According to two recent studies, Vivitrol, a once-monthly injection of naltrexone, is just as effective as daily doses of Suboxone at easing cravings during recovery from opioid addiction. During the 24-week study, Vivitrol patients relapsed into active substance use at a slightly lower rate than patients given Suboxone. These two studies – an American one just published this month in The Lancet and a smaller Norwegian one in October – came to the same conclusion: both Suboxone and Vivitrol are viable treatment options for patients struggling with opioid dependency or addiction. These were the first direct head-to-head comparisons of these two medications. This announcement should come as good news for the estimated 2.6 million Americans currently struggling with a Substance Use Disorder (SUD) involving such drugs as:
In 2016, approximately 43,000 Americans died from fatal overdoses involving opioids.
Vivitrol—What You Need to Know
Vivitrol is the brand name for a specific extended-release injectable formulation of naltrexone, a prescription given for opioid or alcohol dependence. First approved for opioid-dependent patients in 2010, Vivitrol is a relative newcomer compared to other, better-known options such as methadone, Subutex, or Suboxone. Medications containing naltrexone are opioid antagonists that work by binding to specific receptors within the brain, thereby creating a barrier that blocks the effects of all opioids. This means that the person will experience far fewer drug cravings than they would if they tried to abruptly quit opioids “cold turkey”. Of special relevance, this also means that even if an individual receiving Vivitrol injections suffers a relapse and tries to abuse any opioid, they will not get high. Vivitrol is not an opioid, and is not addictive. It also does not produce euphoric highs. According to no less of an authority than the Substance Abuse and Mental Health Services Administration, Vivitrol and other naltrexone formulations have “no abuse and diversion potential”.
What About Other Medications for Opioid Addiction?
This is very different from how methadone and buprenorphine medications work.
- Even though it is used to treat opioid dependency, methadone is itself a powerful opioid with a high potential for abuse and addiction. This is why each daily dose must be administered by medical personnel, typically at a methadone clinic. In 2014, 23% of fatal opioid overdoses involved methadone.
- Buprenorphine drugs such as Subutex, Suboxone, Zubsolv, and Bunavail are also synthetic opioids, but they are different from methadone because of one important factor—buprenorphine is an opioid partial agonist. This means it carries a lower risk of abuse, addiction, and overdose than full agonists such as methadone, heroin, and commonly-abused prescription pain medications.
Lower risk does not mean NO risk, however. Long-term use of medications containing buprenorphine can still result in physical dependence. Abrupt discontinuation of the drug can trigger painfully-uncomfortable withdrawal symptoms that may increase the risk of relapse into active abuse. Because it DOES cause a high (albeit of lower intensity than other opioids), the abuse of buprenorphine is a real concern. Between 20% and 35% of people seeking treatment for opioid addiction self-report misusing buprenorphine within the past 30 days in order to get high. Even the “abuse-deterrent” formulation is frequently misused. Charlie Cichon, Executive Director of the National Association of Drug Diversion Investigators, says, “This was great drug for its intended use. But the abusers found out that this was another drug that they liked. It’s not a drug that gets them on that high plain like the other drugs that they abuse. But if they can’t get that drug that they like, Suboxone is readily available and it keeps them at this mellow stage until they can get the next drug.”
Why Was a Head-to-Head Comparison So Important?
Despite recent efforts, the opioid epidemic in America is getting worse. Every year, drug deaths in the United States are setting tragic records:
- 2014: 47,055 deaths, up 7% from 2013
- 2015: 52,404 deaths, up over 11%
- 2016: an estimated 64,000 deaths, an increase of more than 22%
- 2017: on pace for 71,600 deaths, a jump of almost 12%
To put those numbers in a historical context, consider the number of lives lost from other causes:
- Homicides (1991) – 24,703
- Traffic Accidents (2016) – 40,200
- Breast Cancer (2017) – 40,610
- Suicides (2015) – 44,193
- Firearm Injuries and Deaths COMBINED (2016) – 45,699
- AIDS (1995) – 50,628
- The Korean War (3+ years) – 36,914
- The Vietnam War (19+ years) – 58,200
That’s right– annually, drug overdoses kill more Americans than several years of war. Here’s the thing – this plague of fatal overdoses is fueled by the opioid crisis – 2 out of every 3 overdose deaths involve opioids. And an increasingly-larger proportion of those opioid deaths are being caused by heroin and synthetic opioids like fentanyl and its related analogues.
- 2002-2016: Fatal heroin overdoses in the United States skyrocketed 739%. In 2016 alone, there were 15,546 overdose deaths involving heroin.
- 2015-2016: Overdose deaths involving synthetic opioids more than doubled. In 2016 alone, synthetic opioids killed 21,405 Americans.
These statistics tell us that there is a desperate need for more proven treatment solutions that can be applied to what President Trump called “the worst drug crisis in American history.” 90% of people with an SUD aren’t receiving treatment. Research has proven that one of the most effective weapons in this fight is Medication-Assisted Treatment (MAT). So these studies are important because they have determined that Vivitrol—like methadone, Subutex, and Suboxone – is another viable MAT option that can be used to help the millions of people still needing specialized care.
Vivitrol versus Other MAT Drugs
Although the overall effectiveness of Vivitrol is roughly equivalent to that of Suboxone, the injectable medication does have a number of other practical advantages:
- No potential for abuse and addiction – Subutex, Suboxone, and methadone are all addictive opioids that are frequently divergent for misuse.
- No respiratory depression – When abused or taken with alcohol or benzodiazepine tranquilizers, opioid MAT drugs present a risk of overdose death.
