The Other Opioid Dependence Medication

Today I met with representatives from Alkermes who were promoting Vivitrol, a long-acting mu opioid antagonist that is indicated for treatment of alcoholism and opioid dependence.

Naltrexone
Naltrexone

I admit to some pre-existing bias against the medication.  I’m not certain, to be honest, whether that bias was based upon sound clinical reasoning, or whether it was based on personal, negative reactions to naltrexone in my past.  Or maybe, as a recovering opioid addict, I have negative feelings about anything that blocks mu receptors!
Vivitrol consists of naltrexone in a long-acting matrix that is injected into the gluteal muscle each month. The medication is expensive, costing about $1000 per dose (!)  That cost is usually covered by insurance, and like with Suboxone, Wisconsin Medicaid picks up the tab save for a $3 copay.  Alkermes, the company that makes Vivitrol, also has a number of discounts available to reduce or even eliminate any copays required by insurance companies.
I’ll leave the indication of Vivitrol for alcoholism for another post.  The indication for opioid dependence came more recently, and appears more obvious, given the actions of naltrexone at the mu opioid receptor.
In short, naltrexone blocks the site where opioids—drugs like oxycodone, heroin, and methadone—have the majority of their actions.  Blockade of that site prevents opioids from having any clinical effect.  There is some dose, of course, where an agonist would regain actions— an important feature in the case of surgery or injury.  But even in those high doses, the euphoric effects of addictive opioids would be muted.  People on Vivitrol, essentially, are prevented from getting high from opioids.
Back in my using days, I took naltrexone, thinking that doing so would help me get ‘clean.’  I didn’t wait long enough, however, and so I became very sick with precipitated w/d.  The makers of Vivitrol recommend waiting at least a week, after stopping opioids, before getting an injection of Vivitrol.  I suspect that a week is not long enough to prevent w/d, but I realize that it would be very difficult to expect patients to last longer, without using anything.  I would expect that any precipitated w/d could be reduced through use of comfort medications, at least for a day or two until the symptoms are mostly gone. This requirement, though, to be clean for a week or more is one of my problems with the medication.
As an aside, I was also prescribed naltrexone (oral tabs) at the end of my three months in residential treatment, and I took the medication for another three months.  I had no withdrawal or other side effects to naltrexone at that time.
Another issue was the concern that naltrexone has been connected to hepatic toxicity.  We discussed that issue today, including the studies that led to that connection—which are not compelling.  The discussion allayed most of my concerns about liver problems from Vivitrol.
Finally, I have always recommended buprenorphine over naltrexone because of the anti-craving effects of buprenorphine that result from the ‘ceiling effect’ of the medication.  I worried that naltrexone, by blocking the actions of endorphins, would actually increase cravings.  But that is not what the data shows.  In the studies with Vivitrol, cravings for opioids were dramatically reduced by the medication.  The mechanism of that effect is not entirely clear;  some of the anti-craving effect may be psychological, as addicts stop wanting something when they know there is no way to get it.  But there may be other complicated neurochemical effects at presynaptic opioid receptors that are not fully understood.
The bottom line is the result of treatment;  the very sick opioid addicts treated in the studies used by Vivitrol to gain FDA approval showed a profound reduction in opioid-positive urines, over a span of 6 months.
I suspect that I will continue to favor buprenorphine.  I do not buy into the ‘need’ some people describe to ‘get of buprenorphine as fast as possible.’  Buprenorphine is a very effective, safe, long-term treatment for inducing remission of opioid dependence.  But because of the cap, I am glad that another option is available to treat this potentially-fatal condition.  And I admit to perhaps being too quick to judge Vivitrol, which appears to be a safe alternative—particularly for people who have a lower opioid tolerance that do not want to push it higher, or for people who have been free of opioids for a week or two.
I would invite local people who are on my buprenorphine waiting list to consider Vivitrol as an option.
 

Do Interventions Work?

It has been a while, it seems, since I’ve checked in.  I’m at the point in the life cycle of a ‘blogger’ where I feel like I’ve said most of what I came here to say… so help me out by sending your questions, particularly those with broad implications, and I’ll chime in with an opinion.
In the meantime, check out the ‘best of’ page;  I have links there to some of the more popular post.   And for now, I’ll answer a question I received today on ‘TheFix.com’:
Do you believe in intervention of someone who does not ask or desire (to be clean)?
It is hard to predict human behavior; sometimes people rise to the occasion when all appears to be lost, and other times people who have everything going their way make surprisingly poor decisions.  But in my experience, real sobriety requires the addict to feel a profound need to change that comes from within. 

