Response to the heroin epidemic: 3. OST, the economics of diversion, and the dangers of naltrexone

…by Shaun Shelly…

Percy Menzies’ post has stirred up a lot of controversy! Here, Shaun’s extensive rebuttal gathers some of these arguments, plus many of his own, and launches them in torpedo-like fashion. Shaun’s command of the research landscape is awesome, but let’s take care to keep a balanced perspective.

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In the previous post on this site Percy Menzies makes what appears to be a persuasive argument for naltrexone as a favourable intervention when addressing heroin use disorders. Where Dr. Menzies and I agree is that people who have a heroin use disorder should have a wide range of options for treatment, all the way from non-pharmaceutical to antagonist to agonist. Having said this, I have some major problems with his argument, and I believe that the promotion of naltrexone as a valid response to the heroin epidemic, compared to agonist and partial agonist therapies, is flawed.

The first thing we need to know is that opioid substitution therapy (OST) works. It is the gold standard recommended by the World Health Organisation, and for the last 50 years methadone has been proven to reduce mortality, reduce crime, improve health, improve retention in treatment and allow people the space to resolve shootingupmany of the issues that have made drug use so meaningful to them. It also reduces the spread of HIV. Through robust head-to-head clinical trials, buprenorphine has also been shown to be effective, in some cases more so, in some cases less, but it is effective and has a better safety profile.

Dr. Menzies suggests that the treatment of heroin use disorders is “overwhelmingly dominated” by OST. This is simply not true. According to a 2015 SAMHSA report, only 22% of people between the ages of 22 and 34 accessing treatment for heroin use disorders received OST. Even judges playing doctor are ordering people to stop OST. Further, Dr. Menzies argues that if OST was made more available it would “exacerbate the existing problem, as the pool of opioids will greatly increase along with abuse and diversion.” The data simply do not support this: In Switzerland, where 92% of people in heroin use treatment are receiving agonist therapies, the number of people with a heroin use disorder is dropping by 4% per year and no one has died from a heroin overdose since the programme was started in the early 90s. Similarly in France, where buprenorphine is the norm, 70% of heroin users have access to OST and there has been an 80% reduction in heroin-related deaths and a 75% drop in HIV prevalence among injecting drug users. 20% of French physicians prescribe buprenorphine compared to 3% in the US.

bupebottlesAs far as diversion is concerned, diversion is a function not of greater availability but of lack of availability. The diversion of methadone and buprenorphine occurs because they have a street value — because people cannot access these medications or because the services that offer them are not attractive to them. This is basic economics, and it has been proven throughout history. Increased access through appropriate services will reduce diversion!

The most concerning aspect of Dr. Menzies argument is his promotion of naltrexone in lieu of OST. Naltrexone has been available since 1984 in the oral form for treating opioid dependence and XR-NTX, the extended release injectable version, since 2010. Naltrexone is an opioid antagonist. In other words it has affinity with the opioid receptor but has no intrinsic value and therefore no efficacy. Theoretically this blockage causes the dissipation of Pavlovian learning over time. But for this to occur, the naltrexone needs to be taken over time, and retention and compliance are listed as a major problem in all the studies. The 28-day injection (XR-NTX) was developed, and this has improved compliance, but in many studies patients do not complete the course — in a phase four trial only 36% of participants completed the treatment. Dr. Menzies and his organisation, Assisted Recovery Centers of America (ARCA), also describe naltrexone as an anti-craving medication on their website. But what does the data say?

A Cochrane and other reviews have shown that naltrexone performs no better than placebo in reducing heroin use. Craving has only been shown to be reduced with the XR-NTX formulation, but studies suggest this is linked to period of abstinence independent of the drug. Further, due to the antagonist nature and subsequent upregulation of opioid receptors, once naltrexone is stopped it significantly increases the risk of overdose. Some studies have suggested that this risk can be 7 times higher than with methadone.

Further, the studies that were used to secure FDA approval for XR-NTX in the treatment of heroin use disorders were done in Russia, where OST is outlawed. It is a basic principle of clinical trial ethics that if there is an existing treatment option, placebo controlled trials are not ethical. There have been no head-to-head trials in the US for naltrexone vs. OST. A Malaysian trial ended prematurely because the difference between buprenorphine and naltrexone was so great that it would not have been ethical to continue!

