliance. XR-NTX (the 28-day-acting Vivitrol injection) guarantees compliance for a month at a time, with the individual is making an irreversible pre-commitment to abstinence. Through this pre-commitment to a longer-term antagonist, the individual mediates the effects of short-term cravings because they can’t be resolved through heroin use. However, this is often “tested” and it has been suggested that this “testing” of the blockade through heroin use is what improves abstinence (9).

As for cravings, studies have been unconvincing. Retention rates alone show us that daily-dose naltrexone does not address craving. OST does—hence its far higher retention rates. This is not surprising, as naltrexone is an antagonist. In some studies with XR-NTX, results have shown a perceived reduction in craving, although closer examination shows that craving diminishes with abstinence independently of naltrexone (10).

So naltrexone is no better than placebo unless compliance is enforced, and it has no effect on craving. And that’s the good news.

Naltrexone and Mortality

The biggest danger of naltrexone, both as oral daily dose or a 28-day injectable, is the substantial risk of overdose.

To be clear, during initiation methadone is also not without risks, and all OST, when terminated, presents a risk due to reduced tolerance. But naltrexone seems to increase that risk (11).

In one study, the risks with naltrexone were found to be between 2.8 and 7.4 times higher than with methadone (12). This study has been criticized by some, but what’s in little doubt is that naltrexone reduces tolerance. It is well known that antagonist use leads to upregulation of opioid receptors—meaning that receptors become super-sensitive—and therefore those that stop using naltrexone are at significantly increased risk of overdose.

Who Could Benefit?

All that said, we should not simply dismiss naltrexone—there is enough data to suggest that some recipients can do well. The UK National Institute for Health and Care Excellence (NICE) concludes its 2007 guidelines for naltrexone for the management of opioid dependence as follows:

“In summary, the Committee was convinced of the clinical effectiveness of naltrexone treatment in a selected, highly motivated group of people. The Committee concluded that for people who preferred an abstinence programme, who were fully informed of the potential adverse effects and benefits of treatment, and who were highly motivated to remain on treatment, naltrexone treatment would fall within acceptable cost-effectiveness limits.”

These sentiments are echoed by the World Health Organization. Their 2009 guidelines suggest that people who are employed, who have been using for a short time or are under supervision are best candidates for naltrexone. Those who really are well motivated and have good support structures—and perhaps a lot to lose—tend to benefit most from naltrexone.

Since compliance is the biggest issue, the question of who is likely to be compliant with XR-NTX has been examined. People less likely to be compliant include those who identify as homeless, injectors or people with co-occurring mental health issues (13). This is clearly not a population-wide solution.

Reservations Around Naltrexone Research

It’s important to note that there have not been robust clinical trials comparing naltrexone to methadone and/or buprenorphine in the US.

A study in Malaysia, comparing buprenorphine to naltrexone, found the differences in effectiveness were so great that the trial had to be stopped when it became obvious that buprenorphine was a far superior intervention—to continue with the naltrexone arm of the study would have been unethical (14). A study in Iran that compared methadone to naltrexone reported:

“In spite of the fact that patients undergoing methadone treatment had more severe symptoms and prognoses regarding their age, duration of drug abuse, and number of treatment attempts, these patients showed better general health and social functioning comparing to patients undergoing naltrexone treatment during the 6-month period of this study.” (15)

Much of the data has been sourced from studies conducted in Russia (16), where the policy framework excludes agonist or partial agonist interventions and the punitive approaches to addiction treatment leave such studies to be constructed on dubious ethical foundations (17).

A confounder to note is that almost all the research on naltrexone was done with concurrent psychosocial interventions taking place (18). As one study concludes: “The improvements in opioid craving, depression, anxiety, and anhedonia among those who remained in treatment and did not relapse are most likely an effect of treatment success and not specifically related to naltrexone since they occurred regardless of medication group”(19).

Pharmacological, Philosophical and Ethical Concerns

The pharmacology of naltrexone is clear: It blocks opioids. But while this may be great for blocking the effects of heroin, this blockade is non-selective, so all opioids are blocked. In the case of medical trauma it would be very difficult to treat pain, and if high enough doses of opioids were given, this could potentially result in overdose. But of greater concern is the blocking of the body’s endogenous opioids. Recent literature has shown this to have an effect on the processing of social stimuli (20), and it is something that needs to be monitored over time.

Philosophically, I am concerned that we might potentially see the creation of this blockade as the resolution of a heroin use disorder. “Addiction” is not merely a function of pharmacology; it’s extremely complex. To simply block the effects of heroin on, for example, a person living on the streets, is potentially more damaging than allowing that person to use heroin when they choose.

I realize that this thinking will offend some people. But the evidence does not lead me to believe that abstinence is a desirable outcome for all heroin users. It may be for some—but for others, continued heroin use is a choice and for still others, a necessity.

