Further Reading

Does naltrexone work?

Dear Stanton:

I understand that you don't subscribe to the disease theory of addiction. (understatement of the year!). However, do you believe that some therapies may allow patients to exert greater control over their substance abuse problems? I am thinking particularly of Naltrexone/Revia which may allow patients to drink without kindling major relapse.

This would seem to be a potentially useful adjunct in the transition from uncontrolled to controlled drinking. I would be interested in your thoughts on this. While AA claims no official position on Revia or 'any other drug,' it's clear they don't like the implications of the widespread use of drugs like this because it will ultimately begin to erode their influence.

I am a physician and a member of the American Society of Addiction Medicine. However I find the 12 step approach facile. Frankly I think there is as much science in a 12 step meeting as there is in a meeting of Elks or Goodfellows (the latter making no claims and providing an infinitely better time).

Sincerely,
Peter [...], MD

P.S. Superb Website!


Peter:

Thanks for the kind words. By the way, what is the scuttlebutt around ASAM concerning the judgment and million dollar award against G. Douglas Talbott — the founder and past president of ASAM — and his colleagues for false imprisonment, fraud, and malpractice for the misdiagnosis and forced treatment of a Florida doctor (and also that former ASAM president Anne Geller testified on behalf of the plaintiffs against Talbott et al.)?

Naltrexone is a long-acting opioid antagonist that blocks opioid receptors, supposedly reducing craving while diminishing tolerance for both opioids and alcohol. Why this drug should also act to block alcoholic craving when alcohol does not have target receptor sites always puzzles me. This suggests that naltrexone is acting through general experiential effects rather than through its specific action as an antagonist. You know, for centuries, therapies have been built on alternate drug experiences that block or replace opiate and other cravings (heroin was introduced as a chemical substitute for morphine, alcohol, and cocaine; barbiturates were likewise marketed for their anticraving effects; and so on).

Obviously, a drug that reduced the likelihood of alcoholic relapse, even after drinking, has a place in treatment. But, I strongly suspect early enthusiasm about naltrexone in alcoholism treatment will quickly fade.

This has already occurred in heroin addiction treatment, and especially in the country (Australia) where its use was most quickly and widely embraced (for use by general medical practitioners). Of course, naltrexone has been used for decades in heroin treatment. There was widespread enthusiasm for its generic use in Australia, and GPs were given prescribing privileges for it. There has now been considerable retrenchment. James Bell, in Australia, indicated, "We have enough research in Australia to say Naltrexone is of limited value [for opiate addicts]. Overseas evidence suggests only about 10 percent do well on it." Of course, any improvement with Naltrexone has to be matched with the improvement shown by untreated addicts.

Bell's evaluation of the actual (as opposed to experimental) use of Naltrexone in the Medical Journal of Australia was scathingly negative: not only did Naltrexone fail to end addiction for virtually all addicts, it increased the risk of overdose. Of 30 addicts prescribed naltrexone, by three months only six were still taking it, four of whom still sometimes used heroin.

Right now, Naltrexone is being pushed by Charles O'Brien and Joseph Volpicelli, at the University of Pennsylvania, as well as government agencies. In experimental programs, Naltrexone has been reported to reduce drinking days and quantities. But we must be aware that these findings — just like those in Project MATCH — occur under highly artificial clinical trials. When the drug is spread to the general population of clinicians and alcoholics, I predict its apparent efficacy will disappear.

Remember, Peter, you heard it here first.

Best wishes,
Stanton


Stanton:

Thanks for getting back to me so quickly. I am not quite so saturnine about the prospects of Naltrexone. Certainly a universal problem with this drug is patient compliance. I was unaware of the Talbott case but you have certainly piqued my curiosity. I assure you it hasn't been headline news in the ASAM newsletter!! I believe that this discipline suffers under the weight of a tyrannical orthodoxy. Is any other area of medicine so at the mercy of a cult? Thank you for having the courage to challenge this juggernaut.

Best wishes,
Peter


Hi my name is Alison and I have drinking excessively for about 2 years and I want to stop but I just can't how, I take Naltrexone every morning but it doesn't help lot and I have a kid who is begging me to stop he is 15 and cries almost every time he sees me drink, how can I stop this? or some ways to help me stop would be great, please help me.

Sincerely Alison