Enthusiasm for Vivitrol premature
Dear Del. Riley Moore,
I saw the article in the Chronicle about the planned use of Vivitrol at Jefferson County Day Report. Thank you for your concern about the health and other consequences of drug abuse and drug policy. The ideal time to give this injection is immediately on release from jail or detox, when a patient is free of opiates and alcohol. I am a family doctor and have treated addiction for the last 25 years in the office. I have noted fair success with Vivitrol, but with the usual delays in pre-approvals, my patients often relapse.
The enthusiasm for Vivitrol is premature. I want to know if this program will be effective compared to other available treatments. I have not been able to find adequate studies comparing Vivitrol, Suboxone, Methadone, and generic tablet naltrexone (the medicine in Vivitrol). I contacted the Vivitrol manufacturer and they have no studies either. Since only five West Virginia counties will be starting this program, I hope Jefferson county’s experience will be compared with the other counties.
Vivitrol was approved after very few studies that only compared it to monthly injections without any medicine (placebo). You could, for example, have patients take naltrexone tablets under observation during counseling at Day Report, then compare the results to the people getting injected Vivitrol.
Naltrexone, the active generic drug in Vivitrol, has been available for over 30 years. In the tablet form it costs about $50 monthly with Vivitrol over $1000. The manufacturer has been granted a long term patent, although the technology is nothing new. I’d like to know how it measures up. As a tax payer I would love to save $950 a month.
Naltrexone blocks alcohol and opiates, but also reduces motivation, and enthusiasm in general. I have seen one report that Vivitrol patients might not even enjoy music. Only highly motivated people will continue oral Naltrexone (mostly doctors and other professionals under supervision who risk losing their licenses). We know the proportion of patients who continue the injections even in the mid term is low. How many will continue Vivitrol even with the constant threat of incarceration. The risk of overdose from opiates is higher after patients discontinue Vivitrol. There is significant risk in using this medicine for people with liver disease.
The medical standard of care for opiate addiction is Methadone or buprenorphine/Suboxone with counseling. Methadone has been available for 30 years and is well studied. In my practice, the introduction of Suboxone made a huge difference for the better. Most of my patients stabilize, keeping jobs, paying the rent and taking care of their families. Patients return for appointments consistently and have little risk of overdose. I am concerned that my patients may be trading or selling their Suboxone, but unless the street users are taking high doses of sedating drugs or alcohol, they won’t land in the ER with overdose.
Over 15 years the price for a month of Suboxone treatment has risen, from $45 to $800. Medicaid only approves the expensive brand, with its renewed patent. The new foil package allegedly improves safety for children. Bubble packs with generic could be just as effective.
In the context of the severe health legal and social consequences of drug addiction, I would like to see verifiable research on medication assisted treatment and know the relative effectiveness before committing to major funding of one type of treatment.
Chess Yellott MD