Does Vivitrol work? This is a legitimate question

I think the one think that isn't being addressed in these posts is cross addiction principles and the thought process of needing to take a medication to control an addiction. Once we commit to a chemical solution for our addictions, or for how we feel we are one step further down a very slippery slope. Abstinence from ALL medications which are supposed to control how we feel and crave is the gold standard for treatment. Vivitrol is no exception. Second, the addicted mind set is one of finding a chemical solution for emotional discomfort. Take away the craving for alcohol (and I question whether Vivitrol does this effectively), and your mind will do one of two things...figure out when/how/why to stop taking Vivitrol, or find a new substance to abuse. That is the reality of addiction. None of the drugs that are on the market address these issues. And all bring with them the mentality of once again using medications to control how we feel. Many of you have been dupped by big money pharm companies with very clever marketing and very questionable research.

Addiction Medicine Physician

 

I do not work for Cephalon or Alkermes but did work for Cephalon selling Vivitrol at one point. What pops out at me is that you choose not to put your name to your posting. You are an Addiction Medicine Physician. I would think that you would want your name out there as anti-Vivitrol.
Second, no Sales Rep has ever made the statement that the cravings for alcohol is taken away, those were the individuals that were on the medication. How do you measure cravings in your practice anyway Doctor? Vivitrol blocks the opioid receptors. Doctor, what happens to a individual consuming alcohol or opioids when the opioid receptors are blocked? What happens to an alcoholic brain and opioid receptors when the brain is thinking about, or getting ready to drink?

Finally, Vivitrol is not the total answer. It is one of a series of possible answers. The package insert actually says that therapy must continue for Vivitrol to see the results that are reported. Therapy in conjunction with medication therapy is the best total answer. The figuring out when/how/why to stop taking Vivitrol is worked through in therapy while Vivitrol is working and the patient is thinking clearly and not through a fogged brain soaked by alcohol.

 

What I see in this post is a questioning of my credentials then a pop quiz. At no point in this post did I see any sort of well thought out response to my post. If you have points to make by the questions you bring up, terrific...make them. Second, sales reps are able to post anon, so I should be able to as well. Why would I want to bring the recovery center I work for into one of my debates? Why would I want any more Vivitrol reps here trying to "educate me"?

Vivitrol in conjuction with therapy is an 800 dollar per month addition that IMO is detrimental to treatment in most situations. You did not respond to my points about chemical solutions for addicted minds. What keeps an addict from stopping the Vivitrol? What keeps an addict from switching drugs? Adding a chemical to control an addiction, only does two things...it tells an addict that there is a chemical solution to their addiction. And two it places a patient in a physicians office who also believes there is a chemical solution to their addictions. Once committed to a chemical solution, then what keeps a physician from adding a little elavil for sleep? How about a little prozac for the depression? Hey maybe we should add a lil seroquel for your moodiness. I see addicts who go into treatment centers addicted to one thing and leave on 4 new meds. This all comes from a mentality of treating addiction with chemicals. What happens when these meds stopping working? (and in most cases they will) Yep, you guessed it...more drugs...higher dosages, then eventually none of it's working and a relapse. We have seen it happen over and over again.

Unfortunately for pharm companies there isn't alot of money in people staying sober chemical free. What I have seen from my experience, you still can't beat what a dollar per meeting, a good sponsor and willingness will buy you.

 

First you have difficulty reading if you didn't see a response. I said that it requires the addict to continue in therapy, so in essence Vivitrol with therapy treats the body and the mind. Additionally, Vivitrol is not a medication that is taken for a lifetime. 6 months to a year along with therapy. Is Vivitrol 100%, the standard that you seem to be holding before it. Absolutely not. But we know very well that a dollar per meeting, good sponsors and a willingness to buy is no where near perfect.

For instance using Quarterly Journal of Studies on Alcohol and AA's own figures:

In an article in the Quarterly Journal of Studies on Alcohol.vii it is reported that of 393 AA members surveyed, 31% had been sober for more than one year; 12% had been sober for more than one year but had had at least one relapse after joining AA; 9% had achieved a year's sobriety; 6% had died; 3% had gone to prison; 1% had gone to mental institutions; and 38% had stopped attending AA.