The problem is not the heroin use, nor any drug use, but the context that alienates a person to the degree that their identity and vocation is tied to their drug use. The problem is the drivers that make drug use the most attractive solution to cope with daily life. This cannot be addressed by blocking the drug’s effect.

Agonist therapies reduce harms significantly and still give the person the choice to use heroin, although methadone and buprenorphine both out-perform naltrexone when it comes to reduced heroin use (21). Of course, heroin users should have the additional option to use heroin safely: Diacetylmorphine should be available in supervised injection facilities.

And this leads to my ethical concerns around XR-NTX. When you start offering 28-day naltrexone to people in the presence of loved ones—or if you over-sell it to people who are desperate but unaware of the full consequences, or people who are ambivalent about their drug use—there is the very real risk of coercion.

Already, we are seeing it being used for criminal justice offenders (22). In 2013 a teen was ordered to take XR-NTX, and Ohio courts are ordering heroin users to take it. In a paper published in 2006, Caplan argued that mandated XR-NTX is justified because “heroin addicts” are incapable of making autonomous decisions. Prisoners about to be released in Massachusetts are also offered XR-NTX—but only the first injections, and I wonder what the risk is after the first 28 days? A clinical trial intended to provide additional details about XR-NTX’s efficacy and safety profile (known as a phase 4 pilot) provided pre-release prisoners the option of XR-NTX on release for six months claims that completing the course “may reduce opioid use,” although only 37 percent of the cohort completed the course of injections (23).

Why would we even consider naltrexone as a significant option in addressing heroin use disorders? A basic principle in medical ethics is that when you have an intervention that works, you don’t introduce an alternative unless there are significant advantages and/or improved safety. Naltrexone offers none of this. It produces results no better than placebo in randomized samples and it significantly increases risk of overdose on termination.

What’s more, the Phase 4 pilot does not go head-to-head with OST. A further basic principle of medical ethics is that if a known treatment exists, a placebo-controlled trial is not appropriate. The only justification for its ethical approval was that the research took place in Russia, where OST is banned. The only advantage that I can see for XR-NTX is that it satisfies a moral agenda that prescribes that agonist and partial agonist therapies are somehow “less than” or immoral.

If policymakers really wanted to address the harm caused by drugs, they would first look at the sickening and deadly prohibitionist policies, legal frameworks and agendas that put every drug user at risk. Then, if we are really to address this “heroin epidemic,” we need to increase access to the interventions we know save lives so that people find the time and space to resolve their addictions and stay safe in the interim.

Methadone and buprenorphine need to be accessible to all heroin users with as few restrictions as possible. If we deliver these in compassionate, person-centred harm reduction settings, where autonomy is respected and each person is considered the expert in their own life, then we will see results.

Naltrexone for heroin use disorders should perhaps be available for those who really want it and are fully informed. However, if the current attempts to mandate use of XR-NTX to already vulnerable populations, as we are seeing in the criminal justice system, continue, it will be seen by future generations as another example of how prejudices and stigma have yet again resulted in a gross violation of medical ethics and human rights.


References:

(1) World Health Organisation 2004; Maremmani & Gerra 2010; Lawrinson et al. 2008; Connock et al. 2007; Connery 2015
(2) Mattick et al. 2014; Saxon et al. 2013
(3) WHO 2009
(4) SAMHSA 2015
(5) Adi et al. 2007; Kirchmayer et al. 2002; Minozzi et al. 2011; WHO 2009
(6) Minozzi et al. 2011; Johansson et al. 2006
(7) Johansson et al. 2006
(8) Minozzi et al. 2011
(9) Sullivan et al. 2013
(10) Dijkstra et al. 2007
(11) Davoli et al. 2007
(12) Gibson & Degenhardt 2007
(13) Cousins et al. 2015
(14) Schottenfeld et al. 2008
(15) Sayyah et al. 2013
(16) Krupitsky et al. 2011; Krupitsky et al. 2015; Krupitsky et al. 2013
(17) Wolfe et al. 2010; Cousins et al. 2015
(18) Meyers et al. 1989
(19) Krupitsky et al. 2015
(20) Wardle et al. 2016
(21) Connery 2015
(22) Lee et al. 2016
(23) Gordon et al. 2015


Shaun Shelly is dedicated to the understanding of drug use, addiction and the development of effective drug policy. He is on the advisory boards of Families for Sensible Drug Policy and Harm reduction Abstinence and Moderation Support Network (HAMS), and is a pioneer of harm reduction in South Africa. His last piece for The Influence was “Did Stephen King, the Master Storyteller, Lose His Truth in Writing About Addiction?” You can follow him on Twitter: @ShaunShelly.

  • Olmy Olm

    This is brilliant. Definitely sharing.

