Drug Addiction Treatments: The Role of Long-Acting Naltrexone

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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: Now, there’s a new drug. I wanted to talk about Vivitrol. What is Vivitrol?

Joshua D. Lee, MD, PhD: So, methadone is a full agonist. Buprenorphine is a partial agonist. Both are really good because they’re long-acting, they sit at the receptor, and they are stickier—or they block heroin or oxycodone, if you’re using those on top of those. They’re excellent candidates for medical drug treatment. They are, themselves, opiates, and you maintain physical dependence on opiates while you’re on them. Now here comes naltrexone. Naltrexone goes to the same receptor. It’s very sticky. It binds very tightly. It also blocks heroin and oxycodone, but it is an antagonist. It’s at the receptor and nothing happens. It’s not good for pain control. It doesn’t make you sleepy, you can’t get high on it. It’s essentially an inert, or a nonactive, chemical at the receptor, but it’s blocking any N1Ls from getting in there…

Peter L. Salgo, MD: Let’s be very clear. Naltrexone is Narcan, right?

Joshua D. Lee, MD, PhD: Naltrexone is the long-acting form of naloxone, which is in Narcan, which is now famous for overdose reversal.

Peter L. Salgo, MD: Doctors who work in the hospital, who’ve worked with narcotics, they know Narcan. It’s been an old friend.

Joshua D. Lee, MD, PhD: Yes. It’s on every crash cart.

Peter L. Salgo, MD: What I know about the drug is that it’s got a lot of upside; it works. It has almost no downside. The side effect profile of that drug is nil.

Joshua D. Lee, MD, PhD: Yes, arguably so. It’s nonaddictive, it’s not habit forming, and it doesn’t cause physical dependence.

Peter L. Salgo, MD: Unless you give it to someone who’s already dependent and you knock all the narcotics off the receptor.

Joshua D. Lee, MD, PhD: Then, they would go into withdrawal.

Peter L. Salgo, MD: They go into full withdrawal suddenly. They’re very unhappy clients.

Joshua D. Lee, MD, PhD: Naltrexone for opiate dependence is really used as relapse prevention of someone who is already detoxed, which makes it highly applicable to criminal justice populations where you’re about to leave jail or prison. That’s one model we’ve studied. Or, “I’m out. I’m in the three-quarter house, parole officers busting my butt, and I’ve got to do urines every week. I haven’t picked up yet, but I’m getting the cravings. I was just down the block, I saw my old buddy, and it’s only a matter of time.” So, I start naltrexone on this person. They are essentially—in the formulation we use now, it’s a monthly shot—going to be dosed for the whole month with an opiate antagonist that is not going anywhere and is going to block the receptor. And then they go, “I got my shot from Dr. Lee. Two days later I want to see if he’s telling the truth about this blockade, and I go use heroin, nothing happens. I don’t get high, and I don’t have any opiate effects. It’s a waste of time and money, so I’m unlikely to keep doing that.” And that’s the basis of Vivitrol, or extended-release naltrexone, for opiate relapse prevention.

Peter L. Salgo, MD: It’s given by injection once a month, so you really don’t have to be there every day. You’re not tied to the clinic.

Joshua D. Lee, MD, PhD: Correct.

Peter L. Salgo, MD: That already seems, to me, to be an advantage. You’re not on a narcotic, so that nobody says to you, “Oh look, you’re addicted to methadone now, just not the heroin.” And it’s a complete blockade, right?

Joshua D. Lee, MD, PhD: Yes. I can’t just quit buprenorphine for methadone. And, it turns out, that’s a good way to keep people on those drugs that are otherwise doing well and think they’re getting something out of it. They can’t just stop, all of a sudden, agonist maintenance. They would have to slowly taper. You were telling us about methadone. You can’t just take the guy in the facility on 30 mg of methadone and never give him any more; you slowly work him off it. And people in outpatient maintenance will be on even higher daily doses. And so, it can be a chore, it can be uncomfortable, and some patients just shouldn’t do it because they’ll have enough discomfort. Then, they’ll go back to being off everything that their risk of relapse would be too high.

But, with naltrexone, there is no withdrawal syndrome. You don’t have to take the next shot, for instance, and you’ll feel fine. So, the challenge with naltrexone is convincing people to get a shot in the butt once a month, even though they can’t really tell they’re on anything. And if they’re completely abstinent from it, which tends to be the successful and common outcome you see on naltrexone, they’re less aware on a daily basis that there’s a fight going on still. The naltrexone is helping win the fight, but it’s hard to have a daily dose that lets them know that’s happening. It’s a different ballgame with naltrexone versus buprenorphine maintenance.

And counseling is important in all this stuff. You have to do everything you can at that point to keep people on drug A. Drug A is awesome. All you’ve got to do is take drug A. That’s easy, right? “Well, I don’t have a house, I have schizophrenia, and I’m still smoking crack cocaine. Everything else has to be going essentially right and support the medication adherence or any other part of medicine and any other chronic disease. If I never take my metformin and insulin, my diabetes is not going to be very controlled. And I can never get that, because I lost my insurance and I live 100 miles from a pharmacy.” So, all the logistical stuff and psychosocial stuff really should happen at the same time.