From the Archives: Treating Opioid Addiction

It is estimated that between 26.4 million and 36 million people abuse opioids worldwide; the US government estimates that 2.1 million people in the United States have substance use disorders related to prescription opioid pain relievers in 2012 and another 467,000 are addicted to heroin. Consequences include a spike in the number of unintentional overdose deaths from prescription pain relievers (including the recent death of the musician Prince), and growing evidence to suggest a relationship between increased non-medical use of opioid analgesics and heroin abuse in the US.

OBrien_Charles_featWhat can we do to help? This spring, Charles O’Brien and colleagues reported results of the latest in a series of studies testing the drug naltrexone as a preventive against opioid relapse in people greatly at risk for relapse: formerly addicted convicts. “This U.S. multisite, open-label, randomized effectiveness trial showed that among adult offenders who had a history of opioid dependence, the rate of relapse was lower among participants assigned to extended-release naltrexone than among those assigned to usual treatment,” they write.

These studies started in 2007, the year after the FDA approved a long-acting (monthly) injectable form of naltrexone for treating alcohol addiction. The researchers got funding from the National Institute on Drug Abuse for this study, which builds on a three-year pilot study funded by the Dana Foundation in 2006. O’Brien, at University of Pennsylvania, is also a member of the Dana Alliance for Brain Initiatives.

This grant wasn’t investigating a drug or procedure’s efficacy: Researchers already knew naltrexone negates the effects of heroin and other opiates so that addicts “get no kick” from them. But at the time, treatment required taking a daily pill, something many addicts find difficult, and now that there was this longer-lasting treatment O’Brien and colleagues wanted to test if it might work better. It was an unusual patient population, too—people in the criminal-justice system—which meant researchers had to design their method to make sure participation was voluntary and no one was coerced into the experimental treatment.

O’Brien, Richard Bonnie, and Donna Chen discussed some of the ethical issues in our Cerebrum journal in 2008, “The Impact of Modern Neuroscience on Treatment of Parolees”:

Assuming that the FDA approves the use of extended-release naltrexone for opioid addiction relapse prevention, there are three approaches that criminal justice policymakers could take toward facilitating its use: (1) a “voluntary” approach, in which the treatment is not linked to the offender’s status in the criminal justice system and the offender’s decision to participate (or not) in treatment and to take (or not) naltrexone is unequivocally voluntary; (2) a “leveraged” approach, in which the offender agrees to undertake the treatment in return for a more favorable disposition of the case; and (3) a “no choice” approach, in which the offender is simply ordered by the court to take the drug. Each of these approaches raises distinct ethical concerns. …

Because most individuals in the criminal justice system likely will not have the resources to obtain naltrexone on their own, particularly early in its patent life, a significant policy matter—and indeed a significant ethical matter—is whether such treatment should be subsidized for any addicted offender who wants it. The NIDA-funded study mentioned earlier, which is using extended-release naltrexone with offenders who are under community supervision and who have volunteered to participate, will help inform policymakers about the effectiveness of this policy option in reducing relapse and repeat offenses. …

Do the new results, showing naltrexone is, indeed, effective, mean doctors everywhere will start prescribing medication to treat addiction? Maybe not: The track record so far for using other medicines to prevent relapse has not been as good as one might hope, said O’Brien in a 2011 Q&A interview.

There is an incredible amount of ignorance on the part of physicians who choose not to use medications that were developed by the NIH and have been approved by the FDA. In the case of alcoholism, for example, there are so few doctors in the United States who know about treating alcoholism with medications that the vast majority of people who seek treatment don’t receive medications. This is true even for those who go to very expensive programs, which may charge tens of thousands of dollars a month. It’s just a shame, because in some of these people, naltrexone would take away their cravings for alcohol and they would feel great. Treatment for opiate addiction faces similar hurdles.

In some cases, doctors are actively against using medication. They say it’s against their philosophy or that they don’t believe in giving medications for a drug problem. Yet, the double-blind studies show that the medications work. This is a tragedy, because patients who happen to fall into the hands of physicians with that lack of knowledge may be condemned to keep relapsing.

In 2012, O’Brien expanded his remarks in a Report on Progress: “If Addictions Can Be Treated, Why Aren’t They?”:

So the question remains, why are effective medications being withheld from alcoholics and patients addicted to other drugs despite scientific evidence of their value? Why are patients being deprived of a treatment that could change their lives for the better? When the disease does so much damage to so many people suffering from addiction and to their families, why are most patients not even given a trial of medication in most respected treatment programs?

The answer seems to be that there is a bias among treatment professionals, perhaps passed down from past generations when addictions were not understood to be a disease. Medically trained personnel are minimally involved in the addiction treatment system and most medical schools teach very little about addiction so most physicians are unaware of effective medications or how to use them.  Numerous studies have shown that addiction treatment is cost effective so that designers of health care reform have built addiction treatment including FDA approved medications into the new system.  We can only hope that medical schools will catch up with the need for education on the treatment of this common disease.  Patients and their families can also help by raising questions about the availability of medication with their treatment professionals.

Last summer, O’Brien took his message to Capitol Hill, briefing staffers and members of Congress on drug addiction and incarceration:

—Nicky Penttila

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