Grandma needs an intervention
More common than you think!

That doesn’t mean, necessarily, that interventions never work—but the intervention should be set up in such a way that the addict or alcoholic—him or herself– comes to the realization that getting clean is the only option. 
For example… let’s say that grandma has a problem with pain pills, taking more than what is prescribed, going to multiple doctors, going to the ER for pain pills, etc.  Her children don’t like her behavior, so they stage an intervention, to show her the problems her behavior is causing.  At the intervention, they tell her how hurt her grandchildren are by her absence at their functions, and they explain the risks of her behavior.  They set her up at a treatment center, and she is shipped off for 30 days.
She may go to all of the groups and meetings in treatment, agreeing politely in every setting that she has a serious problem, and that she really ‘gets it.’  And that would be great for the treatment center; they would collect their $30K, and everyone there would congratulate each other on how compassionate and bright they are. And later, when grandma is doing the exact thing she was doing before treatment, the counselors would put the blame on HER, acting as if SHE has a problem for not sticking to plan—even though almost all of their patients end up the same.
I used to be a bigger fan of residential treatment. But at some point I let go of the fantasy of residential treatment as the ‘gold standard’, and accepted the real numbers.  It is easy to clean a person up for a month in a closed environment.  But in regard to long-term sobriety… residential treatment rarely works.  Sorry to say something so horrible—but that emperor, sadly, has no clothes.
So back to grandma… I would expect her to go back to the same behavior after treatment. Why, after hearing from all the family, would she do that?
Because true change is very, very difficult. 
Besides, she has plenty of reasons to keep things the same.  She will likely think that the problem isn’t the use of pain pills, but rather that she didn’t hide things well enough.  Or she will assume that other people simply don’t understand what it is like to be 70 years old, trying to live with pain. She used to change the smelly diapers of these kids;  what could they possibly tell her that she doesn’t know?
And the major reason she won’t change?  For her to truly realize that her behavior is a problem, she would have to endure the shame for what was going on—and shame is a very strong motivator for denial.
In treatment, the team will try to try to break through that denial and have her admit, to herself, that she has a problem.  But that type of admission is rare, and only comes out when a person is desperate—and when there is no choice but to change.
But there are other ways to manage an intervention.  It would be best if grandma herself decides, at some point, that things must change.  How does that happen?  First, everyone has to stop enabling her.  If the grandchildren are angry that grandma didn’t show up at their birthdays, they should be allowed to express that anger—and when grandma protests, she is forced to hear why people are mad.  If grandma runs into problems with the doctor or pharmacist, nobody should help her sort things out;  she is left to juggle excuses on her own.  If she needs the ER for pain pills, she drives herself—or waits for a cab.
I chose ‘grandma,’ by the way, because I wanted to present the challenge of dealing with a person who deserves sympathy.  Nobody does her a favor by keeping her miserable.  Realize, though, that we are discussing addiction here;  I’m not suggesting that people abandon loved ones struggling with painful conditions!
The doctor should prescribe medications on a tight schedule, with strict refill dates that are maintained without exception.  Doctors are sometimes afraid to let people go into withdrawal, so they order ‘a few extra pills’ to get to the next refill;  medications should be long-lasting, so that withdrawal is uncomfortable, but not dangerous.  A short period of the medication- i.e. a one-week supply—will reduce the period of withdrawal.  If a person struggles to follow limits, the prescribing period is shortened until the person CAN follow it—even to the point of 3-day prescriptions with multiple refills.  If grandma complains about the multiple trips to the pharmacy, she is told that period will be lengthened if she sticks to the schedule— and shortened if she doesn’t.
The point of all of this is to make the person with the problem feel the consequences of their problem.  Too often, everyone else is aware of the need for an intervention, because everyone else feels the consequences—everyone but the addict.  The trick is to make the consequences hit the person who has the problem—and for everyone else to get on with life, until the person with the problem is sick and tired of those consequences.
Of course, every now and then an intervention turns out to be meaningful enough to get a person’s attention, and to spur change.  But in my experience those types of outcomes—the things we see on TV and in movies—are not the norm.

