Media Bias Against Suboxone

First Posted 2.8.2014
After Philip Seymour Hoffman’s death, I anticipated a flood of articles describing the ineffectiveness of non-medication treatments for opioid dependence.  I assumed the media would finally report on the need for long-term treatment of a long-term illness.  Instead we read more articles describing Suboxone (i.e. buprenorphine) as a ‘bad drug’, since Hoffman may have used the drug to reduce withdrawal between heroin binges.
Taking buprenorphine within a few days of using heroin blocks most of heroin’s effects and makes overdose much less likely– a fact rarely reported.  Out of about 400,000 overdose deaths over the past ten years, only 400 deaths included buprenorphine as one drug in the fatal mix– a stunning statistic that calls out for more life-sustaining buprenorphine treatment, not less.  In most of those cases, death would not occurred had there been more buprenorphine in the victim’s bloodstream.
Vivitrol is the brand name for a monthly, injectable form of naltrexone that appeals to a superficial approach to opioid dependence.  Naltrexone advocates focus on the months of abstinence when patients are taking the medication, often during forced compliance mandated by drug courts. Rarely questioned is the long-term effectiveness (or lack thereof) of naltrexone for reducing the morbidity and mortality of opioid dependence.
The uncritical acceptance of naltrexone by some prescribers begs some important questions.  If short-term use of a treatment causes an increase in long-term mortality, is the treatment ethical?  If patients mandated to receive a course of treatment only relapse and reoffend a year later, is the treatment an efficient use of resources?
Naltrexone appeals to the same people who push abstinence programs that have long-term success rates well below 10%.  Current abstinence treatments often center around programs developed in the 1920′s, that ignore the advances in our understanding of neuroscience and addiction since that era.  Abstinence programs blame failures on patients rather than recognizing failed treatment approaches. The case of Philip Seymour Hoffman should call out for a new paradigm, where patients are treated with medication that works and continues to work over the years of a person’s life.
Naltrexone is a ‘blocker’—a great thing for the anti-drug attitudes in all of us.  But does it matter that people treated with naltrexone die from overdose at a rate 7-fold higher than people on methadone?   Proponents of naltrexone ignore the long-term nature of opioid dependence.  And whether naltrexone is administered by shot or by tablet, patients inevitably stop taking it.  The ‘naltrexone paradigm’ calls for only 6-12 months on the medication, and many patients drop out even sooner, when their probation ends.
Many patients learn from the internet or elsewhere that naltrexone increases their sensitivity to heroin, a ‘reverse tolerance’ effect that makes relapse impossible to resist. The same hypersensitivity causes greater risk of death, making ‘one last time’ a self-fulfilling prophecy.
On the other hand, headlines that decry ‘abuse of buprenorphine’ greatly exceed true harm from buprenorphine. Most buprenorphine abuse consists of self-treatment by addicts who have no access to the medication, because of limits on patient enrollment and regulations that discourage physicians from prescribing the medication.   ‘Abuse’ of buprenorphine is far more likely to prevent overdose than to cause harm.  Even one dose of 8 mg buprenorphine prevents death for several days by blocking opioid receptors.
Given the safety of buprenorphine, it is hard to justify the use of temporizing measures or ineffective step treatments.  Addiction deserves proper medical treatment—not superficial approaches that delay death for a year or so.