The success rate calculated through analysis of the 1996 AA membership survey is hardly more impressive. The survey brochure indicates that 45% of members have at least five years' sobriety.

Using the figure of five years' sobriety as the criterion of success, one arrives at an AA success rate of approximately 2.6% to 3.5% (in comparison with the total number of "alcoholics" in the U.S. and Canada). And the success rate is lower than that if one defines "success" as AA does-as lifelong abstinence

Yea, great numbers Doc.

 

And Vivitrol somehow improves these numbers? Using this same criterion for success what is Vivitrol's success rate? What is the 5 year improvement? How do you measure that improvement? I understand you are saying to use Vivitrol with AA and/or therapy, but you still didn't address my concerns about the addicted mind. My concerns are not what the numbers show 3 months out, my concern is using another chemical to treat chemical dependency. The points I bring up are not just ignored by you, but many addictionologists as well. The fact is this, we are currently being held hostage by ivory tower medical theory in the name of "evidence based medicine". Give me practice based evidence. And here we have been watching this phenomenon of big pharm companies undermining recovery for decades. Unfortunately the very questionable studies, and harm reduction criterion show very little in terms of true and meaningful recovery. But, I suppose as long as people slow down the robbing, pilaging and can keep their job at Chick Fil-a, then we can all rest a little better at night.

Of those numbers you listed above, how many were motivated for treatment? Second, how many of those were totally 100% mood altering chemical free? This does make a significant difference. Also, how many of those got a sponsor and worked steps? When you have a motivated individual who actually complies with the suggestions of AA on all fronts we see much better than a 3% success rate...and we have over 40 years of looking at recovering populations. I have seen nothing within the evidence to suggest adding a chemical to an addicts therapy enhances AA or therapy. What I have seen is some cleverly or not so cleverly crafted studies to either measure the obvious, or to shade data to support the use of chemicals. If there are some specific studies you wish to break down in support of Vivitrol or any other chemical in the use of addiction, I invite that conversation.

 

Someone who is currently selling Vivitrol is going to have to jump in here now and "breakdown" studies. I am growing tired of you and your AA cheerleading.

If AA were so great, wouldn't it be performing better than a 3% rate? Anyway, I have to tell you if your entire argument is based on "how many are motivated for treatment" then probably the 3% rate may be correct for AA. Maybe not though...

How do you actually look into the heart of an individual and determine if they are "truly" motivated or only "slightly" motivated, or for that matter not motivated at all? Is that little unmeasurable static only decided after treatment in your eyes. If they are successful, the 3% of AA members who are successful, they were motivated. If unsuccessful, the remaining 97%, they weren't? That 97% of people, usually alcoholics who have failed all other treatments, AA, Campral, intensive in-patient are the ones that are trying Vivitrol. In otherwords they are the hardcore alcoholic. Anything better than 3% success with Vivitrol is a vast, vast improvement over AA alone because these alcoholics are the ones that have failed with AA and all other treatment options.

Finally, this notion that you represent as "big pharma" undermining recovery. That is just laughable. If "big pharma" could discover a 100% cure for alcoholism with a pill or a shot, don't you think that they would jump on it? That cure would be worth billions of dollars which is a huge motivation factor for developing a cure. You begrudge big pharma for making a profit but the majority of noteable discoveries in history have been motivated by one of two things, and in most instances both. Money and fear. And don't even get me started with the cost savings of successful treatment of alcoholics in society to the healthcare system, judicial system and the emotional and financial toll it takes on families.

 

I'm sorry you are agitated and have such a poor opinion of AA, but it's not just about AA. It's about treatment, CBT and AA. And just as important, it's about all that being done chemical free. People need time away from chemicals for their brains to heal, and to be able to accept, associate and internalize those things within treatment and AA. IMO, any chemical that is supposed to help that along is detrimental due to the underlying motivations and the addicted mind.

As for your Vivitrol studies...there won't be a line of people waiting to debate me on this subject. The reason is because the Vivitrol studies are weak at best, and deceptive at worst. 3 month end points are a joke. The way success is measured is another joke.