  • OK wait a second. Naltrexone/naloxone is useful if someone is overdosing and you think they could die. In that case, it will wake them up immediately – and can save a life. But beyond that, I agree that Vivitroll is liquid suicide. Because people are just about ready to blow their brains out after about 2 months of it. The simple fact is, people take opiates (or methadone or suboxone or any other drug) because they enjoy it, and ‘blocking cravings’ isn’t going to change that. I think it’s particularly pernicious when coerced – such as a requirement for probation. Thanks for providing some examples of coercion. Such policies will only increase the suicide rate, even if it is delayed for a few months.

    • Kenneth Anderson

      Naltrexone is not naloxone. Naltrexone cannot be used for overdose reversal. Vivitrol cannot be used for overdose reversal either. With naloxone the N-methyl group of oxymorphone is substituted with an
      N-prop-2-enyl group, with naltrexone this substitution is with an
      N-cyclopropylmethyl group. http://opiophilia.blogspot.com/2013/07/opioid-antagonists-naloxone-and.html

      • OK maybe I am “worse than AA” after all. Sorry. Also I am still blocked from your twitter.

  • Steve Todd

    Has anyone here used ibogaine root bark? I had a serious habit 15 years ago; took it, and I was clean in 3 days, no withdrawal whatsoever! Follow up counseling needed, as I went back to it a few days later! I’ve heard there was some “offshore research” years ago!

    • titifolol

      I’ve never heard of that but since you mentioned it here i am definitely going to look it up…thanks 🙂

      • Steve Todd

        It does work!I was on methadone several times; there was/is an “underground” group that used to offer “sessions” lasting about 3 days! $3k! I think the stuff is available through African “pharmacists” on line, and from Amsterdam! Would love to see it used! You need someone around when you take it; it’s a “witch doctor” drug and is a hallucinogen! Been used by the Ibo tribe in West Africa for centuries like peyote has been used in the southwest! Please keep me posted; always have an interest in this field!

        Sent from my MetroPCS 4G LTE Android device——– Original message ——–From: Disqus Date: 5/2/2016 10:40 (GMT-08:00) To: canyonsteve74@gmail.com Subject: Re: Comment on Pushing Naltrexone as the Answer to Our Heroin Problems Is Unscientific and Unethical
        “I’ve never heard of that but since you mentioned it here i am definitely going to look it up…thanks :)”

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        titifolol

        I’ve never heard of that but since you mentioned it here i am definitely going to look it up…thanks 🙂

        1:39 p.m., Monday May 2

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    • Ibogaine has shown some promise for certain individuals. It is not a “cure” for “addiction” but does provide an experience and possibly increase neural-plasticity that can help resolve an underlying existential crises that can drive compulsive drug use and create the space for sustained change. However, there are significant cardiac risks involving prolonged Qt interval up to 72 hours after acute ingestion. Certainly should be explored further, as should all psychedelics.

      • Steve Todd

        I agree! Nothing is a cure! But I have considerable experience with both; it PHYSICALLY worked for me!

        Sent from my MetroPCS 4G LTE Android device——– Original message ——–From: Disqus Date: 5/2/2016 15:09 (GMT-08:00) To: canyonsteve74@gmail.com Subject: Re: Comment on Pushing Naltrexone as the Answer to Our Heroin Problems Is Unscientific and Unethical
        “Ibogaine has shown some promise for certain individuals. It is not a “cure” for “addiction” but does provide an experience and possibly increase neural-plasticity that can help resolve an underlying existential crises that can drive compulsive drug use and create the space for sustained change. However, there are significant cardiac risks involving prolonged Qt interval up to 72 hours after acute ingestion. Certainly should be explored further, as should all psychedelics.”

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        Shaun Shelly

        Ibogaine has shown some promise for certain individuals. It is not a “cure” for “addiction” but does provide an experience and possibly increase neural-plasticity that can help resolve an underlying existential crises that can drive compulsive drug use and create the space for sustained change. However, there are significant cardiac risks involving prolonged Qt interval up to 72 hours after acute ingestion. Certainly should be explored further, as should all psychedelics.

        6:09 p.m., Monday May 2

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        Shaun Shelly’s comment is in reply to

        Steve Todd:

        Has anyone here used ibogaine root bark? I had a serious habit 15 years ago; took it, and I was clean in 3 days, no … Read more

