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Man sitting alone in abandoned area; image via Pxhere, CC0.
Man sitting alone in abandoned area; image via Pxhere, CC0.

There’s a concept in the social sciences known as the law of unintended consequences. The results can be unexpectedly beneficial, unexpectedly detrimental, or perversely contrary to intent. At least one is unfolding right now in regards to the opioid epidemic, perhaps aided and abetted (unintentionally) by the drug courts.

The law of unintended consequences has been around in regard to substance abuse for at least a century.

During Prohibition (1920—1933), some people took to drinking industrial alcohol, which was never intended for human consumption, and which was actually poisoned — “denatured” — for tax purposes in 1906, before Prohibition was enacted. When bootleggers started “renaturing” it, the feds ordered more poisons added. Whether the bootleggers couldn’t “renature” the new mixture, or if they weren’t aware of the additional poisons, people started dying.

More recently, once drug officials realized the extent of the abuse of prescription opioids such as oxycodone and hydrocodone, they worked on cutting off the over-prescription by doctors and pill mills. This has spurred the abuse of even more dangerous illicit opioids.

Heroin is one, but an even greater threat is fentanyl, a powerful opioid up to 50 times stronger than heroin.

Fentanyl is a prescription drug, sometimes used for pain in terminally ill cancer patients. It also is synthesized for the black market and used to create fake pills that look like more common and popular opioids because it is cheaper and easier to obtain. Users don’t always know what they are getting, increasing the risk of overdose. Musicians Prince and Tom Petty, and actor Philip Seymour Hoffman are among the prominent cases of fentanyl overdose deaths.

Fetanyl – Know your source sign; image by Jeff Anderson, via Flickr, CC BY 2.0, no changes.
Fetanyl – Know your source sign; image by Jeff Anderson, via Flickr, CC BY 2.0, no changes.

One component of opioid abuse treatment is medication-assisted treatments (MAT), the use of drugs to wean or keep people with addictions from relapsing. According to the best comparison studies, the three most common MAT drugs work about equally well once treatment starts, though not with all patients.

The three MATs are methadone, buprenorphine – often combined with naloxone as Suboxone as a sublingual pill and film – and naltrexone – a daily tablet or the once-monthly injection, Vivitrol.

Methadone and buprenorphine themselves are opioids – opioid agonists, to be precise — but when taken as prescribed do not produce a high. Naltrexone is an opioid antagonist, that cancels the effects of opioids.

Because taking naltrexone makes it almost impossible to get or stay high, patients already must be detoxed from opioids – a seven-to-10-day process – before naltrexone treatment starts or they will go through cold-turkey withdrawal. Methadone and buprenorphine can be taken almost immediately.

Because of this time lag – and a dislike of injections—Alkermes, the maker of Vivitrol, was having trouble getting patients with opioid addiction or their doctors to agree to the treatment method. So instead they directly lobbied drug court judges that Vivitrol was better because it wasn’t an opioid – “why trade one drug/addiction for another?” – and because it only had to be administered once a month.

That’s good marketing, not good drug policy, medicine, or jurisprudence.

The cost also may have been a factor. Suboxone sublingual film is much less expensive than Vivitrol. So is naltrexone in daily tablet form – about $30 vs. $1,300.

A lot of drug court judges listened. Thirty-nine states now have a Vivitrol program, almost a dozen each on average. This is an unprecedented and medically unsound method of marketing prescription medicine because judges aren’t physicians, and often the judges don’t permit any other form of MAT.

Neither does the US government. According to US Health and Human Services Secretary Alex Azar, a Substance Abuse and Mental Health Services Administration (SAMHSA) directive mandates Vivitrol for those entering MAT after detox. Azar admitted, however, “that doesn’t mean it’s the best form for all populations”. Both methadone and buprenorphine have a longer track record than naltrexone in general or Vivitrol in particular. It shouldn’t be a choice only between Vivitrol or jail.

Sometimes it’s both. In several states, Vivitrol is given to inmates convicted of a drug-related charge as they leave prison, despite the risk of medical side effects. One patient experienced a whole raft of symptoms, including sinus and chest problems, a rash and white splotches on his arms. Even then the court ordered him to stay on Vivitrol.

Now there may be another unintended consequence: methamphetamine addiction. At least that’s what some in one rural Ohio community think is the cause of the uptick in methamphetamine addiction cases. That Ohio is the home of Alkermes may be relevant.

Amanda Lee, a counselor at Health Recovery Services in Ohio’s Vinton County, told a National Public Radio reporter that Vivitrol may be part of the reason for the increased use of methamphetamine since a Vivitrol program started at about the same time.

Lee reasons that even in recovery, people with opioid addictions want to get high. Since opioids don’t work if you’re on Vivitrol, they switch to methamphetamine, a stimulant not affected by naltrexone.

Methamphetamine’s side effects, Lee said, include paranoia, hallucinations, and other schizophrenia-like symptoms. Lee said methamphetamine scare her “more than opiates ever did.”

But methamphetamine has been enjoying a resurgence elsewhere, too. And one study suggests naltrexone may be a part of the solution for meth rehab. A small study ongoing at the Center for Neurobehavioral Research on Addiction at University of Texas Health Science Center in Houston is studying whether naltrexone combined with the anti-depressant bupropion can be an effective MAT for methamphetamine addiction.

Even if it is, there’s no antidote for a methamphetamine overdose like there is for opioids. Suboxone abuse is real, but methamphetamine abuse has worse outcomes.

The courts and SAMHSA shouldn’t limit themselves to one treatment model because new treatments may arise. Buprenorphine is available as a multimonth implant, Probuphine, and Suboxone will soon be available in a once-monthly injection similar to Vivitrol.

Given that there are at least two alternatives to naltrexone, if there is a reasonable chance that mandating Vivitrol is causing people to become addicted to methamphetamine instead of opioids, there’s no real choice. Judges and lawmakers must stop listening to the hype and permit the best available treatment, not the best marketed.

Sources:

  1. drug courts
  2. poisoned
  3. drugs work about equally well
  4. not good drug policy
  5. much less expensive
  6. $30 vs. $1,300
  7. Thirty-nine states, as they leave prison, home of Alkermes
  8. judges don’t permit any other form of MAT
  9. Azar admitted
  10. told
  11. part of the solution
  12. Probuphine
  13. once-monthly injection

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