As for 3% and AA, you keep quoting that number because we both know it's not correct. It's another statistical manipulation. If I select people by a certain criteria, I'm confident I could push that % up close to the 50% range at the 5 year mark. But, that too would be a statistical manipulation. What we see is that if you give someone enough time away from alcohol, drugs (treatment, half way house, CBT, AA) all in combination chemical free for about 12-18 months about half will stay sober 5 years+. I wouldn't do what I do if I was only able to help 3%.

Another question, why is it that airline pilots and physicians have a 90%+ success rate in staying sober 5 years+. Vivitrol? It's called accountability. Can you put that in a pill and sell it? I'm sure big pharm is working on that as we speak.

 

PS-Do I think big pharm would cure alcoholism or drug addiction with a shot if they could?

Heck no. The money is in taking something for the rest of your life. Why would they kill the milk cow?

 

You and I really aren't that far off. We both believe it is important to help addicts and alcoholics, we just differ on success stats and the methods. I am all for whatever helps an alcoholic stay sober, I don't care what it is, that includes AA, CBT, etc. including Vivitrol. You are a proponent of therapy in patients. I am too. You don't believe in Vivitrol because of the introduction of a chemical into the treatment regimen. I do because there are many, many alcoholics that can not stay sober long enough to digest enough therapy to make any type of difference. You say Vivitrol is a short term solution to a long term problem. I do too. It is s 6 month to 12 month window for the alcoholic to work on the addiction.

 

ps: you probably aren't going to get anyone on here debating Vivitrol studies because no one on this board sells Vivitrol. Alkermes sells Vivitrol now.

 

Now these are some pretty good talking points. So, in an inpatient setting where someone is going to have long term accountability (treatment, CBT, half way house, AA) Vivitrol would not make sense. Since it's mainly about buying time (which I agree with by the way), then in a very structured environment Vivitrol (if it has any positive effect) would likely be wasted. But, by your logic Vivitrol might have a role in the outpatient setting where we are needing to buy some time in a less structured environment.

For the record, I'm not inherently against the use of chemicals if they indeed help. If there was a shot that truly promoted sobriety, I would be first in line to use it with my patients. But, I take a very cautious approach because of my concerns listed in previous posts. Because of these concerns, the data needs to be impressive...and I do need to see long term numbers. While I agree 3 months MIGHT buy you some time initially, what happens after this time has been purchased with chemicals, written by a doctor who believes in chemical management of addiction? That is my #1 concern. If we buy initial sobriety at the expense of long term sobriety, then it is a moot point.

I take a very cautious approach with any chemical. Methadone and suboxone (which are a huge problems in detox) support my concern. IMO, it's not about harm reduction as I believe those who suffer from addiction are more than just people we need to contain.

 

..And on the way out from inpatient to give them a fighting chance...

 

And this is where we can agree to disagree. We don't have long term numbers on Vivitrol. I don't agree with the measures of success either. I'm not a harm reductionist. I know many who are drinking the Vivitrol Kool-aid without any real long term evidence that it helps.

So, lets stick with what we know...

1) In order for a addicted individual to get Vivitrol they will have to be treated by a physician who believes in chemical managment for addiction. Most who are of this mind set also believe in chemically altering mood and sleep which by mere common sense is not a smart thing for an addicted individual. We have lost the right to a chemical solution for our emotional problems.

2) Vivitrol while it may prevent someone from getting high from their drug of choice, can actually promote overdose if someone is determined to get high on their DOC while on Vivitrol.

3) If an addict is in legit and significant pain, they can not be given narcotics for that pain. So, an addict can have his leg and pelvis crushed in a freak tractor accident, and the only way he will be receive relief is to be placed on a ventilator and anesthetized.

4) The slippery slope mind set within addicts of using a chemical to control a chemical. From our 40 years of experience here, we realize this ultimately leads to relapse in most cases. And in this case would most likely lead to either a person stopping their Vivitrol or relapsing on a new mind altering chemical.

So, you'll have to forgive me if I'm not drinking the Vivitrol Kool-Aid. There isn't enough data supporting its use that outweigh my concerns above.