Dr. Menzies is suggesting that we use a medication that has: not been through head-to-head clinical trials with a known effective treatment (OST); that performs no better than placebo unless autonomy is taken away and it is given in a 28-day formulation; and that has been shown to significantly increase the risk of mortality on termination. He further suggests that it may be especially useful for “patients who are not well-to-do and who are, as a result, often trapped in a very limited set of choices.” This despite the recommendations of the World Health Organisation and the UK National Institute for Health and Care Excellence (NICE) guidelines recommending that only employed, fully informed, short-term users who want total abstinence and are well informed of the consequences of naltrexone would benefit. Studies looking at retention and efficacy have shown that people who are homeless, injectors, or have co-occurring disorders are not suited to naltrexone. At US$1000 a shot, I wonder how long the “not well-to-do” will be compliant.

In the interests of autonomy, disclosure and choice, naltrexone should be on the menu, as Dr. Menzies suggests. But based on the evidence, Dr. Menzies’ post promoting naltrexone as the most promising response to the heroin epidemic appears to be less of a reasoned argument and more of a biased stance that capitalises on the fear and stigma so many have towards opioids and those who use them.

For a more complete argument against the use of naltrexone, complete with references, please see my piece in The Influence.

23 thoughts on “Response to the heroin epidemic: 3. OST, the economics of diversion, and the dangers of naltrexone

  1. matt May 4, 2016 at 4:35 am #

    Hey Shaun

    Great post! I’ve found that naltrexone works for those it works for, and for others, it doesn’t (me, for one). That along with often unpredictably shifting tolerances, make it an option, not the go-to. It’s another tool in the armamentarium, but we don’t want to miss the forest for the trees… We need every option we can get, and most people end up succeeding with a synergy of a number of things, of which naltrexone is only one.

  2. Colin Brewer May 4, 2016 at 5:15 am #

    I haven’t read the previous post but my experience of NTX in opiate dependence started in 1985 when it became available in Britain and I was the first physician there to take it seriously. However, I was also one of the few physicians at that time who was enthusiastic about agonist maintenance during the two decades from 1980 when the establishment view was that methadone should be used sparingly if at all. Giving patients some choice is important, especially as the more sophisticated and thoughtful heroin addicts (in contrast to alcoholics) are often well informed about treatments.

    Although well-supervised oral NTX (like well-supervised disulfiram) gets better results than unsupervised medication (I recall that one trial of probation-linked oral NTX was stopped prematurely because the NTX wing was doing so much better) depot and – even better – long-acting implant versions of NTX unsurprisingly give even better results. The claim that ‘autonomy is taken away’ by long-acting preparations completely ignores the fact that imprisonment takes it away in a much more brutal, brutalising and unhelpful manner and often for longer periods. It was precisely its beneficial effect on their ‘autonomy’ that made my patients request NTX, sometimes after years of successful agonist treatment. As I’ve pointed out (Editorial: Harm-reduction for unwanted pregnancies and unwanted addictions: an instructive analogy. Adicciones, 2008;20(1):5-13) the same requests for help to control ‘autonomy’ are a prominent feature of most family planning programmes. Most residential units also take away a lot of ‘autonomy’ but instead of offering agonist or antagonist medication to patients who find it harder to stay clean than they thought, they usually kick them out. Happily, even formerly rigid 12-step units are now starting to see sense (and the evidence base).

    Like disulfiram, NTX should be seen not just or primarily as a medication but as part of the re-educational toolkit that all addicts need if they are to have a lasting change of attitudes and habits to their problem drugs. Really long-acting implants giving around six months of blockade make that re-educational process easier for both patients and the therapeutic team. There is also persuasive evidence that they reduce very considerably the risk of opiate overdose compared with both drug-free abstinence programmes and methadone maintenance because their very long pharmacological ‘tail’ means that they can block the respiration-depressing effects of opiates for 9 months or more, even when NTX levels have fallen below the levels needed to block euphoria. One of my most touching patients came to see me two days short of his discharge from prison and still handcuffed to a warder. He had relapsed instantly after every one of his many previous discharges and saw a NTX implant as a good way of trying to change this pattern. A year later, he was succeeding. I know: anecdotes are not evidence but when backed up with clear and simple pharmacology (and psychology) they can illustrate the wider picture.

  3. Cordelia Naumann May 4, 2016 at 9:49 am #

    Thanks for posting this article. I am currently fighting long-term alcohol use, and I recently saw a doctor in the SF Bay Area who prescribed Naltrexone for alcohol reduction. This “addictionologist” charged me $425 an hour (she’s not on my insurance plan) to prescribe me low-dose Naltrexone which my insurance pay for — my out of pocket cost was only about $5 for the drug.

    The first week I took it I did pretty well, but she only gave me enough for two weeks so that I would come back and pay her outrageous fee to get more. It did reduce my cravings. For 3-4 days I didn’t drink more than 1-2 units of alcohol.

