Adherence Considerations in Substance Abuse Treatment

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Drug-related convictions place a substantial burden on the criminal justice system and on society. The MD Magazine Peer Exchange “Medication-Assisted Treatment in Drug Abuse Cases: A Path to Success” features a panel of experts in the criminal justice field who provide insight on medication-assisted re-entry programs.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

The panelists are:

• Phillip Barbour, master trainer with the Center for Health and Justice at Treatment Alternatives for Safe Communities, in Chicago, IL
• Jac Charlier, director for consulting and training, also with the Center for Health and Justice at Treatment Alternatives for Safe Communities, in Chicago, IL
• Jonathan Grand, MSW, LICSW, senior program associate at the Advocates for Human Potential in Sudbury, MA
• Joshua Lee, MD, MSc, associate professor in the Department of Population Health, and a research clinician at Bellevue Hospital Center, NYU Langone Medical Center, and the New York City jails

Peter L. Salgo, MD: You pointed out that, “I don’t have a house, I don’t have a job, I don’t have this infrastructure.” There was a study among medical students and they were given 100 to 300 pills. They said, “Take one of these a day, these are placebo. Take it for a year, like the way tuberculosis therapy might be.” And at the end of the year they said, “Just turn in your unused pills.” These were people who had tremendous infrastructure. They were in medical school; they were involved in a research project. And at the end, about one-third of the pills were untaken. So, I take your point, this is hard.

Joshua D. Lee, MD, PhD: Yes. Getting people to take 100% of their pills is essentially impossible in real life.

Peter L. Salgo, MD: Vivitrol is just once-a-month regimen though, 12 shots a year?

Joshua D. Lee, MD, PhD: That’s right, once-a-month shot in the buttocks on alternating sides, which can make people sore and uncomfortable. And some people just are never going to do that. “I don’t like needles. I can’t stand it. It made me too sore last time.” So, there are legitimate reasons why it’s not for everybody, even if they otherwise would benefit from it.

Peter L. Salgo, MD: Are there any risks to the drug, other than the actual shot? Are there drawbacks?

Joshua D. Lee, MD, PhD: Yes. All these medications have side effects. With the opiates, you’re stuck on them. They could make you constipated, itchy, you could take too high a dose, stuff like that. When you start out on naltrexone, you can get a little flu-y, seasick-y, a headache. That’s typical of naltrexone, once it’s initially, and suddenly, in your system. But, that generally is tolerable and gets better. It doesn’t continue, because now you’re acclimated or used to it. You get pills every month, you’re already on it.

And then for Vivitrol, it’s an intramuscular injection once a month. It’s a fairly large injection for medications that we use that way. So, you can get muscle soreness, or in rare but serious cases, you can get an injection site reaction. This is a little like an abscess or nodule that is painful and doesn’t go away all of a sudden. It might have to be treated through antibiotics, steroids, or, in rare cases, surgery. I don’t want to go on about that, it sounds horrible, but it’s very rare. Yet, it’s a possibility, because it’s an inner muscular injection.

And then, it’s also an opiate blocker. So, if I break my wrist a week after my shot, I can’t get adequate pain control at usual doses if I’m in the emergency room and I get some morphine or Dilaudid. There are ways to overcome the blockade if you do it carefully in a controlled medical setting. But, that’s a potential side effect in certain people. For instance, if I have to have surgery in a month, I’m not going to start you on extended-release naltrexone.

Peter L. Salgo, MD: Let’s talk about it. There are NSAIDs, there are other ways to get at pain relief. Some of them are quite good. And if you need general anesthesia, you don’t need narcotics.

Joshua D. Lee, MD, PhD: Absolutely. So, you don’t have a problem with 98% of acute pain. And then, if it’s a chronic pain or an elective invasive procedure, you’re just going to delay the next dose or something like that.

Peter L. Salgo, MD: If I hear you correctly, the injection-site issues are common to all IM (intramuscular) injections. It’s not a factor of the drug, it’s a factor of the delivery system.

Joshua D. Lee, MD, PhD: That’s right.

Peter L. Salgo, MD: If we buy this kind of system for some drugs, we’d buy it for this one, too. But, what’s remarkable to me, hearing about this drug, is that they get this so that it lasts a month. That’s pretty impressive.

Joshua D. Lee, MD, PhD: Yes. It’s a basic logic to adherence boosting. We have other drugs that we use that way, like antipsychotics. It’s the same technology in Vivitrol that we’re using in Risperdal Consta, the brand name of long-acting risperidone. Populations that are prone to poor adherence, schizophrenia, alcoholism, and heroin disorders, you have a safe effective therapy. Then, you figure out a way to package it in a long-acting thing. That makes sense, and we do it in other areas.