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  • titifolol

    I think they should talk to each addict in turn that comes into substance misuse services and work it out with them what will be best to help them abstain from using, having been an addict for 20 yrs heroin/crack/benzo’s,amphetamines,weed you name it tried it but heroin + crack + Benzo’s where my drugs of choice, myself and my partner we where both given Dia-morphine ampules because we said we already had one addiction to morphine and so why should we get another to methadone and as a result we where given the dia-ampules we went to the pharmacy each day to pick up 4 100mg ampules of dia-morphine and within a week both our lives had turned round 360 degree’s, I KID YOU NOT! and as each week went by it got better and better and for the first time in decades I could see myself having a normal life, our money was going on the things it was mant for, food and bills etc unfortunately after 6 wks i had to have mine stopped it came to light that because i had already had a DVT (deep vein Thrombosis) I couldn’t be allowed to carry on with them and i was devastated, i can still now 15yrs later remember howling in my partners arms i could not believe i had a life put in front of me only to be snatched away, anyway i came off them but only because i had no choice and stayed on green methadone but i carried on using, my partner ended up in prison from an old warrant from before he got the ampules so he came off them to then i decided to get clean myself and moved to a new town, i have been clean 10yrs my partner came out of prison and was given the ampules back after about 9 wks when he already had got his heroin habit back and he also moved down to the new town with me, we got our first real home in the new town as I had been there why my partner had been in prison i got place in an hostel that gave me lots of help and who i cedit with being 30% of the reason i got on my feet and stayed on them and my partner came to me when i he got out and first of all along side of me he built a life in our new place, he got a job and we did our gardening, wet shopping for food each week, did housework each morning, painted our home and took pride in it, we loved it and where like a ouple on their honeymoon because we here so happy, we where doing it getting a life together and we were winning and it felt so good, it still does now 🙂 our families came back into our lives and all through this my partner was getting his ampules each day and then one day when he felt stable enough he decided to cut them down so he dropped 1 amp a day and he got off that and 4 months later he dropped another and after 15 months he was off them all together……so thats what worked for us….we are all different and most heroin addicts that I knew had a problem with the needle as much as the drug, i would never smoke heroin i used to think it a waste of time and would only ever have it if it was in a syringe even when my habit was at it worst i still wouldn’t smoke it….now some won’t touch a needle but those what do there is no point giving them anything other than something to use with a needle for some reason i haven’t seen anyone speak out loud about this issue but it is out there and it is a massive problem, and if most addicts knew that they could have the ampules and rebuild their lives the way we did then i know for a fact lots of them would go for that option. I am not saying let them have ampules forever just for a few years why they build a life with firm foundations because you see those foundation become precious they did to me and my partner for so long we’d had nothing to call our own, we slept in some right dives and hovels so to suddenly not have to go shoplifting to make money was great, to have clean clothes when we wanted them was great, we loved going grocery shopping and our cupboards being ful, clean sheets on our bed, clean towels all the time, toilet roll we even appreciated toilet roll…alot as it goes because for at least 2 decade we hadn’t any of these things so as we went along we got more and more things for our home and our lifestyles changed to so that by the time my partner was ready to come off the ampules he was glad to do it he said, at that end point he said he felt ashamed for still being on them and there was no reason for him to do so…..and so he did he got off them…myself coming off methadone was a shocking experience, i am a very outgoing person, and always joking around and laughing, i like to make people laugh and get told i am funny a lot of the time but i came off my methadone at the last 20 mls asked my doctor for painkillers and benzo’s to help me get through the first 4 wks and withdrawals and so i did it i dropped the 20mls just like that…..and 9 months later i still hadn’t used drugs again but i was very depressed, i have never been so down in my life, all my family where worried about me taking it in turns to come sit with me and i didn’t know any of this but by the end i was losing the will to live, as soon as i opened my eye’s each morning i wanted to cry, i didn’t want to see anyone or go anywhere and my son cried one day and asked “Where’s my mum, I know she’s in there and your here in her place but you have to go now and let her come back because we love her so much” and i remember crying my eye’s out at that and in the end i asked my partner to go and score for me not because i wanted to be high, that couldn’t be further from the truth but because i wanted to just be ok….I hadn’t been ok for so long and i had kept telling myself it would pass and one morning soon I would wake up feeling well….Luckily my partner as strong for me that day and refused and he held me all that night and i cried and cried and couldn’t stop, he took me to y doctors the morning after and i told him all that had happened, luckily my own local GP was also a drug doctor at a local Community drug team in a town next to ours so he knew what he was doing and i asked him to give me methadone back because if he didn’t i would end up scoring he didn’t fight me on it and he agreed to give me back 20mls a day and i got that that first 20 mls and within a half hour the change was surreal if i hadn’t gone through it i wouldn’t of believed it and it’s since then i have known what a powerful drug Methadone is and why they should not be giving it to heroin addicts, it is a far harder fight to get off than heroin, I’d used methadone on a daily basis for at least 15yrs beforehand and the more I lookd into to it the worse it became, you see it is also a mood suppressant is Methadone and a very powerful one as I found out and my body couldn’t cope with the drop when i stopped taking it, my doctor did say it could be possible that i might have to be on methadone for the rest of my life, he said that theoretically methadone can be got off as long as it’s done properly with no long lasting side affects but another point of view is that after decades of use our bodies could adapt to being a certain state all the time and n the end perceive that as it’s normal and so when methadone was stopped the body didn’t have any other normal to fall back on so that i would do y detox and after a week or two be fine……I left it for another year after that whilst i got myself back on track but it really knocked me badly and since then i don’t feel as if i have te same get up and go that i once did, 12 months later i started to break it down again but this time only dropping it by 2 mls every month and after a couple of years i was free of it…..but even now sometimes i can feel that horrible feeling i had for those 9 months and it scares me…I really don’t think methadone should be given to anyone period…it’s an horrible drug. And so there you have it another point of view from an ex addict….oh and by the way we’ve been in our new place now for almost 13yrs and yes where still clean…..we’ll never ever go back to that horrible life ever again, we appreciate things so much i cannot even tell you how much, we’ve never had before what we have now…and we are not rich at all we have problems every other normal family does and we sleep like babies to…if someone had told me this is how it would end up for me and him I would never of believed it in a million years….we are blessed, truly blessed and so very happy….I love my life and myself……ow how good is that? 😀