    However, one thing I’m not clear on is the studies on women, their hormones, and how that affects their use of alcohol. Just last Sunday, my PMS kicked in really well, and I ended up over drinking even though I had taken the Naltrexone. I would argue that that’s another danger of it — people drinking in excess to because Naltrexone isn’t giving them the reward, so they keep pounding the shots until they do. Thankfully I think I only had 6 units that night (it was still a lot).

    Anyway, I’m going to forego the Naltrexone, the expensive (and not very nice) doctor, and just stop drinking. The most effective thing for me has been the online support of Hello Sunday Morning and Soberistas, not drugs that make me feel weird or think I’m invincible.

  4. Peter Sheath May 4, 2016 at 9:52 am #

    Hi Marc/Shaun, sorry I’ve not been in touch but here goes;
    Having just woke up this morning to the very sad news that yet another friend was found dead alone and with a needle in his arm, over the weekend, this is a timely piece. I read Shaun’s piece a couple of days ago and Percy’s piece when it first appeared here. I didn’t respond to Percy’s piece at the time because I was so angry, much as I am today. Personally I think we’ve all been seduced, in one way or another, by the latest “recovery” panacea, naloxone being one of many. Maybe that “thing” has had an impact on our lives, maybe we’ve witnessed a miracle occurring right before our eyes? Maybe we’ve then become blinded to the massive amounts of evidence that supports other interventions and place all our resources in something that will make a difference for a very few, at best, or could even cause more harm than doing nothing.
    Somehow whole systems have been allowed to evolve that measure success by the numbers of people that can be churned through and, ultimately, spat out the other end as “successful completion, drug free discharge”. Unfortunately, if you are in receipt of opiate substitute therapy, this route is not open to you and, despite the fact that you may have years of abstinence from illicit use and recovery capital coming out of your ears, you will need to stay in treatment. On the other hand if you opt for abstinence and elect to take naltrexone you can leave no problem. There are some very serious implications to this, people quite often present in treatment within, what is very often, a very small and ever diminishing window of opportunity. Treatment should endeavour as much as possible to create and maintain a wide window of tolerance. Because the window of tolerance is being constantly eroded by things like rigid protocols, disinterested people, excessive amounts of unnecessary paperwork, geography and opening times it gets really difficult for the windows of opportunity and tolerance to align and subsequent engagement to occur.

    • Marc May 4, 2016 at 10:56 am #

      Hi Peter. I’m very sorry to hear about your loss. I can imagine how you might feel. Both you and Shaun have emphasized the importance of OST because it keeps people alive, off the street, living decent lives, and of course these are the prerequisites for everything else one can hope for. You also emphasize the need for open, unconstrained availability without the hoops, stigma, and other obstacles. I think where you differ most from Percy Menzies is in emphasis. It seems he also advocates unencumbered choices for addicts…but he sees value in naltrexone as one of these choices.

      I won’t say more. I’m no expert at what goes on clinically, as you know. Peter, it’s good to hear from you, despite the sad circumstances and the anger that I know flows out with your compassion. By the way I got that massive piece from you, and I’m only awaiting time to read it carefully. Keep doing what you’re doing: helping.

    • matt May 9, 2016 at 4:50 am #

      Hi Peter

      I’m so sorry for your loss… all our losses. The “rubber stamp redemption” policies and attitudes have got to stop. The process of getting help when we’re ready gets mired in the tedious swamp of bureaucratic bullshit you describe that people have to navigate.Treatment beds disappear, methods get more expedient and options dwindle, even as the enormity of this public health problem becomes more and more apparent. The “windows of opportunity” get shattered by stones of intolerance and shame. I agree with you. There are windows of opportunity when people are most vulnerable, reachable and more open to change. They are in detoxes, emergency rooms, crisis centers, and the streets. They disappear when we get shuttled out the door with an appointment for three weeks later. The hands of compassion, hope and promise are made busy filing reports, writing obituaries, and “comforting” loved ones. We have to do better.

      No one gets out of here alive. We need to act like we know this.

  5. Paul Regier May 4, 2016 at 12:43 pm #

    Hi Shaun, Thank you for the piece. My initial reaction is to caution against criticism of any viable medication-assisted treatment for addiction, for which naltrexone is one of only a handful. I’ll echo Matt’s comments, that OST won’t work for everyone, just like AA won’t work for everyone, just like naltrexone won’t work for everyone; however, finding the person(s) it will work for – and why – will be extremely important.

