We NEED to consider extended-release Naltrexone for treatment opioid dependence

A study published at the end of 2015 (please see this article summary) showed that opiate addicts benefited more from extended release naltrexone treatment than they previously had with Suboxone. It appears that naltrexone with psychosocial therapy significantly reduced the urge to use opiates when compared with Suboxone treatment. This and other studies (simply google: “extended release naltrexone for treating opiate dependence” for more) have also demonstrated extended release naltrexone’s efficacy in the long-term treatment of opiate dependence.

Naltrexone is an opiate antagonist that does not offer any “buzz” or addiction risks. It minimizes the impact of the effects of opiates and can also be prescribed for alcohol dependence. From my perspective, there are two (2) distinct advantages to naltrexone over Suboxone: 1) Any medical doctor that can prescribe medication can prescribe naltrexone, while Suboxone prescription requires a DEA license; and, 2) there is no risk of diversion with naltrexone, while there is definitely one with Suboxone.

Part of the problem with Suboxone is the close scrutiny doctors must endure from the feds. Many doctors whom I’ve tried to recruit as prescribing docs simply do not want the headaches associated with subs. Because of the DEA oversight, many doctors will not even bother with the licensing process; therefore, there are very few doctors that will prescribe and carry opiate-addicts as patients. This low-supply of prescribing docs has been a challenge for referrals, as there just aren’t enough docs to go around (each Suboxone-prescribing doc can only carry 100 patients). However, because any doctor can prescribe naltrexone, I can refer clients to either their primary care doctor or any medical clinic. This ability provides far more support channels than Suboxone.

Further, the lack of diversion risk makes naltrexone an even better option for referrals. Diversion is when Suboxone is traded or sold or used in any other way than it’s intended. In my experience, this is a huge problem. Suboxone has high street value and can be abused just as any other opiate. I’ve had several clients who were kicked out of Suboxone programs because they were abusing the program and diverting their meds. Since naltrexone has no street value, there’s really no point in its diversion.

There are drawbacks, of course, to naltrexone. The two (2) biggest are its cost and the fact that adherence rates are low. Also, there are physical risks to the liver associated with naltrexone and opiate-addicts with liver problems would not be ideal candidates for this med. However, these limitations should not, in my opinion, be a deterrent for extended-release naltrexone consideration. With heroin and other opioid use rates and deaths increasing, we need all the resources we can get. To learn more about extended release naltrexone, please download this SAMSHA advisory:ER-NALTREX

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5 comments

  1. Your post confounds me. All of the studies you link to compare ER naltrexone to placebo, not Suboxone. Where is the evidence to support your assertions?
    You say that we “need all the resources we can get” in this climate of unprecedented opioid use and related fatalities, but then you denigrate one, and one with a strong evidence base for effectiveness. There’s no evidentiary support for advocating a one size fits all approach; no medication is equally effective for all people.
    Also, you may be underestimating the barriers to people accessing ER naltrexone. Along with the cost, about $1000 – $1200 per injection, there is the cost of the monthly visit and procedure of inserting and removing the implants. How much of this will insurance cover and for how long? Is it covered as a pharmacy benefit or a medical benefit? If it’s covered as a medical benefit, doctors have to buy it and submit for reimbursement.That has been an impediment to uptake in a number of states.
    There are a number of other unknowns and challenges with this medication not mentioned. I touch on this one to point out that it’s more complicated than you laid out.

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    1. While I acknowledge your point, I have seen at least three cases, this week, where subs were sold or traded for heroin. I get that Naltrexone has disadvantages, but Suboxone programs, at least in NM, don’t appear to be working. There are always barriers and learning curves with any treatment; I’m curious as to what YOU recommend. It’s all too easy to criticize; I’m presenting information such that we can discuss options.

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      1. Thanks. I recommend that people have access to buorenorphine (Suboxone), methadone and naltrexone – whatever works best for them.
        I think people focus too much on Suboxone diversion. Yes, it happens, but from all that I’ve read, it is the scarcity of it – and methadone, both of which very effectively block withdrawal symptoms (dope sickness) and cravings for heroin and other opioids – that is largely (not solely) driving the market for it. And deaths associated with it are rare and almost always caused by a combination of drugs like CNS depressants and alcohol. See e.g. the 2015 study from the NYC Dept. of Health (I’ll try to find the link to the paper and forward it , if you’re interested). What we do know is that there isn’t enough evidence-based treatment for people who need and want it , and many folks are dying while they wait to get in (or get kicked out of) treatment. I wouldn’t want to get in the way of a medication that is keeping someone alive and helping them . Suboxone and methadone have shown to do that well for many people. I hope ER naltrexone proves to be effective for many, as well. The evidence is not there yet, and it is being over-hyped, which is not good for anyone concerned.

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        1. I totally agree with you (and please do provide a link). However, subs are a problem for many of the people I work with and they simply become another resource to use on heroin. I get that naltrexone is a tough sell, but all i’m suggesting is that we, as treatment providers, should consider it as an option….I think we’re pretty much saying the same thing…

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