Pubdate: Thu, 03 May 2001 Source: Courier-Mail, The (Australia) Copyright: 2001 News Limited Contact: http://www.thecouriermail.com.au/ Details: http://www.mapinc.org/media/98 Author: John Saunders Note: Professor Saunders, a member of the Australian National Council on Drugs, heads Alcohol and Drug Studies at the University of Queensland and is studying naltrexone in national trials. NALTREXONE'S GOOD FOR THE RIGHT PEOPLE The current furore over naltrexone treatment of heroin dependence is unlike anything I have experienced in 25 years of working in the drug and alcohol field. Understandably, everyone is seeking answers to the problems of heroin addicts. The emphasis in Australia in recent years has been on pharmacological treatments, especially methadone maintenance. Overall, the risk of death, overdose and major disease is reduced by 75 per cent with methadone. Naltrexone is, in principle, a good treatment. In most people, it blocks the effect of injected heroin and suppresses craving but it is only as good as the motivation of users. Patients on naltrexone tablets have to renew their commitment to keep off heroin every time they take the tablet. Unlike methadone, naltrexone has no opiate-like properties and does not cause even mildly pleasant effects. Without the soothing effect of opiates, some people find life hard. With naltrexone, there is a constant need for support and advice. Given and used carefully, it can produce brilliant results. One must recognise that injecting heroin is a dangerous activity. Between one and three percent of regular users die each year. Aggregating the experience of several groups across the country, there is clearly an excessive number of heroin overdoses among people treated with naltrexone, compared with methadone. Indeed, naltrexone treatment may be associated with a mortality rate similar to or even higher than that seen in untreated heroin users. Overdoses occur when treatment stops, often about the third day after the last naltrexone is taken. When people use heroin regularly, tolerance to its effects builds up. This actually protects from overdose, to some degree. When patients start on naltrexone, the unique properties of the drug afford considerable protection from heroin's effects. However, at the same time the tolerance that has built up is diminished. If the person ceases to take naltrexone, they will be as susceptible to the effects of heroin as they were the first time they used it. Given that they will be likely to use a dose similar to what they took during their years of regular use, they will, in effect, be taking a massive overdose. This risk of overdose is inherent in treatment with naltrexone. The claims of some commercial providers of rapid detoxification and naltrexone have been as misleading and irresponsible as I have seen in my medical career. Treatment with naltrexone requires effort by the user, his or her partner, parents, friends and crucially, by the doctor and clinical staff. Treatment with naltrexone in the tablet form clearly has its limitations -- the need for an almost obsessional persistence with treatment being the major one. A naltrexone implant, inserted into the fat underneath the skin via a small incision, allows for slow absorption and usually lasts about two months. When a person has a repeated pattern of heroin use and has developed a dependence, I would normally advise methadone maintenance as the most beneficial treatment. In my view between 5 and 10 per cent of heroin dependent persons are likely to accept and benefit from naltrexone treatment. We need to better identify those who will respond especially well to naltrexone and this is one of the aims of a recent trial at the Royal Brisbane Hospital. Naltrexone is suitable for those who are highly committed to abstinence and have a strongly supportive network of family and friends. We need to progress our research into the treatment of heroin dependence, including controlled trials of naltrexone implants; and the development of vaccines against opiates, which are becoming a practical reality. I am strongly committed to testing new treatments against the best of what we can currently provide. - --- MAP posted-by: Andrew