    After reading your Influence article, I’m roughly in agreement with you. Blocking opioid receptors seems like a bad idea. Actually, partially activating (like the partial agonist, methadone) opioid receptors seems like a bad idea, too. But, hey, it’s the best we have, and it works for some. The problem, in my opinion, is that we’re fixated on manipulating the drug target: nicotinic acetocholine receptors for smoking/tobacco addiction, opioid receptors for heroin/pain killer addiction, etc, without addressing the widespread neurobiological changes as a whole. Instead, we’re replacing one addicting agent in for another, and we’re hoping to taper off the individual with a substance-use disorder. Or, in the case of naltrexone, we’re blocking the pleasure of getting high (as well as other pleasure, as Shaun points out). Since rates of MAT for treating addiction are so low, we probably can’t accurately gauge how effective these treatment options are, but my guess is that until we treat the underlying causes of addiction (e.g., neurobiology, disadvantage), we will probably continue to see low efficacy rates.

    • Marc May 6, 2016 at 4:47 am #

      I very much agree, Paul. But rather than look past the physiology, I think we need to look through it, like a window on a deeper and more intransigent chamber, where our psychological lives unfold.

      Maia’s comment on the last post really spoke to me: that the philosophy of providing opioids to relieve feelings of anxiety or emptiness is exactly the same (or should be the same) as the well-accepted practice of prescribing SSRIs for depression (or anxiety). We are each a highly complicated chemistry experiment, that starts with our genes (and some stuff that went down prior to conception) and continues to get adjusted with ever emotional experience we live through. I don’t know if there are data showing that some people are “naturally” low in opioid metabolism. Of course part of the problem with opioid addiction is desensitization, making the homeostatic balance all the more problematic with ongoing opiate intake. For people on OST this could be a fundamental problem.

      I must do more homework on this, but I sure remember the waves of sadness and emptiness that characterized my last period of quite intense depression, when my previous marriage broke up. Since I know that opioids are relaeased by cuddling, and play, they allow us to bond, and they dissipate when we become more secure, I can easily imagine that I was low on opioids as swell as serotonin.

      From my anecdotal experience and speculation, I believe that we all perform a continuing balancing act as our physiology adapts to life’s slings and arrows. But we’re all very different…at least in some ways…so a chemical “fix” should never be judged morally, only in terms of what works. Our biology is always making the best of whatever we can get our hands on..

      • Gina May 7, 2016 at 5:36 pm #

        Marc, this speaks to me, too: “. . . the philosophy of providing opioids to relieve feelings of anxiety or emptiness is exactly the same (or should be the same) as the well-accepted practice of prescribing SSRIs for depression (or anxiety).” In fact, today in another forum, I read a comment from a young man who has been thriving on Suboxone for several years now (and does a lot of great work in the harm reduction community) to the effect that the first time he ever took an opiate, it made him feel what he believe was likely “normal” for the rest of us. My daughter has described feeling the same way on methadone. It normalizes her and actually has helped with her underlying anxiety much better than any SSRI or anti-anxiety med she’s ever taken. This is not an uncommon experience among those who are most successful on MAT. I would also love to know if there is any data showing that some people are born with hypoactive opiate metabolism (or whatever the correct terminology might be) and if there isn’t, is it even possible to accurately diagnose or study such a thing?

  6. Marcus May 5, 2016 at 10:45 am #

    I totally agree with this post. A recent study showed that hydromorphone/oxymorphone were essentially equal to diacetylmorphine (HAT – heroin assisted tx) and both meds are legal in the U.S. and only ignorance, stigma & bias keeps them from being available tx options for opiate addicts. Some people have hypo-active endogenous opioid systems & a full agonist not only helps their brains function optimally but also helps them & society regain some stabilization before possibly transitioning to other forms of treatment, or just taking the full agonist long term or even lifelong. A dead person cannot recover. Common sense compassionate harm reduction policies are desperately needed in this country. Addicts unfortunate enough to be stuck in this current deadly environment need freedom from the American version of freedom when it comes to addiction, addiction tx, addiction causation & the ability to access viable recovery options. The current mess in addiction is agonic at best and often times deadly.

  7. Percy Menzies May 5, 2016 at 2:13 pm #

    I wish Shawn had responded to some of my comments in the previous blog. I will send a detailed response to your blog which does not issue address the issue of access. The attacks on naltrexone does not do much justice to the present discussion on opioids contributing to the spread of addiction and relapse.

    We have three major streams of opioids contributing to the problem. The first stream is over-prescribing of prescription opioids; the second and growing stream is the illegal opioids, mostly heroin coming into this country and the third stream is opioids used for treating addictions.The first is shrinking as physicians are following the guidelines for prescribing opioids. The second stream is growing at an alarming rate and we are attempting to expand the third stream to increase treatment. These three streams are merging into a river providing treatment for some and sustaining the addiction for others. No other treatment of an addictive disorder is caught in such a bind.