    • Right, addicts must abstain from using, even though you used drugs for decades. This is the “Kick the ladder out from under you” treatment method. Which leads to ‘great happiness’. Nice!

      • titifolol

        I never said they should JUST abstain from using, IN FACT QUITE THE OPPOSITE IS WHAT I SAID HERE …you need to read it again because you didn’t read it right if you thought i said they should just abstain……..But if they cannot abstain no matter how much they might want to then is it not wise to at least make it as safe as possible for them? you would make an Anorexic person comfortable and give them medication, same with lung disease and Diabetes….you would treat them with medicine and painkillers…so why is it so far fetched to treat someone who has an addiction to opiates with opiates and wean them off that way…why not if it works? …GO READ IT AGAIN WHEN YOUR NOT OFF IT…i am advocating for people with addictions to be treated in ways that will work……

        • “work it out with them what will be best to help them abstain from using” – LOL these are your own words.

          But hey thanks for demonstrating typical drug ‘treatment’ strategy: “YOU’RE NOT LISTENING YOU IDIOT! I NEVER SAID THAT! GO SOBER UP AND LISTEN MORE CAREFULLY NEXT TIME! I’M SO HAPPY NOW!”

          • titifolol

            I’ve been sober for over 10yrs you partt and maybe that makes me a bit more best placed to know what i am on about…how else do you think your going to fix it by telling them what to do…thats worked dead well for last 40yrs and cost you untold hundreds in taxes….. you have to work it out with the addict and let them have a deciding factor because you can do what you want and blow smoke as much as you want but if they don’t have any part in what people want them to do then it ain’t going to work period….now go away and learn about drug addiction before you sprout of abut something you have no idea about….been sat watching the shite that comes on the TV news for to long……get educated properly then come back

            Never know you might say something really clever now like for me to go away i’m druggie scum….which would show your true intentions anyways….go on fill yer boots…..i hope you have no children mate because if this ever touches you your going to wish you’d listened to people like me

          • “now go away and learn about drug addiction before you sprout of abut something you have no idea about” and “i hope you have no children” – Thanks for continuing the demonstration of what you will be subjected to if you seek treatment for ‘drug addiction’. And for giving the ‘experts’ the opportunity to demonstrate that they will say nothing even as the bullying goes on right under their nose. (Future historians will find this quite helpful as they try to understand what the hell happened.) Please, continue:

          • titifolol

            I don’t know why you seem to think I am against people seeking help for drug addiction sir if you had read my comments you would know otherwise but because you don’t means you only actually read a line or to thinks me which you copy/pasted here….very clever must say …….I mean does it make you feel like your clever to mention future historians and things like that as if your a very learned fellow?…I had contemplated doing a similar thing but I think looking like a tit suits you much more than myself so carry on 🙂

          • Again, thank you for demonstrating the persistence with which you will be berated by the abstinence mongers-in-denial and called a ‘tit’ whatever that is – I assume a learned fellow. But no, I don’t mind looking like a tit if I can expose how the treatment providers will tell you that methadone is hell and you must abstain and then deny ever saying such a thing and “YOU DON’T LISTEN” and “I hope you don’t have children” while the other ‘experts’ cluck about how treatment isn’t working and then stand back and say nothing as their peers hurl more insults such as:

    • ILoveChis

      Are you from UK? Dia-morphine not available in US. Methadone is and is effective.

