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tinging investigations by the New York Times, National Public Radio, ProPublica, and others have recently exposed how the drug maker Alkermes is promoting Vivitrol — a long-acting injection that blocks the effects of opioids — at the expense of other, better-studied treatments for opioid dependence. We can and should blame prescription drug companies for the misleading marketing they use to boost sales. But we should also look in the mirror and recognize that, in the case of opioid dependence, these schemes work so well because they reflect the bias — often unconscious and well-meaning — that prioritizes the fantasy of being drug-free over the real interests of people in need of help.

The investigations revealed how Alkermes marketers and lobbyists deride the daily administration of methadone and buprenorphine, two medicines that are the gold standard for treating opioid dependence. The sales pitch is that Vivitrol is an opioid blocker and “non-addictive.” The company has blanketed New York and other cities with promotional materials, and has dispatched lobbyists to prey on well-placed community worries about the spiking number of fatal overdoses.

The pitch is working. Sales of Vivitrol have skyrocketed more than 600 percent since 2011, and legislators in 15 states have written Vivitrol — by brand name — into their laws. Multiple jurisdictions have now created “Vivitrol courts.” These require drug offenders appearing before them to use that medication if they wish to avoid imprisonment.

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A recent survey of criminal justice representatives found that most favored Vivitrol over methadone and buprenorphine because, they said, the evidence showed it was better — an astonishing claim given that there is actually no evidence. Not a single published trial (one is now underway in New York, for which Alkermes declined to donate its product) has compared Vivitrol to methadone or buprenorphine.

What criminal justice officials and legislators mean but don’t say is that Vivitrol fits the bias against prescribing psychoactive medicines like methadone or buprenorphine to someone who has used an illegal drug — even if these medicines reduce HIV risk, improve family function, increase employment, and reduce the risk of heroin overdose. Vivitrol’s appeal is largely because its physical blockade of opioids echoes the urge to control and contain, with the medicine locking up receptors in the brain the same way we might lock up a drug offender.

For some people, this blockade is an extremely useful crutch, with the medicine helping them help themselves abstain from drugs. But for many others, the long-acting shot prevents them from getting high but doesn’t relieve their psychological suffering.

Vivitrol’s appeal is largely because its physical blockade of opioids echoes the urge to control and contain, with the medicine locking up receptors in the brain the same way we might lock up a drug offender.

Alkermes did conduct a single clinical trial to demonstrate the efficacy of Vivitrol for heroin addiction and secure its approval from the Food and Drug Administration. But the company did it in Russia, which bans both methadone and buprenorphine. Even there, where treatment options are severely limited, expensive, and abusive, nearly half the people in the trial who were getting free Vivitrol dropped out.

Worse still is the possibility that Vivitrol treatment may actually increase the risk for overdose. Using the drug requires patients to go through a painful detoxification. Evidence shows that those who return to using heroin or another opioid after a period of abstinence are at greatest risk of fatal overdose. We cannot know for sure if there’s a link between stopping Vivitrol and fatal overdose since Alkermes declined to track overdoses among the individuals in the Russian trial who stopped the medication. This omission raises the terrible possibility that the aggressive marketing of Vivitrol might actually accelerate the overdose crisis.

Would we really rather risk that our family members perish than include controlled substances like methadone or and buprenorphine among their treatment options? That has certainly been the Russian way — the country’s ban on methadone and buprenorphine has coincided with skyrocketing deaths from overdose as well as a huge and growing HIV epidemic fueled by contaminated injecting equipment.

Here, as in other matters, the Trump administration seems to have a disquieting alignment with the Putin government. Tom Price, the secretary of Health and Human Services, recently made headlines by disregarding years of studies and millions of stories of patient benefit when he dismissed methadone and buprenorphine as simply “substituting one opioid for another.”

For anyone who has seen the suffering caused by opioids, blocking them out — in the body, or in our society — is a powerful impulse. But when we allow it to deprive patients of options or to blind us to the realities of drugs and effective treatment, it begs the question of how high a price we are willing to pay for a drug-free fantasy.

