by Peter R. Coleman, MD
Recently, the New York Times ran an article proposing that most opiate addicts should receive Medication Assisted Treatment (MAT). I couldn’t agree with them more.
Success rates for patients with opiate addiction who are not treated with any form of MAT are horrible. An important study I have quoted for many years made this abundantly clear. The study was out of Seattle. It followed 124 patients who went into a hospital to start their recovery from opiate addiction. About 26% were not even able to complete the detoxification. The others were all offered good treatment options - 28 day inpatient rehab, outpatient counseling, recovery residences, etc. After 3 months, there were only 4 successful patients. This equates to a success rate of only 3%. And, all of these patients were motivated. They went into a hospital to get clean. But, there is something about opiate addiction that makes relapse so much more likely than other addictions. Hence, the need for MAT.
The challenge is many physicians have little or no experience with naltrexone therapy, so when they think of MAT, the only options they think about are methadone and Suboxone®. (Even the New York Times article recommended MAT, but the article did not once mention naltrexone). Methadone has been used since the 1970s. Experience and numerous studies show that methadone does cut down on crime rates and street drug use. But, most patients do not like being on it, and of course, it is much more addictive than heroin. It is also more difficult to detox off methadone than it is to detox off heroin. The other MAT that most physicians think of is Suboxone®. Suboxone® has been approved as a treatment since abut 2002. When it was first approved, it seemed like it could be a miracle cure. Patients reported reduced cravings and they used less street drugs. But over time, we have found there is quite a lot of abuse of Suboxone® and the long- term success rates are not particularly high. In fact, a recent study in the American Society of Addiction Medicine (ASAM) journal followed a group of adolescents who were started on Suboxone® while in an inpatient unit. Within only 2 months, half of them had relapsed and discontinued treatment. At the end of 12 months, only 10% of the group were abstinent – hardly a perfect treatment.
Naltrexone is the other MAT that is now gaining more acceptance in mainstream medicine. For some time, naltrexone has been available as an oral tablet which lasts for about one day. It is effective if people take it, but in the real world, most people do not take it for more than a day or two. In some settings, particularly when probation officers observe people taking oral naltrexone, it can be effective. But, it is almost never effective if it is not being actively supervised. In fact, there is some thought that the act of taking the oral naltrexone could actually be a trigger, and thereby increase relapse rates. Some patients report that taking daily oral naltrexone actually reminds them they could use if they really wanted to and they sense their cravings go up.
Naltrexone does work if patients are “forced” to take it over a long period of time. If the naltrexone is medically put into patients and they can’t “not take it”, it is extremely effective. For over 18 years, we have been using two-month naltrexone implants and our patients love them. Because they last a longer period, our patients rapidly accept the reality that they can’t use and they do better getting on with their lives. Most report their cravings completely go away. Over the last several years, Vivitrol® has become available as a one month injection, and it too, is very effective. Because it is FDA-approved it is usually covered by insurance, and so a lot more doctors are more familiar with it. In fact, a landmark study was just published in the New England Journal of Medicine (NEJM). In the study, Dr. Lee and his colleagues followed about 300 patients who were involved in the criminal justice system. Half of the patients received monthly shots of Vivitrol for 6 months, along with some counseling. The other half only got the counseling. The patients who received the Vivitrol® had a 57% success rate with no relapse, which is a remarkable finding. This is so much better than the 3% rate for patients without MAT. The other interesting result of this study was that the patients in the Vivitrol® group had no overdoses, while the patients in the group that only received the counseling, had 5 overdoses.
It is exciting for me to be working in a treatment system where we are able to use the naltrexone version of MAT in all of our patients. After every opiate detoxification, we insist on either a 2 month naltrexone implant, or Vivitrol® injection. At TCI, we see incredible success with our patients. Since we recommend that our patients stay on naltrexone therapy for 12 months, we have the opportunity to see most of them back for follow-up visits. Our patients and their families are very grateful.
One of our biggest issues now is convincing patients to stay with treatment. They often feel so good; they start thinking they can stop the MAT. The evidence is clear: naltrexone should be continued for at least 12 months.