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Winehouse

By now, everyone who knows of Amy Winehouse is aware of her tragic death. I’ve always liked her music. So much music these days has been digitally processed and reprocessed, and assaults the senses– I’m thinking of Lady Gaga, for example, whose ‘Edge of Glory’ would be pretty boring in concert if you took away the flashing lights. But Amy Winehouse’s music had an earthy, sultry style that communicated her emotions in a way that words can’t… which is why we even listen to music, at least in my case.
Every now and then I’ll meet a person coming in for help who has an addiction that seems to be almost part of a death wish, as if the person is taking agent after agent with one goal: to eliminate any sense of consciousness or emotion. It is as if life is too painful for the person to tolerate, and the person won’t stop until the brain is finally quiet. I sometimes think that those people would club themselves in the head until they are unconsciousness, if psychotropic drugs were not available! I had that same thought when I read that Amy Winehouse had purchased a grab-bag of drugs including heroin, cocaine, and ketamine in the days before her death.
When I set out to right tonight’s blog I planned on including her picture. But when I went on Google images and searched under her name, I found a number of ‘before and after’ images that demonstrated the horrible toll that drug and alcohol dependence took on her health and physical appearance. The images were so bad that I felt very sad for her and for her family, and I couldn’t bring myself to post them here– as doing so would be ‘piling on’ a horrible tragedy.
I searched around for a suitable tribute, and I think I found one. Her personal, internal battle is apparent in the video, and I’m sorry that she wasn’t able to find a way to tolerate life.
Enjoy the music that she left behind:

Clean Enough, chapter 2.1 and 2.2: My Story

Chapter 2:  My Story
Nature vs. nurture
I grew up in a small town in Wisconsin, the son of a defense attorney and a teacher. I was the second of four children. I will not get into a drawn out psychodynamic exploration of my upbringing at this time except to note that I firmly believe that the way I ultimately turned out is a result of a combination of genetic, developmental, environmental, and personality factors. There were probably elements of my early life and also genetic factors that predisposed me to become an addict, but I believe that each person can point to similar predispositions. I am the one responsible for how I used the gifts and liabilities that shaped my life.
The nerd
I was a very cheerful young child, but at some point I began to struggle with social interactions. By the time I was in high school I was clueless about fitting in. The things that seemed impossible back then look easy now; why didn’t I simply look at what other kids were wearing and imitate them? That idea never entered my mind, and I cringe when I see pictures of myself at that age. Why did I think any boy should enter a school with embroidered blue jeans?!  I did well with the academic aspects of school, always scoring at or near the top of my class with little effort. There was little respect for academic achievement in my rural high school, and I blamed my academic performance for at least some of the harassment directed my way. By the time I was a sophomore I was literally afraid for my own safety on a daily basis. I had several incidents where I was facing bullies, my back against a wall. I was deeply ashamed when the bullying occurred in public, and I certainly didn’t want my parents to know that it was happening. I was physically beat up on two occasions, both times accepting the blows with no effort to fight back or defend myself. The clear message from my father was that real men do not run away from a fight, and so running was not an option. But I didn’t know how to fight back, and was afraid that if I tried I would only be hurt worse, so the outcome of my ‘don’t run’ strategy was not great!
I ‘tried on’ different personalities during my last two years of high school. I became a druggie, growing my hair long and replacing the smile on my face with a look of apathy or disgust. I sported an Afro and used a pick instead of a comb. I smoked pot and drank beer when not in school. The changes worked as intended, and the harassment from other students stopped. But I was still on the ‘outside looking in’.  Some people who lack social skills seem to come to terms with their unpopular position and quit trying.  That wasn’t me; I continued to try to be one of the popular kids, kissing up, tagging along, and laughing at the stupid comments of ‘jocks’… Yuck!  During my senior year I joined the cross-country and track teams, and in retrospect I was fitting in at the time without even realizing it.  But by my high school graduation in 1978, the year when marijuana use peaked in the United States, I was a daily pot smoker with a great GPA, little confidence, and no direction in life.
I attended the same liberal arts college that my older brother was attending mainly because that was easier than finding a college that I liked more.  I took the courses that were the most interesting and ended up majoring in biology.  College came very easy to me because I had a genuine interest in what I was learning.  Everything I learned seemed to answer a question that I always wondered about. That is, by the way, is a great way to attend college!
I was in a couple of relationships in college that in retrospect had addictive traits to them. After a difficult breakup during my sophomore year I became very depressed, and afterward spent several months engaged in the heaviest drug use of my life. My fraternity house provided ready access to pot, opium, cocaine, Quaaludes, marijuana, LSD, and hallucinogenic mushrooms.  I wonder if I carried so much anger under the surface that I had a ‘death wish’; I have hazy memories of walking on a ledge seven stories up, losing control of a motorcycle and ending up in someone’s front yard without wearing a helmet, and wandering around in tunnels under the streets of Milwaukee after climbing down a manhole.  I was lucky to survive those experiences, and I now try to understand similar behavior—extreme risk-taking and impulsivity—in addicts who are patients of my practice.