  8. Percy Menzies May 6, 2016 at 1:38 pm #

    Shawn describing OST as the ‘gold’ standard reminds me of my days in the pharmaceutical world. We had a drug called Coumadin – the only medication for the treatment of thromboembolic (blood clots) disorders. This drug had a very narrow therapeutic index. Too much,and the patient could bleed and potentially die; too small a dose and the patient could develop blood clots. Patients had to be carefully monitored and educated about diet and drug interactions and had to have a monthly blood test. There was no other drug in the market and Coumadin was the ‘gold’ standard.But the quest was on for safer effective drugs. When these drugs started coming to the market we kept talking about the ‘gold’ standard and the long history of the use of Coumadin. Now we have at least three other anticoagulants in the market that do not require routine blood tests and Coumadin is just one of the treatment option. This is the natural progression and life cycle of any medication or therapy. Substitution therapy has been tried and used for the longest time and as newer and safer treatments emerge, they slowly lose the dominant status. Morphine, heroin, cocaine, benzodiapzepines and LSD are just a few of the substitution drugs that appeared to be a ‘cure’ for addictive disorders. We are well-aware of the ramifications. The cure was worse than the offending substance and we backed off. Nobody refers to methadone as the ‘gold’ standard anymore and far more patients are on buprenorphine, a safer less intrusive treatment.

    The present problem with addiction to prescription opioids and heroin is very different than what we saw in the 60’s and 70’s.The patients we see today are often young and started using prescription opioids recreationally and some of them started snorting or injecting heroin. Most live at home and the addiction may have gone on for 6-12 months. Some of them have gone to expensive residential programs in California and Arizona and relapsed within days of returning home. The second group is older people, in the 45-65 age group who were prescribed opioids inappropriately and now they cannot get off the opioids. Is it fair or ethical to tell these patients that their manifest destiny is to be on OST indefinitely? At our clinics we keep patients on OST for periods ranging from a few weeks to a few months and then taper off the dose and offer them Vivitrol as an option to remain abstinent from opioids. Some want to stay on buprenorphine indefinitely. Most of these patients are older and are very compliant with treatment. Their dogs don’t eat the buprenorphine nor do the pills fly away when the bottle is opened! I cannot emphasis the importance of relapse prevention counseling and psychiatric services. Counseling is the ‘recovery park’ that Johann Hari talks so prominently about. The recovery park is not a physical location, but is all about reprogramming the brain away drugs and alcohol and focusing on job, vocational training, family involvement etc. Vivitrol is the hard hat, the steel-toed boot, that protects from accidentally or impulsively using drugs as they navigate the landscape over-run with cues and triggers. Some can get off the Vivitrol in six months while others stay on it longer. The insurance companies are placing no time limits – similar to OST. If the patients change their mind and want to go back on buprenorphine or quit the program and go to the methadone clinic, we don’t hold them back. What is so wrong with this approach? When patients are given treatment choices they welcome it. Patients and their family members often ask us why they have not heard of naltrexone/Vivitrol. It is sad that OST advocates have spent so much time and energy slandering and maligning other treatments and I know the reason why? OST fits neatly in the brain ‘disease’ model that neuroscientists like Marc Lewis are trying to debunk. The brain is an incredibly resilient organ and not every patient addicted to opioid need life-long OST.

    I am surprised that Shawn is unwilling to acknowledge that OST drugs are diverted and sold on the street. How else can you explain the fact that buprenorphine sales have exceed $2 billion and there is nary a dent in the problem. It is only natural that this happens. Financial desperation is very common among my patients. They see dollar signs on each strip or tablet of buprenorphine. The street value is around $10 per tablet. The temptation is too strong to sell or trade the buprenorphine for heroin. Most drug dealers in St Louis have expanded their offerings – heroin or buprenorphine and some are offering methadone tabs.

    This is the reason methadone clinics are rightly resisting calls to allow any physician to prescribe methadone. This is again the reason the federal government is taking a cautious approach in expanding access to buprenorphine. We are caught between a rock and hard place when it comes to opening the floodgates for opioids be it for the treatment of ‘chronic’ pain or OST.

    Lastly, I am deeply offended by the insinuation that naltrexone/Vivitrol is not appropriate for people on the lower rungs of the economic ladder. They do even better than the trust fund kids in treatment. They are also children of God and should be offered the same treatment options. No patient is forced into any one kind of treatment. The gratitude of these patients and their families at finally breaking the shackles of addiction will bring tears to your eyes. I invite you to come to my clinics and spend a day meeting and talking to these patients. They are shocked that the State of Missouri is willing to give them a shot costing over $1000 not just for a month or two, but for two full years! There is no other treatment approach that is more effective in lowering recidivism rates. May I also add that naltrexone/Vivitrol works exceptionally well in treating homeless alcoholics.

    I am thankful to Marc to facilitating this discussion and look forward to more exchange of views.