And to your point above...if someone gets through 5-6 weeks of inpatient treatment and is sent back on the streets without support, community, follow up care, and accountability then the treatment center has failed this individual. And if it's not a half way house, these are the things that will give an addict a "fighting chance".

 

I read all of this but couldn't get past addiction is an emotional problem....coming from an "addiction expert".

 

And let me ask you where I said that. I said we have lost the right to chemically alter emotional problems. I wasn't speaking about addiction. It's clear by reading the entire paragraph what I was speaking about I was speaking about feelings of sadness or anxiety. These worries (emotional problems) can lead to insomnia. So, we go to a physician who believes

But, when you really have no reasonable counterpoints, it's easy to take something out of context in order to deflect and put someone on the defensive. The fact is this, you have never shown me that Vivitrol works. Where is the evidence? You have never addressed the issues with an addicted mind, or the issues of going to a physician who believes in chemical managment of addiction and emotional difficulties. You never addressed the issues with true legit pain. What happens with these people. I can tell you what happens to them here.

And here is a new point for you to ignore, something you won't find in your studies. What happens 5-6 months out...3 weeks into Vivitrol shot? It loses it's efficacy. Opiate addicts begin pushing on those receptors and challenging the drug. Addicts are able to get high on Vivitrol. Do you see a potential problem with that? I can see several.

So, if you ever want to get back to an actual debate on the medication rather than twist my sentences in order to invalidate my statements...let me know.

 

edit-

End of first paragraph...

So we end up going to a physician who believes it's ok to chemically manage addiction. Great, most that believe that also believe it's ok to chemically manage emotional problems as well.

 

You know what's sad and scary. I am a 40y/o nurse who becme addicted to opiates after an accident approx. 8 yrs ago. This has been the hardest fight of my life. I am in the medical field and I have still been led astray by MDs. Went through inpatient therapy and started using again immediately. I started hearing about this suboxone only to find out it is harder to kick than the original opiates. I have been sober for 5 months know on the suboxone now they are telling me I need to go to the vivitrol for a few months. I'll be honest. If it keeps me sober long enough for me to build a support group around myself to stay sober great. It was worth it. I have attended IOP and am in 12 step meetings. I'm doing the work. I think my biggest fear is when it comes time to be off all the meds that I'm going to withdrawel from them and end up right where I started from.

 

So, lets stick with what we know...

1) In order for a addicted individual to get Vivitrol they will have to be treated by a physician who believes in chemical managment for addiction. Most who are of this mind set also believe in chemically altering mood and sleep which by mere common sense is not a smart thing for an addicted individual. We have lost the right to a chemical solution for our emotional problems.
A: Either you believe in fighting the disease of addiction with medications or you don't. It appears your position is the latter. No amount of discussion or company sponsored research is going to change that but perhaps clinical experience might.


2) Vivitrol while it may prevent someone from getting high from their drug of choice, can actually promote overdose if someone is determined to get high on their DOC while on Vivitrol.
A: Yes, this is a possibility and the reason responsible physicians take every opportunity to communicate this issue to their pts. It's also possible that, absent a chemical therapy to reduce cravings, the pt can OD on their DOC.


3) If an addict is in legit and significant pain, they can not be given narcotics for that pain. So, an addict can have his leg and pelvis crushed in a freak tractor accident, and the only way he will be receive relief is to be placed on a ventilator and anesthetized.
A: First, I think we can all agree that somebody who is in a freak tractor accident resulting in crushing wounds of the leg and pelvis is going to go into surgery under GA, anyway! Second, pts are given multiple medical alert items to assure first responders know that they are on NLTX, the opioid blocker in Vivitrol. But even if we allow the worst case scenario, pt is unconscious and no HCP knows they are on Vivitrol, it won't take long at all for the gas-passers to figure it out and administer agents sufficient to clear the opioid receptors.

That being said, there is a unique concern with opioid addicts in that they tend to be hyper-sensitive to pain, a condition probably attributable to their habit. For pts who are on Vivitrol, they may receive some relief from traditional non-narcotic analgesics. Additionally, unmasking the pain response, which may have been muted or obliterated while using, may allow for the discovery of previously undiagnosed issues.


