Stinging 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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  • Ah. A director of a harm reduction coalition. They must offer Methadone and Suboxone at the clinic you work for and not Vivitrol. That would explain the baseless and seemingly uneducated opinion of your article.
    You’d think for someone in your line of work you be able to express the fact that there is no one single treatment that has been proven to cure this disease. It’s dangerous to negate a form of treatment that has saved so many lives as you have in this article. I would think as someone who is in the business of saving lives wouldn’t stoop to publishing something like this. Maybe if this doesn’t work out you could get a job working for the Sacklers of Purdue Pharma. Oh wait if you profit off of Suboxone I guess you already do.

  • For an article with such a strong opinion against this treatment it sure doesn’t offer a lot of statistics or facts to the contrary either. The argument is that there aren’t enough statistics that this works? How about personal experience with every treatment out there? From my experience 12 step programs offer the most relief and of course that takes time. Vivitrol can save a persons life and keep them clean while they work on the foundation of their long term recovery through healthy daily living. Methadone and Suboxone claim to offer the same thing and maybe they do for some people however those drugs didn’t work for me. They aren’t always considered recovery friendly and myself and many others I know continued to use on the latter two medications. Also after ANY period of sobriety with ANY treatment to this disease an overdose is more likely if the person with the disease relapses. It isn’t more likely on vivitrol than any other period of abstinence. Did the person writing this article do ANY RESEARCH at all? It seems like they just have a really strong opinion on something they know absolutely nothing about.

  • Something I would like to add. I have been off and on both naltrexone and vivitrol. It is extremely important to never use either medication’s if you have any fentanyl in your system. It causes immediate incredibly painful withdrawals.

  • I have to disagree with some of your opinions on this since i was on Suboxone for over 3 yrs for my addiction. Suboxone and Methadone offer just as much false hope. Every time ive ever seen people on methadone in the numerous recovery programs ive been in, they would be nodding off, mouths hanging open, drooling with their eyes rolled to the back of their heads. A lot of these drs put you on a higher dose then you need so it’s that much harder to get off so it keeps money coming into their pockets. I chose Suboxone because it didn’t seem to intoxicate people like ive seen with Methadone and i heard about its “ceiling effect” if you try to abuse it by taking more then prescribed. And even while i was on Suboxone, i relapsed twice so even with opiates in your system, you will still get cravings because no medication is going to help you with the psychological part of addiction. Take it from someone who knows and has seen plenty others go through the same thing. The only thing that will help with that is therapy. And since you’re still on opiates that are giving you a slight high from Suboxone, once you get off, you have to get used to what it’s really like to be completely sober and a lot of people aren’t prepared for that. The only reason why it helps with cravings and withdrawal symptoms is because you have an opiate in your system (buprenorphine) while on Suboxone. So unless people stay on it for their entire lives while in recovery, they will end up experiencing those cravings and withdrawals again once they stop taking it. My last thing to add is the most important in my opinion, which is the withdrawals from Suboxone are more intense and last much longer then most opiates. Last year it took me about 6 months to taper down to a low enough dose where i could completely stop taking it. I experienced varied severities of withdrawals throughout that whole time, each time i would taper down i would be pretty sick and very uncomfortable for maybe a week and a half and it would slowly subside until the next time i tapered down and had to go through the whole process again. 6 months of that! And my doctor wanted me to go even slower at some points which would of probably lessened the intensity of withdrawals between each time i would taper down but i would still be experiencing them nonetheless and my life would have been basically put on hold for that much longer. September 24 2018 was my first day without taking any Suboxone and the withdrawals were absolutely horrible. It took about a week for it to really hit me but when it did, it really knocked me on my bottom. The physical withdrawals lasted several months and were by far worse then the psychological withdrawals. Until i experienced this i thought Suboxone was the gold standard as well but after going through that, i really think more research needs to be done on long term side effects of Suboxone and how difficult it is for people to get off because of how long it takes to safely taper down and the intensity and longer then average duration of the withdrawals. Which leads me to believe Vivitrol is a much better option for a lot of people for MAT as long as they’re also in treatment for the psychological aspects of addiction. If the psychological components of addiction aren’t addressed then these medications are only a band-aids and relapse is that much more likely.

    • Those who you say are nodding off are not working the program the way it should be worked. Sounds like they have more than just methadone in there system maybe a Zanex or Valium. In the program they start you off at a low dose and you only go up 5mg each day after that until you have no more cravings. There are Federal Laws(like random urinalysis and Licensed counselor’s)in place that let the program work if you do it the way it’s set up. Sorry to hear your so bitter. That stinks.

    • Sparky, that’s what you would think but the people i saw nodding off like that on methadone were in detox, rehab and psych facilities so there’s really no way they could be on anything else other than what they are prescribed. A lot of doctors really seem to be giving patients way too high of doses. Which makes it that much harder for them to get off methadone so the doctors benefit since they have so many long term patients. Im not saying all doctors are like this but it seems to be pretty common in MAT clinics. You would probably be dumbfounded to see how high one older woman i was in a psych facility with was off methadone and it was a step down unit so there’s no way she came in under the influence from street drugs or anything that isn’t prescribed. She would nodd off standing up, she kept dropping everything and spilling her drinks all over the place. She was a MESS. I can’t understand how she was being given a dose that was obviously way too high for her and how her doctor that was prescribing it didn’t see how dangerously high she was.

      Jackie, if you take any opiate on Vivitrol (naltrexone) you will either feel none of the effects of the opiate high since the receptors are blocked or go into withdrawal from what i understand.

    • Id also like to clarify that I’m not bitter. I am just concerned about these programs being pushed on recovering addicts not being as safe and helpful as they claim to be. Especially after my own experiences as a recovering addict and MAT. I thinks addicts going into recovery should have more accurate information about the cons of MAT instead of just focusing on the pros like most people do. When I started Suboxone I was told it was a great medication and has no adverse side effects, it was almost made out to be a miracle drug. Nobody told me how much longer and more intense the withdrawals last and that it screws up your body just as much as any other opiate. People should know the reality of these medications and not just the fantasy they’re associated with.

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