    • Shaun Shelly May 7, 2016 at 11:59 pm #

      You state: “Nobody refers to methadone as the ‘gold’ standard anymore and far more patients are on buprenorphine, a safer less intrusive treatment.” – The search “gold standard methadone” produces 25 studies on pubmed for the last 5 years, with a 2015 Harvard Review of Medication-Assisted Treatment for Opioid Use Disorder stating: “The evidence strongly supports the use of agonist therapies to reduce opioid use and to retain patients in treatment, with methadone maintenance remaining the gold standard of care.”

      To use your example: How would Warfarin be replaced as the “gold standard” for anti-coagulants? Randomised control trials that go head-to-head with Warfarin, not against placebo. Please see my piece at The Influence that discusses this issue. NTX does really badly in head-to-head trials with OST and none have been done in the USA.

      Your discussion around the patients you see is interesting, because many of them would fall into the groups that could do well on XR-NTX, and as said, the option should be available for them. I still don’t think it should be 1st line, but it should be on the menu. Certainly XR-NTX can help with pre-commitment for those well motivated and fully aware of all the implications and specifically seeking abstinence. I do not doubt some have benefited greatly.

      Again, my issue is not with making NTX available, it is with promoting it as a solution to the “heroin” epidemic, and particularly to indigent populations and prisoners and being prescribed by orders of the court.

      Regarding diversion: It does happen. This is the area of my current research. But it happens because of lack of access to services and because the services are high threshold. We see that syringes become commodified when there are no needle and syringe programmes. The solution is to increase and saturate. Heroin users do not, as a rule, seek methadone or buprenorphine to get high, but rather to prevent withdrawal or to “take a break”. The solution is to increase access through low-threshold community based programmes.

      When I refer to people on the lower rungs of the economic ladder, I refer to people that are homeless or living in shelters or close to this. These people do not do well on NTX for many complex reasons. From a much longer piece of mine: “I would agree that methadone is not a solution to a heroin epidemic, but OST certainly keeps people alive, and low threshold self-empowering services give people the space to feel human. The problem is not the heroin use, or any drug use, it is the context that alienates an individual to such a degree that their identity and vocation is tied to their drug use. The problem is the systemic drivers that make drug use the most attractive solution to cope with daily life. This cannot be addressed by blocking the drug 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. Of course, heroin users should have the additional option to use heroin safely – diacetylmorphine should be available in safe injecting facilities.”

  9. Marc May 7, 2016 at 7:18 am #

    Percy, please note that Shaun was NOT “unwilling to acknowledge that OST drugs are diverted and sold on the street.” That’s a misstatement on your part. Rather, he explained that diversion was caused by a lack of availability and other obstacles facing people who needed these drugs….hence reduced supply led to greater demand. Let’s keep our ducks in a row here.

    But thank you for the thorough explanation of how “gold standard” treatments are routinely replaced by new meds with better profiles. This is a valuable look into the life cycle of medicines.

  10. Percy Menzies May 7, 2016 at 10:58 am #

    Thank you Marc for pointing this out. We are circling back to my original assertion that opioids used for OST are exacerbating the problem particularly in the US, because, unlike other countries, we are awash in prescription opioids and heroin. Shaun rejects this argument and cites data from Switzerland and France. He asserts that diversion occurs because of lack of availability of these meds and/or services that are not attractive to patients. This is precisely the ongoing challenge in using opioids for any indication. When physicians were encouraged to prescribe opioids more liberally, it was almost de facto legalization of opioids. Patients could just walk into a doctor’s office, complain of ‘chronic pain’ and walk out with a prescription for the most potent opioids. Sadly too many ‘pill mills’ propped up leading to so many overdose deaths and a steep increase in diversion. Nobody has suggested that the diversion of prescription opioids occurred because of limited access to physicians! Now that physicians have backed off from prescribing opioids, the diversion has dropped drastically and people are switching to the more readily available and cheaper heroin.There is no doubt that the present restrictions on methadone and buprenorphine need to change, but nobody knows how to do it without exacerbating the problem. If the restrictions on methadone clinics are removed and they can treat any number of patients; any physician can prescribe buprenorphine, the diversion will increase not decrease. Addiction does not follow any rules of economics. This takes me back full circle to my original argument that easy access to drugs is the major contributing factor to the spread of addiction and a major contributor to relapse.