And a fantasy it is. Vivitrol patients, who require a monthly injection, are not drug-free, and the medication’s price tag is many times that of methadone and buprenorphine.

Far more important, patients pay a terrible cost including, in some instances, their lives, when we allow criminal justice officials or health providers who have internalized the thinking of drug control to predetermine what treatments work. Anyone who insists that there is only one acceptable approach to treating drug dependence is motivated more by ideology than evidence.

The siren song of enforced abstinence — no matter the human or financial cost — is distracting, deadly, and as old as the drug wars.

Daniel Wolfe is the director of international harm reduction development at the Open Society Foundations.

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  • Vivitrol has been a game-changer for me and my alcoholism. I am very thankful to have found this drug. Just sorry I have to drive 2 hrs to a provider. My small town is too conservative to support this not-so-new med – probably because of articles like this.

  • WHO IS BRIBING YOU TO WRITE THIS ARTICLE? I am absolutely appalled by this slanted, foolish ‘REPORT’! I own an outpatient drug treatment center where we have used Vivitrol as a part of our regimen for alcohol and opiates for years! We have experience with hundreds of patients. Nothing works better to give treatment time to take root than this medication. Methadone and Suboxone are addictive trapping people for in an endless vicious cycle of addiction to drugs that get them high! I have treated people who have been addicted to no opiate or than Suboxone and/or combined with Xanax which creates a more powerful experience than heroin, I hear consistently from those who have combined them. When Vivitrol is discontinued no withdrawal, no craving and no combining it to produce an new high. STOP WRITING THIS KIND OF BIASED TRASH.

    • Hey Michael, we are on the same page! I was dumbfounded when reading this article. I have been working with folks struggling with addiction for about 6 years now… no doubt in my mind that Vivitrol is an absolute blessing.

  • Addressing the addiction is most important. Being drug free never guarantees remission of the need for the drug

  • It’s true that Vivitrol is newer and has been subject to less study and, like all the rest in the world of pharmagreed, the mfgr’s have been heavy footed in the race for the best bottom line. However, as an adjunct to an intensive program, it seems to have less side effects and should not be dismissed out of hand. One inaccuracy in the story; it is available as a daily pill and the pill is less expensive by an order of magnitude or two. The daily pill, in many ways, is also a potential plus when an entire family/group can engaged in supporting a person’s recovery. Administration becomes a daily connection to the recovery process. Of course, this varies from addict to addict, but then, in the best of all possible worlds, treatment should vary depending on each individual case. The other benefit is that naltrexone is an opiate antagonist and not worth selling on the illegal market. Selling Vivitrol as an intervention by itself would be wrong, but as part of the recovery tool kit, it can be a useful adjunct. The story does the recovery world a disservice by setting these different treatment options as a dichotomy. We need all the help and thoughtful analysis we can get (and hard to come by these days!).

  • This is disturbing to me, as I work in forensic psychiatry, and many patients have “Dual Diagnosis”, meaning that substance abuse is often a result of untreated mental illness.A “Vivitrol” kind of intervention doesn’t address the underlying issues. Sounds dangerous and irresponsible

    • I agree with you that many people who suffer from addiction also have some underlying mental health condition. Vivitrol works great on it’s own, but that’s not the whole picture. It’s ALWAYS recommended that it be used in conjunction with good psychosocial support– that’s the part of the treatment that addresses mental health. The Vivitrol helps starve the addiction so we CAN work on other things.