4) The slippery slope mind set within addicts of using a chemical to control a chemical. From our 40 years of experience here, we realize this ultimately leads to relapse in most cases. And in this case would most likely lead to either a person stopping their Vivitrol or relapsing on a new mind altering chemical.
A: One of the mistakes we've made in the past is a failure to insist on a practical exit strategy when we've stepped pts down using the harm reduction model. The end goal, IMHO, must be sobriety without medication, including Vivitrol. Prior to NLTX we didn't have a non-narcotic option for addressing cravings and to prevent euphoria when relapse occurs. We simply replaced one addictive medication with another one that we thought, incorrectly in the case of medicinal cocaine, heroin and methadone, was less addictive. Even today I see too many physicians eagerly buying into the 'maintenance' phase of suboxone BS. While there may be a small percentage of pts who need to be on sbx after the acute withdrawal period, my observations tell me the 'business model' of sustained sbx therapy is driving the train, not pt care considerations.

It may be helpful to point out that the active component of Vivitrol in naltrexone. NTLX is not an opioid and will not foster chemical addiction. IMO the lack of a euphoric affect provides 'traction' against the slippery slope you described. Second, I can assure you the 'business model' (profitability) of Vivitrol to the prescribing physician is neutral, at best. Third, it's been my understanding that the manufacturer doesn't have many physician speakers on their payroll and tends to reimburse them below industry standards. I don't speak for them so this is second and third hand info.


So, you'll have to forgive me if I'm not drinking the Vivitrol Kool-Aid. There isn't enough data supporting its use that outweigh my concerns above.
A: Alternately, there appears to be a wealth of data indicating that the way we've been treating opioid addiction isn't working very well. Professional studies I've read indicate a 5-year sobriety rate of 5-12% with an annual mortality rate of 2-3%. Poor results in one therapy are seldom justification to aggressively adopt another one, but IMO I have an obligation to explore all available options, and Vivitrol is one of them. I don't believe I've become intoxicated on the kool-aid but my personal experience with Vivitrol for opioid addiction has been fairly positive.

 

Vivitrol -is- a miracle drug. It has changed my life. I never thought I could be free of my cravings for heroin, but I have been given back my freedom of choice. If you really want to quit, there is simply no better way. The physical part of the addiction is almost completely gone, and the mental is working it's way out.

 

1) In order for a addicted individual to get Vivitrol they will have to be treated by a physician who believes in chemical managment for addiction. Most who are of this mind set also believe in chemically altering mood and sleep which by mere common sense is not a smart thing for an addicted individual. We have lost the right to a chemical solution for our emotional problems.
A: Either you believe in fighting the disease of addiction with medications or you don't. It appears your position is the latter. No amount of discussion or company sponsored research is going to change that but perhaps clinical experience might.

My Response-My clinical experience has led to me not believing in the use of medications. I have seen and treated the addiction themselves, the process addictions, and also the addictions to doctors/attention/and any med not just the mind altering meds. The whole mentality around medication, and needing to change something wrong within us by the use of medications is a problem as great as the DOC. It’s that mentality that must change. Why would a medical profession reinforce destructive thought patterns?


2) Vivitrol while it may prevent someone from getting high from their drug of choice, can actually promote overdose if someone is determined to get high on their DOC while on Vivitrol.
A: Yes, this is a possibility and the reason responsible physicians take every opportunity to communicate this issue to their pts. It's also possible that, absent a chemical therapy to reduce cravings, the pt can OD on their DOC.

My Response-Vivitrol doesn’t reduce cravings, that we know by experience. It blocks addicts ability to get high, at least for a portion of the month. But, we both know it doesn’t work for as long as the Vivitrol reps tell us it works. And in that lies a problem. Addicts know this, and begin pushing on those receptors. And in order to test those receptors many are tempted to push opiates past their comfortable boundaries chasing a high. No amount of education will change that behavior in most addicts. Also, what we know is if you block an addicts ability to get high from their DOC, they merely switch DOC or stop taking the Vivitrol. It’s a big 800 dollar what’s the point.