      • titifolol

        yes

  • The fact that this article uses ‘naltrexone’ and ‘vivitrol’ interchangeably is proof of the larger inaccuracies of this article as a whole, not to mention that it uses the oldest trick in the book which is to milk one research study dry to “prove” the point of the author. Here, I can do that too. Here’s an article on the efficacy of VIVITROL ‘proving’ the exact opposite: https://www.vivitrol.com/HCP/Efficacy

    And here’s an article I wrote that discusses the issue that the biggest barrier to Vivitrol treatment is that people like the author of this article refuse to raise their expectations for substance abusers to get on this type of treatment. Continued heroin use has a much higher rate of overdose and death than vivitrol, so to use that as a con for vivitrol treatment is irresponsible. To say that users have less of a chance of overdose on methadone or suboxone is to remain rooted in the belief that heroin users cannot get clean without some sort of OPIATE/narcotic replacement therapy: http://www.theday.com/article/20160207/OP03/160209500

    • Andy Miller

      “The fact that this article uses ‘naltrexone’ and ‘vivitrol’ interchangeably is proof of the larger inaccuracies of this article as a whole…”

      Vivitrol is a brand name for the injectionalbe form of Naltrexone…what’s the problem? Are you suggesting Vivitrol is NOT Naltrexone? According to Vivitrol’s (biased) website, “The active ingredient in VIVITROL® (naltrexone for extended-release injectable suspension) — naltrexone — works as a “blocker.” Actually, take a look at the picture at the top of this article…does it not say “Vivitrol – Naltrexone for extended release?” There’s nothing magic about Vivitrol, no matter how people like you try to spin it. Vivitrol is injectionable, extended release Naltrexone, period.

      “To say that users have less of a chance of overdose on methadone or suboxone is to remain rooted in the belief that heroin users cannot get clean without some sort of OPIATE/narcotic replacement therapy”

      That’s a ridiculous assertion. To say that users have less of a chance of overdose on Methadone or Suboxone, and to show some evidence that this is the case…is simply to call into question the viability of Vivitrol or Revia to treat opiate substance use disorders – nothing more, nothing less.

      To top it off, you post your own article…which in order to read, you must login or register. I won’t bother, because if the gobbledegook you posted above is any indication, it’s not worth my time to register.

      • The problem with using ‘naltrexone’ and ‘vivitrol’ interchangeably is that one requires the patient to comply with autonomously taking the pill on a daily basis, and one is a 30-day injection. Conducting scientific research requires the use of ‘variables,’ or any factor, trait, or condition that can exist in differing amounts or types. It shouldn’t be too hard to see why a study that attempts to make a statement as to the efficacy of Vivitrol when they studied naltrexone would be unsound.

        Users have less of a chance of overdosing on methadone and suboxone, because they are still addicted to a partial opiate; using this fact as a con for Vivitrol is contributing to the belief that heroin users cannot get clean without some sort of opiate replacement therapy. That is the assertion I was making. The scope of a good debate cannot apologize for elevating an argument above simple cause-and-effect.

        As for the fact that you have to login to read my article, that is the policy of every major newspaper in the country. I wasn’t trying to make it difficult to keep the conversation on this topic going. If you are interested in reading it, I’d be happy to email you a copy, christaqua@gmail.com.

        • kimberly

          Christa, the active ingredient in Vivitrol is naltrxone. Vivitrol is merely the extended-release shot; the pill prescribed for everyday use goes by a different name, but also contains naltrxone as the active ingredient. Suboxone actually has a ceiling effect, so it is virtually impossible for someone with opiod use disorder to overdose on it. Methadone is usually given in an extremely controlled setting, so the risk of fatal overdose when taken as prescribed is also quite low. There is also a cross-tolerance between medications like Methadone and Suboxone and other opiods, so overdose from relapse is far less likely upon cessation of these drugs than upon cessation of a naltexone-based blocking agent.

        • Andy Miller

          By your logic, we should be more worried about the continuation of “addiction” by using MAT’s like Suboxone and Methadone, than the potentially greater risk of overdose and DEATH by using Vivitrol or Revia instead of Suboxone or Methadone.

          Again, Naltrexone is Naltrexone….the different forms all result in the blocking of the effects of opioids. Sure, the different methods of administration could and probably would have an effect on scientific research results.

          Speaking of scientific research results, in the face of decades of research on other MAT drugs, we know very little in comparison about the long term effects of Vivitrol and Revia. And yet, treatment clinics are RAMMING forms of Naltrexone down every client’s throat. I wonder why that is? I have serious doubts that it is because it works so well…seems the author does too…