  • I am so happy that this article was written. As someone who is alive and writing this comment 100% because of methadone, I’m a little bothered by the responses of other comments, which is taking anecdotal evidence and putting it above science and statistical evidence. Anyway, the author didn’t really go into detail on how methadone works so I wanted to add a few important points. First of all, as an opiate agonist, methadone fills your opioid receptors which has two positive effects: one no longer feels the agonizing withdrawal symptoms (which Vivitrol DOES NOT do) AND it also prevents any other opiate/opioid from getting into those receptors thus blocking any euphoric high from using heroin if you’re on a stable dose of methadone. So it also achieves everything that Vivitrol achieves and more. I also think its better that people have to go every day in the beginning (which is alleviated over time; more clean time = more ‘take home bottles’ = less days taking your dose in front of a nurse at the clinic) because it helps to establish a routine. The counseling is also MANDATORY which I’m not sure is true in all cases with Vivitrol. I know it is when it’s court-mandated treatment or if someone is smart enough to know they can’t get clean solely from Vivitrol, but I don’t know if it actually is mandated, if that’s a state decision, etc. I do know you cannot get methadone without counseling, and in fact the counseling continues after you detox off of it (if you choose to, some people stay on it for life which is perfectly healthy). The author’s view of Vivitrol is not “narrow.” He says what is factually true and accurate about it. He’s talking about it just in terms of the company’s advertising and lobbying plan to say it’s better than methadone. This is not true no matter how many anecdotal stories you can find of someone who got help from Vivitrol (no one’s saying it’s impossible, just that’s not the gold standard of treatment ALL AROUND THE GLOBE like methadone has been for the past 60 years [in our country at least] and it isn’t better than methadone) the statistics and scientific evidence and um common sense are not on your side. Sorry not sorry.

    • Nobody is saying Vivitrol is greater than methadone. There are pluses and minuses to both. Methadone isn’t the ‘gold standard’ it’s just one way to combat heroine addiction. The more tools we have in this fight the better.

      Counterpoints: I’m not aware of any treatment that doesn’t have counseling, particularly in state funding.
      Methadone can be, and is, resold by people who take it home. Vivitrol doesn’t have this problem.
      Depending on the case and despite it’s high cost per shot, vivitrol can be cheaper than Methadone over the long term.

    • You cannot get vivitrol without counseling. Neither insurance nor the state will pay for it without counseling. The statistics which abound regarding vivitrol are not anecdotal, and drug treatment is always evolving that is the wonderful thing about medicine in general. Methadone is still used in many places, but it is also quickly being replaced by Suboxone. There are several options out there for treatment that can be tailored to individual choices. As for the withdrawal, nobody gets a vivitrol shot while they are still in the withdrawal process, that would be ridiculous. They are completely detoxed off all opiates before they begin a vivitrol program. I spent 4 years working as a nurse in a medical detox, I only left a few months ago to move into longer term treatment, but people make the choice to come in and go through the detox process so that they can make a change in their life.

  • This article gives a very narrow view of Vivitrol, the majority of people who are on it made the choice voluntarily. It is also used in conjunction with treatment, it is not as if people show up for a shot once a month and that is all. They attend counseling and group therapies. It has been effective in helping both opiate addicts and those with alcohol addiction achieve sobriety.

  • Any person detoxed from opioids is at high risk for overdose if they use again and fail to take into account that their tolerance for the drug has been reduced. That person could have maintained sobriety on Vivitrol or been involved in abstinence only treatment or been recently detoxed in a hospital after overdosing. To suggest Vivitrol increases the risk of overdose is to say that curing heart disease increases the odds the patient will die of cancer or some other illness. Further, we know that within two weeks of release from prison or jail, persons with opioid use disorders have been found to be 174 times more likely to die as a result of an overdose than the general population because of their enforced abstinence while incarcerated. Thanks to the Vivitrol provided by Alkermes, the many prisons and jails that provide an injection of Vivitrol immediately before release are currently saving lives, giving these vulnerable individuals time to get engaged in treatment and recovery supports. None of the FDA approved medications for opioid use disorder offer miracle cures.

    • ^^ agreed, I also know someone who is wanting to get off the methadone that she had been on for years and get on Vivitrol, unfortunately it is not offered in her state as an option through state funding like it is here.

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