3) If an addict is in legit and significant pain, they can not be given narcotics for that pain. So, an addict can have his leg and pelvis crushed in a freak tractor accident, and the only way he will be receive relief is to be placed on a ventilator and anesthetized.
A: First, I think we can all agree that somebody who is in a freak tractor accident resulting in crushing wounds of the leg and pelvis is going to go into surgery under GA, anyway! Second, pts are given multiple medical alert items to assure first responders know that they are on NLTX, the opioid blocker in Vivitrol. But even if we allow the worst case scenario, pt is unconscious and no HCP knows they are on Vivitrol, it won't take long at all for the gas-passers to figure it out and administer agents sufficient to clear the opioid receptors.

That being said, there is a unique concern with opioid addicts in that they tend to be hyper-sensitive to pain, a condition probably attributable to their habit. For pts who are on Vivitrol, they may receive some relief from traditional non-narcotic analgesics. Additionally, unmasking the pain response, which may have been muted or obliterated while using, may allow for the discovery of previously undiagnosed issues.

My Response-So you acknowledge that an addict will need to be anesthetized in order to gain pain relief beyond COX-2’s. That is even in cases where a patient would not have needed anesthesia normally.


4) The slippery slope mind set within addicts of using a chemical to control a chemical. From our 40 years of experience here, we realize this ultimately leads to relapse in most cases. And in this case would most likely lead to either a person stopping their Vivitrol or relapsing on a new mind altering chemical.
A: One of the mistakes we've made in the past is a failure to insist on a practical exit strategy when we've stepped pts down using the harm reduction model. The end goal, IMHO, must be sobriety without medication, including Vivitrol. Prior to NLTX we didn't have a non-narcotic option for addressing cravings and to prevent euphoria when relapse occurs. We simply replaced one addictive medication with another one that we thought, incorrectly in the case of medicinal cocaine, heroin and methadone, was less addictive. Even today I see too many physicians eagerly buying into the 'maintenance' phase of suboxone BS. While there may be a small percentage of pts who need to be on sbx after the acute withdrawal period, my observations tell me the 'business model' of sustained sbx therapy is driving the train, not pt care considerations.

My Response-You make some terrific points about exit strategies. I have more respect for addiction medicine physicians who actually acknowledge the need for chemical free sobriety. We might disagree on how to get there, but at least we are moving towards the same goal. I can accept that.



It may be helpful to point out that the active component of Vivitrol in naltrexone. NTLX is not an opioid and will not foster chemical addiction. IMO the lack of a euphoric affect provides 'traction' against the slippery slope you described. Second, I can assure you the 'business model' (profitability) of Vivitrol to the prescribing physician is neutral, at best. Third, it's been my understanding that the manufacturer doesn't have many physician speakers on their payroll and tends to reimburse them below industry standards. I don't speak for them so this is second and third hand info.

My Response-The fact is we don’t really know what effect naltrexone has on long term sobriety, and that is the most honest answer a physician can give. How physicians get paid really is irrelevant to me.


So, you'll have to forgive me if I'm not drinking the Vivitrol Kool-Aid. There isn't enough data supporting its use that outweigh my concerns above.
A: Alternately, there appears to be a wealth of data indicating that the way we've been treating opioid addiction isn't working very well. Professional studies I've read indicate a 5-year sobriety rate of 5-12% with an annual mortality rate of 2-3%. Poor results in one therapy are seldom justification to aggressively adopt another one, but IMO I have an obligation to explore all available options, and Vivitrol is one of them. I don't believe I've become intoxicated on the kool-aid but my personal experience with Vivitrol for opioid addiction has been fairly positive.

My Response-This is the only true dishonesty I seen in your responses. 5-12%? Where are you getting your figures and how were these studies set up? What population are we talking about, any who walks into an AA meeting? Or are we talking about someone who completed 5-6 weeks treatment, and a year at a half way house? Also, if the inadequacy was within the programs themselves, then why do airline pilots and physicians have 90+% 5 year sobriety rates? It’s not a program problem. It’s an accountability problem. Give me some legal leverage on a patient to help with motivation and we can produce 5 year numbers that would exceed most people’s expectations.