  11. Shaun Shelly May 8, 2016 at 3:03 am #

    To answer the point on access to opioids – I quote from a longer rebuttal that I edited down:
    This is simply wrong. It is only a small minority of people who use drugs that develop a substance use disorder. In cancer patients who are prescribed long-term opioids and have no previous history of a substance use disorder, less than 0.27% will develop an opioid use disorder (Cochrane review). This is not simply a process of access and pharmacology. One can argue that this is a numbers game; the more people who use opioids the more will meet the criteria for a substance use disorder. This is true, but ignores the basic question of “why, if so many people can use opioids without developing an “addiction”, is it a problem for some people?” That is the key. If we look at what is called by Mr Menzies as “the spread of addiction” we need to see beyond the availability of drugs. Drugs have always been there in one form or another. Heroin “addiction” is one of the array of “addictions” we see – and one could argue that the levels of addiction are increasing in certain sectors of the population and in certain communities. This has very little to do with drug availability or pharmacology. If we look at the work of Siegal, particularly his book “Intoxication: The universal drive for mind-altering substances” we see that drug use is common across many species, and “addictive” drug use is firmly in the domain of those that are stressed or excluded from their troop, community or like. For example, many quote the stories of Vietnam vets, but what about the Water Buffalo in Vietnam who, when stressed by the chaos of war, decimated poppy fields to the point of intoxication without previous history of doing this, and abruptly stopped when the war was over? This supports the larger body of work of Bruce Alexander as described in his book “The Globalization of Addiction: A study in the poverty of spirit”. Alexander constructs a compelling theory showing that “addiction”, in its multiple manifestations, is driven at a population level by social, political and economic drivers.

    My point is, that while the increase in opioid availability will by logic increase the numbers of people with heroin use disorders, this is not the main driver of the “spread of addiction”. The main drivers of addiction are systemic issues that contribute to and capitalise on individual vulnerabilities. And right now we are seeing increases in the consequences of drug use in white middle-aged America because for the first time this population group is feeling betrayed, disposed, hopeless and psycho-socially dislocated. They are searching for meaning in all the wrong places, including Donald Trump and opioids! https://www.washingtonpost.com/news/wonk/wp/2016/03/04/death-predicts-whether-people-vote-for-donald-trump/

    While opioids may be over-prescribed and incorrectly prescribed – certainly methadone for pain management is an example – the answer is not to put arbitrary restrictions on prescribing – the horse has bolted and now limiting supplies can only have negative consequences. Rather, there should be more education both for doctors and consumers, and when people do become “addicted” they should have access to OST with minimal barriers. These meds will not contribute in any way to increasing addictions – please explain to me why this would happen and quote the data?

    • Rebecca Breiman May 8, 2016 at 4:26 pm #

      Shaun,

      Hear hear!

      I am very much inclined to agree with you that diversion is caused by a LACK of availability rather than an overage- I have spent 10 years in the front lines, from the homeless shelter to jail diversion treatment centers and now in the community government funded methadone clinic and watched several people purchase OST medications off the street in order to best halt their addiction.

      I have seen amazing things happen with OST, but to be clear, I am pro-recovery and not pro-OST necessarily. I’d like to see people stop dying, with whatever method is most appropriate for them.

      But I maintain my stance- health care costs drive recovery and the lack of availability thereto. Populations that can access Vivitrol likely have fewer barriers to recovery to begin with- financial resources, a place to live, perhaps insurance- and we can’t remove privilege from measurements of efficacy, as William White’s recovery capital scale suggests.

      It is my understanding Percy that you are somewhat involved with ACA clinics, who are also located in my state (utah). While you and I agree on many points, I am also aware that ACA clinics are private for-profit clinics who serve those who can afford it, which may also lean toward serving a population where ntx is an option. For my population, it is not.

      The very few who have been able to access the long acting injection rarely return for counseling or any support for lifestyle change which ultimately contributes to their frequent return to our clinic citing that their medication was ineffective. Sure it was if you expected it to do everything… But Vivitrol, Methadone, and Suboxone won’t change your phone number if your dealer still knows how to get a hold of you nor shut the door on the doctor that prescribes your lortabs. Behavioral change through counseling, however, is a great jump start for these needed changes.

      Any suggested treatment needs a financial review before we even consider promoting it. If we are expecting addicted populations to afford what we promote as the medication of choice- or best practice- we need to investigate our own ignorance of the health care inequality in the United States. To me, at the risk of sounding trite, health care providers promoting a medication to clients that cannot afford it is near criminal.

      Trust me, I dream of the day that I can offer my clients a variety of options or refer them to a higher level of care without a 6-month wait- Utah is currently #5 in the nation for rates of overdose and I’m sick of seeing people die. Access to OST overall needs to be increased before we can have the conversation of promoting $1000 treatments. We need to ensure our highest risk individuals that they can seek care without barriers before we create yet another one.