          • I’m not sure what grounds you have to make such dramatic assumptions about my theoretical orientation, or what I consider ‘addiction’ to be. I worked at a methadone clinic for three years. I did my internship at a suboxone clinic. I am in no way, shape, or form, pushing one treatment over any other. I discuss Vivitrol because so many treatment providers are still unaware of its existence, while methadone has been around since the 1930s, and suboxone is on everyone’s radar with the push for physicians to have licenses that accommodate more patients. I am no longer working full-time as a counselor, so I certainly do not consider myself a healthcare provider working with addicts… I am a member of Shine A Light On Heroin, an advocate, working to expand treatment awareness and education.
            You cannot hold someone to a higher expectation than they have for themselves, but addicts typically do not have a high enough opinion of themselves, or feel they are worth it, so if ‘we,’ meaning those in recovery, healthcare providers, reform advocates, etc., don’t raise those expectations, who will? I acknowledge methadone, suboxone, naltrexone, vivitrol, 12-step, medical marijuana, and a great many other treatments as legitimate pathways to recovery, however there are a huge proportion of addicts that have been told for a very long time that their best options are opiate-replacement, because it’s such a stretch to expect them to take the steps necessary to get on vivitrol. That is the only thing that I am ‘pushing’: that treating a narcotics addiction with other narcotics is not the only way.
            I also think you’ve confused how I used research studies in my comments above. I was being tongue-in-cheek, showing that I too, can use studies to manipulate, I was not negating any one study over another, but showing that they can be spun to meet the author or social media poster’s objective.
            And finally, please note that all of my comments were in response to the fact that someone went out of their way to title article “Naltrexone as the Answer to Our Heroin Problems Is Unscientific and Unethical.” If that’s not a challenge for forsaking one treatment in favor of others, or skewing expectations, than I’m not sure what is.

          • Andy Miller

            I take issue with your side stepping and miminization of the concerns raised by the author – even going so far as to label them “scare tactics.”

            That’s funny, I didn’t assume anything about you. And it doesn’t really matter to me what your “theoretical orientation” is, nor what addiction means to you. I guess you assumed that these things would matter to me. Respectfully, if anyone is confused, it seems to be you.

          • You didn’t ask me a direct question so I’m not sure what it is that I’m ‘side-stepping.’ I, however, have a direct question for you: if I’ve stated that I’m not a proponent for any one form of treatment over the other, that I just don’t like to see an article blatantly taking a treatment out of consideration completely, I’m interested as to what your stance is; are you so in favor of OST that you are against Vivitrol being on the table at all?

            I also never said the author was using “scare tactics” so I’m not sure why you out that in quotation marks. I didn’t assume that the points of my comment would matter to you; you stated that “by [my] logic, we should be more worried about the continuation of ‘addiction’ by MAT’s like Suboxone and Methadone…” therefore I was explaining my stance to you becusing because I do not think that’s what we should be worried about. Methadone and suboxone are perfectly viable treatments. It’s not right to demonize them, just as it’s not right to spin facts to demonize another viable treatment like Vivitrol.

          • Andy Miller

            1. It is not “spin” because you say so. Remember, the author actually cited *some* research that has been done. What research have you cited (other than that study on Vivitrol’s website…which, as you said, was only to prove a point)?

            2. Your post, at one time, referred to the author’s argument against Vivitrol as “scare tactics.” – I wouldn’t have put it in quotes if I wasn’t directly quoting you…and I certainly wouldn’t make up something so inflammatory. Your post no longer says that. I can only assume that you edited the post, once I called you out.

            3. To answer your question, I am in favor of any available treatments (including Vivitrol & Revia) remaining available at the disposal of doctors, patients, and everyone in between. However, I believe the concerns brought forth by the author (and others) about Vivitrol and Revia warrant significant and thorough additional research. The pace with which Vivitrol and Revia are replacing other MAT options, largley because of lack of access of Methadone and Suboxone (for example), is also rather concerning, from ethical and scientific points of view.

            4. Above all, people ought to consider what research does exist already, and form their own opinions – independent of biased points of view which exist here on the Internet and elsewhere.

          • I cited one study to demonstrate the efficacy of Vivitrol, exactly like the author, who discussed one study in which the efficacy of naltrexone was the subject of the research. I’m not presenting myself as a leading researcher in the field of addiction, again, I am an advocate, working to expand treatment awareness and education; I volunteer my time to help those suffering from addiction find WHATEVER means of treatment might work for them. As for offering very little conclusion, I’m not denying that the research to support Vivitrol is not nearly as vast as that which supports methadone or suboxone, but therein lies my point; there is some data that shows the naltrexone tablets weren’t much better than placebo in maintaining abstinence from opiates, and some research that after detox, opioid-dependent patients who participated in counseling and took vivitrol, compared to those participating in counseling and taking placebo had significantly higher rates of complete abstinence, stayed in treatment longer, reported less craving, and were less likely to relapse to physical dependence.

            I regret to tell you that you are mistaken regarding my ever using the words ‘scare tactics.’ I have not edited any of my posts in this comment feed, that’s why I was curious as to your use of quotation marks. You’ve attempted to discredit many of the things I’ve said; if I was concerned by any of these attempts, I’m not sure why I would choose to start editing my posts over those words in particular. I’m not suggesting you made it up (I’m also not sure why you consider it inflammatory), I’m just certain you saw it elsewhere than within the content of my posts).

            I’m glad that you are in favor of any and all treatments remaining available for patients. I wonder too, where in the country you are located. I live in RI and currently work in CT; my work in methadone and suboxone was done in MA. All three of these states not only have dramatically more patients on methadone and suboxone than Vivitrol, a simple search of the Substance Abuse and Mental Health Services Administration will show you that the availability of methadone clinics and suboxone doctors far outnumber the Vivitrol prescribers.