- Convenient compliance –It is easier for someone in recovery to show up for one monthly injection that it is for them to make a daily trip to a methadone clinic or remember to fill and take their once-a-day buprenorphine medication.
- Promotes evidence-based recovery – Other MAT drugs have “harm reduction” as a primary goal in sobriety as a secondary goal. However, because Vivitrol lowers the user’s tolerance for ALL opioids, abstinence is the ONLY option while receiving monthly injections.
- Helps in recovery from other addictions – Vivitrol has shown to be effective when treating other addictive disorders, including:
- Alcohol Use Disorder
- Cocaine abuse
- Methamphetamine addiction
- Compulsive gambling
- Pornography addiction
- Trichotillomania (hair-pulling disorder)
- Kleptomania
- Non-suicidal self-harm
In comparison, methadone has no other applications that can aid in recovery from other addictions, while buprenorphine medications’ only additional use is for the treatment of cocaine dependence.
The Inconvenience of Methadone
Availability and accessibility of drug treatment is part of the problem. This is especially true when it comes to MAT. Methadone is typically ONLY offered in specialized clinics. Patients have to physically come into the clinic every single day in order to receive their dosage. This can be hard enough for ANYONE, but it’s made even harder for someone trying to manage an opioid addiction. And if the person doesn’t have a vehicle or has had their driver’s license suspended or revoked, then they have to rely either on their friends and family, or even worse, on public transportation. Significantly, if they miss even one dose, they quickly become “dope sick” – going into opioid withdrawal within a matter of hours. The discomfort of withdrawal leads many to start using again. But if they live in a rural area where there are no local clinics, then methadone may not even be an option.
The Constricting Regulation of Buprenorphine
Patients who opt for Subutex or Suboxone may have it even harder, because not every doctor can prescribe that class of drugs. Before they are allowed to dispense medications containing buprenorphine, doctors must first undergo several hours of specialty training and fulfill other certification requirements. This severely limits the number of available prescribers in any given area. Nationally, only about 1 out of every 30 physicians is allowed to prescribe buprenorphine. Even more significantly, during the first year following certification, these doctors are only permitted to treat 30 substance-dependent patients at a time. This means a shortage of prescribers. It means potentially-months-long waiting lists. And, in rural areas, it may mean that there are no buprenorphine doctors locally. There are several states that have less than 20 certified physicians.
Vivitrol Is Available Everywhere
These facts highlighted one of the chief advantages of Vivitrol – it can be prescribed by ANY licensed physician, without the need for special training or certification. And, because the injection only needs to be administered once a month, arranging transportation is also much easier.
Vivitrol Is Not a Stand-Alone Treatment
As any addiction specialist will tell you, the odds of successful recovery are maximized when anti-craving medications are given in conjunction with individual counseling and group therapy. A six-month double-blind clinical study comparing the relative effectiveness of addiction treatment using only counseling versus counseling and Vivitrol injections was conducted, with the following results:
- Opioid-free weeks – 35% of counseling/placebo patients versus 90% of counseling/Vivitrol patients.
- Reduced opioid cravings – 3% versus 55%.
- Length of treatment stay – 96 days versus 168 days.
Not surprisingly, patients given the placebo were 17 times more likely to relapse than those given Vivitrol. The encouraging news is that two-thirds of patients given naltrexone medications will complete their rehab program. And when they are given both naltrexone and clonidine, the “graduation rate” jumps to over 85%.
Addressing Concerns About vivitrol
As with any medication, there are some potential barriers for patients who wish to receive Vivitrol injections.
- Concern—Patients must complete opioid detoxification and be completely opioid-abstinent for two weeks before they can be given Vivitrol.
- Solution—Detox is a common first step for many people starting recovery. Medically-supervised facilities can help patients detox as safely and as comfortably as possible.
- Concern –Because Vivitrol lowers opioid tolerance, patients must totally abstain from all opioids during for the length of treatment.
- Solution – There are many ways to manage pain without opioids. In fact, according to the latest federal guidelines, doctors should only prescribe opioid painkillers as a “last resort”, when other non-narcotic options have proven to be ineffective. Even then, they are only to be prescribed for the lowest dose and shortest duration possible.
- Concern – It is still possible to overdose on opioids while taking Vivitrol.
- Solution – Vivitrol treatment should be combined with specialized behavioral counseling to reduce the chances of relapse.
- Concern – Vivitrol injections cost over $1000 per month, compared to approximately $100 for a 30-day supply of Suboxone.
- Solution – Many private insurance carriers approve Vivitrol injections because of the long-term treatment savings.
- Concern – Vivitrol may not be right for some people suffering from liver disease or damage.
- Solution – You should ALWAYS discuss your personal health history with your doctor before starting ANY new medications.
What’s the Future of Vivitrol?
Even before these two recent studies, Vivitrol was gaining popularity as a convenient, safe, and effective addiction recovery medication. From 2015 through 2016, year-over-year sales increased by 70%. Going back a bit further, Vivitrol sales have spiked 600% since 2011. Programs that are ideologically opposed to opioid-replacement drugs like methadone and buprenorphine – drug courts, correctional facilities, and abstinence-focused rehabs, for example – have no such objections to Vivitrol or other naltrexone medications. In fact, right now, there are approximately 450 court/correctional facility-sponsored treatment programs across the country that incorporate Vivitrol as a recovery medication. What does all this mean for YOU? If you or someone you care about is dependent on or addicted to heroin or prescription painkillers, then the results of these studies should give you renewed faith in the possibility of recovery. If you have concerns about the addictive potential of other MAT drugs, then Vivitrol may just be the solution you have been waiting for.