      I don’t profess to be monitoring the science behind all of this, but my thoughts come from being a direct service provider to opiate addicted populations. Every time someone comes into my clinic and asks about Suboxone, I’m the one telling them the price and watching them switch to methadone. When others want to seek the vivitrol shot, I’m the one letting them know the cost and seeing them opt for Methadone.

      Methadone works, and so long as other medications are ruled out due to affordability, what we are left with is a conversation about why Alkermes and Beckitt Benckiser have the rights to life saving drugs that are so high priced that our clients- the very lives we want to save- cannot afford them.

      Best,

      Rebecca Jo Breiman, LSUDC
      Licensed Substance Use Disorders Counselor

      • Shaun Shelly May 9, 2016 at 12:02 am #

        Just go check out the Reckitt web page and see how they have manipulated the research to ensure the strip is now preferred over the SL tab because of patents to see how mercenary this is!

        Unfortunately things are not equal for all!

    • Marc May 9, 2016 at 5:23 am #

      Shaun, I am very much persuaded by your arguments, and I think that Percy has to do more than repeat his declarations that increased access leads to increased misuse and addiction. He’s got to prove his point, not just make it, and tackle your argument more explicitly.

      Yet Percy has opened another important dimension in this debate, and by resolving the seeming opposition here, I think we can reach a productive consensus. As you know, I agree with you, Johann Hari, and Bruce Alexander that the opposite of addiction is connection, not control. Poverty and alienation are huge factors at the societal level. At a more local level, people need help fixing broken lives. Yet, exposure and access also contribute to young people trying and then staying with strong drugs, as Percy argues. So both arguments are correct, in my view.

      Your standoff with Percy is far more specific than either of you think. Percy says fewer doctors should be handing out opioids, because they are too hard to control. You say more opioids should be available and SO SHOULD THE CONTROL needed for safe and sensitive administration. It seems you’re arguing more about resources and allocation of efforts than anything else.

      You say “while the increase in opioid availability will by logic increase the numbers of people with heroin use disorders, this is not the main driver of the “spread of addiction”. So you are tipping your hat part way to Percy’s core argument. Yes, agreed, it’s part of the problem, but not the main part. But aren’t you conceding too much here? If bupe and methadone were easily available AND well controlled, wouldn’t people steer away from heroin, such that the number of people with heroin use disorders (and the OD rate that’s coupled with it) would actually go down?

      At the clinic I visited in Belgium, control and access were nicely coupled, at least so it seemed to my inexperienced eye. If people were using heroin, then their methadone supply was proportionately diminished. And when they ran out of money and got tired of the stress of scoring on the street (and the risk, etc, etc) they’d say OK, Doc, I’m ready to just go with the methadone now. And the dose would be increased to a comfortable maintenance level, without any extra hoops to jump through, no scolding, no waiting period…. It seems that this balance isn’t so hard to achieve….when people agree that it’s vitally important.

  12. Percy Menzies May 9, 2016 at 10:15 am #

    When it comes to opioids it is near impossible to achieve the right balance between access and control. We need opioids to treat pain; we need opioids to treat the minority of patients who become addicted to opioids. Herein lies the challenge.

    The divide is too great and the discussion is getting way too argumentative with little hope of reaching a consensus. It is clear that each of the participants is passionate about caring for his/her patients and this is most laudable.

    I am going to sign off with an open invitation to anyone to visit my clinics in St Louis, Missouri and see how we are treating the 400 plus heroin addicts a month that come from the broadest cross section of society. Maybe, we can learn something from your visit and hopefully you pick up a thing or two and take it back to your respective clinics.

    All I know is that the present problem with heroin is growing alarmingly and we need to deploy every resource both at the treatment and policy level to save lives and help patients overcome the disorder.

    Marc, thank you once again for providing this great opportunity to express our views and and keeping us focused and civil.

    Peace

    • Shaun Shelly May 13, 2016 at 12:47 am #

      Dear Mr Menzies,

      Thanks for participating and contributing. I think that we have found some common ground, and it sounds like your clinic is a very valuable resource – certainly different from the usual offering, which as we both know is at best not useful and at worst iatrogenic. I think our differences are philosophical, but I feel confident that when an individual is in front of us we would both have their best interests in mind.

      When and if I visit your area I would most certainly like the opportunity of visiting your clinic.

  13. R Johnson June 1, 2016 at 11:34 am #

    Your arguments are valid. Methadone maintenance treatment as part of a comprehensive plan has been proven effective for many people over the years as an effective means for long-term recovery.

  14. rachel yuri June 7, 2016 at 9:57 am #

    When I refer to people on the lower rungs of the economic ladder, I refer to people that are homeless or living in shelters or close to this. thank you for the thorough explanation of how “gold standard” treatments are routinely replaced by new meds with better profiles. This is a valuable look into the life cycle of medicines.
    Reply

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