The Opioid Dependence Big Picture

First Posted 1/16/2014
Below, internet colleague Paul Dessauer shares his extensive knowledge of opioids in comments about my naltrexone post. His comments were particularly interesting in that they provide evidence that at least someone is aware of the big picture about addiction to heroin and pain pills.
In my post about naltrexone, I described how some people favored the drug over buprenorphine because of its lack of opioid effects. Unlike buprenorphine, naltrexone is an antagonist that has no abuse potential.  But I wondered… at a time when so many young people are dying, shouldn’t the primary issue be whether naltrexone saves lives?  Sure, it is ‘safe’– but does it work?
Paul provided references to answer my question.  While everyone is focused on the fact that naltrexone can block opioid receptors, Paul’s data shows that when naltrexone is used in the real world, people die.  I’m excited that someone, somewhere, has the courage to investigate the one thing that is never addressed in discussions about addiction, whether related to residential treatment, counseling, or medication: Does it work?
Paul’s comments:
You wrote;
<<< If ‘success’ consists of moving to naltrexone—a medication that many real-world addicts reject– how long is naltrexone continued, and what happens when it is stopped? Do people go back to heroin again? If not, why not? The cycle of ‘use, treat, cease treatment, use, and repeat’ should be a black box warning on naltrexone >>>
The other “black box” issue is dropped tolerance overdose when someone exits naltrexone treatment and relapses to illicit opioid use.
You asked; <<< How many people will die in their quest—or their doctor’s quest—for ‘abstinent recovery’ with or without naltrexone? >>>
This study used Australian coronial records to compare mortality rates amongst patients in methadone treatment, buprenorphine treatment, and naltrexone treatment. The authors make it clear that they believe the mortality rates for naltrexone calculated here are significant underestimates, as coronial data does not record such deaths consistently, and they found the majority of known naltrexone-related deaths did not appear in this data.
<<< When expressed as deaths per number of treatment episodes, it was estimated that naltrexone had a mortality rate of 10.1 per 1000 treatment episodes. If the mean treatment retention in naltrexone treatment was estimated at 3 months (rather than two months, as assumed in the above estimate), the mortality rate for naltrexone treatment increased to 15.2 deaths per 1000 treatment episodes.
Naltrexone was associated with a mortality rate of 22.1 per 100 person years during the period of high risk (2 weeks post-treatment), and 1 per 100 person years during the period of low risk (during treatment)…. >>>
<<< …The estimated mortality rate was 0.02 per 1000 treatment episodes for buprenorphine and 2.7 per 1000 episodes for methadone.
The mortality rate for naltrexone was four times higher than for methadone when calculated as deaths per number of episodes of treatment, and substantially higher than for buprenorphine.
When considering deaths per periods of high and low risk, the mortality related to naltrexone was approximately seven times that of methadone during the period of high risk and three times the rate during the period of low risk. Naltrexone treatment was associated with a mortality rate of 22.1 per 100 person years during the period of high risk (two weeks following treatment cessation) and 1 per 100 person years during the period of low risk (during treatment). Buprenorphine mortality rates were not expressed in terms of periods of high and low risk due to the low number of deaths detected with this search method. >>>
<<< In comparing mortality rates associated with these pharmacotherapies, it is important to draw the reader’s attention to the rates of mortality for active heroin users. It has been estimated that mortality rates for heroin-dependent persons not in treatment are in the vicinity of 0.9 per 100 person years of risk, very similar to the mortality rate of a person in naltrexone treatment (during the period of low risk) calculated in this study. >>>
Actually, this is slightly less than the risk of naltrexone-associated death calculated in the study, which is believed to be an underestimate.
And the risk of naltrexone-related death calculated for the “high risk” period (the two weeks immediately following cessation of naltrexone) is more than TWENTY TWO TIMES higher than the risk of death estimated for someone using street heroin who is not in any form of treatment at all.
<<< While maintained in methadone or buprenorphine treatment after the initial induction stages, opioid-dependent people are at lower risk of dying. Clearly, an important aspect of methadone and buprenorphine treatment for opioid dependence is the improvement of treatment retention rates.
The mortality risks associated with oral naltrexone treatment, particularly following treatment cessation, warrant serious attention. This is especially the case considering that the majority of unselected opioid-dependent persons will return to opioid use soon after leaving naltrexone treatment. It is recommended that future trials of all treatments for opioid dependence include monitoring of post-treatment mortality risk >>>
Gibson, A. and Degenhardt, L. (2005) Mortality related to naltrexone in the treatment of opioid dependence: A comparative analysis, Sydney: National Drug and Alcohol Research Centre