            I agree with your last point completely. I’m just still in awe that readers are not seeing this post as biased. I can’t stress enough that I’m an equal opportunity believer in whatever treatment works. I have friends and loved ones for whom suboxone saved their lives. I’ve seen Vivitrol pull individuals back from the brink of death, from overdoses and heroin-induced car crashes and a lack of a will to live. And I helped hundreds of patients utilize methadone to regain control of their lives. In the wake of an epidemic this great, our society cannot afford to turn away from any prospective treatment.

          • Hi Christa

            Thanks for commenting. I agree that we should be aware of all the options, and indeed both WHO and the UK’s NICE guidelines say XR-NTX can help some people, but the data is far from conclusive, and there have been no head-to-head trials in the US. The study you cite had a low retention rate and those that did not complete the treatment were excluded from the results. You may also be quoting the Russian study, but I have some serious questions around that study considering the environment and policy framework it was done in.

    • kimberly

      I think the author of the article is simply looking at the reality that abstinence-based approaches to opiate/opiod use disorders don’t tend to work long-term; there is a high rate of relapse. With substitution therapy, there is a cross-tolerance between the substitute and one’s opiate/opiod of choice, so overdose from relapse is far less likely upon cessation of the substitute. Also, there is an incentive, beyond the mere desire to “stay clean” for people to stick with opiod substitution-therapy: the desire not to suffer withdrawal. If the desire to “stay clean” were usually enough, we’d need not look any further than abstinence-based approaches which emphasize willpower. I don’t think options like vivitrol (the active ingredient of which is naltrxone) will become less available in a prohibitionist society like ours, which already champions abstinence, simply because people write articles exposing its shortfalls.

    • “it uses the oldest trick in the book which is to milk one research study dry to “prove” the point of the author.”

      By one study you mean 4 literature reviews, a Cochrane review, 2 head-to-head studies, a WHO recommendation, the UK clinical guidelines and 15 other articles published in peer reviewed journals?

      • I am not negating the studies you cite in response to opioid substitution therapy. Note in my comments below that I worked in methadone and suboxone for years and view these treatments as indispensable. However you use one study that looked at the efficacy of naltrexone, not Vivitrol (in another comment below I discuss the dangers of ignoring differing variables in research), yet here’s an article on the efficacy of VIVITROL exhibiting the opposite: https://www.vivitrol.com/HCP/Efficacy You also simply state ‘various literature reviews…’ which tells me nothing, and again, your Cochrane review looks at naltrexone, not Vivitrol. You state that heroin use on Vivitrol “is often ‘tested’ and it has been suggested that this ‘testing’ of the blockade through heroin use is what improves abstinence (Sullivan et al. 2013), yet discuss nothing of the fact that patients can also ‘test’ much more easily on methadone, which is a synthetic opiate, or suboxone, a mixed agonist-antagonist opioid receptor modulator.

        Finally, you state “The biggest danger of naltrexone, both as oral daily dose or a 28-day injectable, is the substantial risk of overdose. To be clear, during initiation methadone is also not without risks, and all OST, when terminated, presents a risk due to reduced tolerance. But naltrexone seems to increase that risk (11).” I have a question then… Are you against abstinence as a treatment option? AA and NA? Because it seems to me that would pose the biggest risk of decreased tolerance and overdose of all. So should we abandon these treatments because there is a risk of overdose, despite the very obvious fact that the highest risk of overdose is continued use of heroin itself???

      • Andy Miller

        Exactly.

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  • F(u)dxdydzdt

    or stop the cia afghan northern alliance from producing 90% of the world supply without which there would onlt be enough for 100,000 h addicts

    A heroin epidemic is on fire all across America. Heroin deaths shot up from 1,779 in 2001 to 10,574 in 2014 as Afghan opium poppy fields metastasized from 7,600 hectares in 2001 (when the War in Afghanistan began) to 224,000 hectares currently.

    The Taliban outlawed opium in Afghanistan in 2000 and within a year it was all but gone, demonstrating that Afghan opium can be eradicated quickly for any administration that chooses to do so. Afghanistan is, by far, the number one source globally of both opium and heroin.

    In 2014, 7,554 tons of raw opium were produced worldwide, including 6,400 tons in US-occupied Afghanistan and 173 tons from Mexico and Colombia. Opium plus chemicals (like acetic anhydride) produce heroin. US-occupied Afghanistan produces 85% of the world’s heroin. Mexico and Colombia produce only 2% of the world’s heroin. Mexico and Colombia produce enough heroin for only 115,000 heroin addicts.

    http://dissidentvoice.org/2016/10/congresss-take-on-the-heroin-epidemic/