1) In order for a addicted individual to get Vivitrol they will have to be treated by a physician who believes in chemical managment for addiction. Most who are of this mind set also believe in chemically altering mood and sleep which by mere common sense is not a smart thing for an addicted individual. We have lost the right to a chemical solution for our emotional problems.
A: Either you believe in fighting the disease of addiction with medications or you don't. It appears your position is the latter. No amount of discussion or company sponsored research is going to change that but perhaps clinical experience might.
My Response-My clinical experience has led to me not believing in the use of medications. I have seen and treated the addiction themselves, the process addictions, and also the addictions to doctors/attention/and any med not just the mind altering meds. The whole mentality around medication, and needing to change something wrong within us by the use of medications is a problem as great as the DOC. It’s that mentality that must change. Why would a medical profession reinforce destructive thought patterns?
2) Vivitrol while it may prevent someone from getting high from their drug of choice, can actually promote overdose if someone is determined to get high on their DOC while on Vivitrol.
A: Yes, this is a possibility and the reason responsible physicians take every opportunity to communicate this issue to their pts. It's also possible that, absent a chemical therapy to reduce cravings, the pt can OD on their DOC.
My Response-Vivitrol doesn’t reduce cravings, that we know by experience. It blocks addicts ability to get high, at least for a portion of the month. But, we both know it doesn’t work for as long as the Vivitrol reps tell us it works. And in that lies a problem. Addicts know this, and begin pushing on those receptors. And in order to test those receptors many are tempted to push opiates past their comfortable boundaries chasing a high. No amount of education will change that behavior in most addicts. Also, what we know is if you block an addicts ability to get high from their DOC, they merely switch DOC or stop taking the Vivitrol. It’s a big 800 dollar what’s the point.
3) If an addict is in legit and significant pain, they can not be given narcotics for that pain. So, an addict can have his leg and pelvis crushed in a freak tractor accident, and the only way he will be receive relief is to be placed on a ventilator and anesthetized.
A: First, I think we can all agree that somebody who is in a freak tractor accident resulting in crushing wounds of the leg and pelvis is going to go into surgery under GA, anyway! Second, pts are given multiple medical alert items to assure first responders know that they are on NLTX, the opioid blocker in Vivitrol. But even if we allow the worst case scenario, pt is unconscious and no HCP knows they are on Vivitrol, it won't take long at all for the gas-passers to figure it out and administer agents sufficient to clear the opioid receptors.
That being said, there is a unique concern with opioid addicts in that they tend to be hyper-sensitive to pain, a condition probably attributable to their habit. For pts who are on Vivitrol, they may receive some relief from traditional non-narcotic analgesics. Additionally, unmasking the pain response, which may have been muted or obliterated while using, may allow for the discovery of previously undiagnosed issues.
My Response-So you acknowledge that an addict will need to be anesthetized in order to gain pain relief beyond COX-2’s. That is even in cases where a patient would not have needed anesthesia normally.
4) The slippery slope mind set within addicts of using a chemical to control a chemical. From our 40 years of experience here, we realize this ultimately leads to relapse in most cases. And in this case would most likely lead to either a person stopping their Vivitrol or relapsing on a new mind altering chemical.
A: One of the mistakes we've made in the past is a failure to insist on a practical exit strategy when we've stepped pts down using the harm reduction model. The end goal, IMHO, must be sobriety without medication, including Vivitrol. Prior to NLTX we didn't have a non-narcotic option for addressing cravings and to prevent euphoria when relapse occurs. We simply replaced one addictive medication with another one that we thought, incorrectly in the case of medicinal cocaine, heroin and methadone, was less addictive. Even today I see too many physicians eagerly buying into the 'maintenance' phase of suboxone BS. While there may be a small percentage of pts who need to be on sbx after the acute withdrawal period, my observations tell me the 'business model' of sustained sbx therapy is driving the train, not pt care considerations.
My Response-You make some terrific points about exit strategies. I have more respect for addiction medicine physicians who actually acknowledge the need for chemical free sobriety. We might disagree on how to get there, but at least we are moving towards the same goal. I can accept that.
It may be helpful to point out that the active component of Vivitrol in naltrexone. NTLX is not an opioid and will not foster chemical addiction. IMO the lack of a euphoric affect provides 'traction' against the slippery slope you described. Second, I can assure you the 'business model' (profitability) of Vivitrol to the prescribing physician is neutral, at best. Third, it's been my understanding that the manufacturer doesn't have many physician speakers on their payroll and tends to reimburse them below industry standards. I don't speak for them so this is second and third hand info.
My Response-The fact is we don’t really know what effect naltrexone has on long term sobriety, and that is the most honest answer a physician can give. How physicians get paid really is irrelevant to me.
So, you'll have to forgive me if I'm not drinking the Vivitrol Kool-Aid. There isn't enough data supporting its use that outweigh my concerns above.
A: Alternately, there appears to be a wealth of data indicating that the way we've been treating opioid addiction isn't working very well. Professional studies I've read indicate a 5-year sobriety rate of 5-12% with an annual mortality rate of 2-3%. Poor results in one therapy are seldom justification to aggressively adopt another one, but IMO I have an obligation to explore all available options, and Vivitrol is one of them. I don't believe I've become intoxicated on the kool-aid but my personal experience with Vivitrol for opioid addiction has been fairly positive.
My Response-This is the only true dishonesty I seen in your responses. 5-12%? Where are you getting your figures and how were these studies set up? What population are we talking about, any who walks into an AA meeting? Or are we talking about someone who completed 5-6 weeks treatment, and a year at a half way house? Also, if the inadequacy was within the programs themselves, then why do airline pilots and physicians have 90+% 5 year sobriety rates? It’s not a program problem. It’s an accountability problem. Give me some legal leverage on a patient to help with motivation and we can produce 5 year numbers that would exceed most people’s expectations.
