The Price of Naltrexone
In The New York Times Abby Goodnough wrote
” she got a Vivitrol (naltrexone) shot but it was so expensive — her co-payment was $600 — that she never got another” !!!
This is insane. Naltrexone is an opioid antagonist. It prevents opioids from causing a high (and relieving pain and suppressing coughing and breathing). In no way is it conceivably a drug of abuse. But opioid addicts who wish to cut off all effects of opioids have to pay for their Naltrexone.
Also (as explained in the excellent article) some of the same people who oppose the use of methadone and buprenorphine oppose naltrexone too. I have never understood their logic. I am sure it is based on a moralistic belief that there are no simple easy solutions. It isn’t even “no pain no gain” as cold turkey withdrawal while using naltexone is just as horrible as any other cold turkey withdrawal. Pointless speculation after the jummp.
But for now two practical proposals. Everyone who wants naltrexone for any reason should be given naltrexone (given no co-pay). I think this is obvious. Now somehow a drug which has been around practically forever is expensive, but the cost of paying off the pharmaceutical company whatever they demand for such a program (which will be great for them) is trivial compared to the costs of the opioid epidemic.
I should have provided a link to the Wiki on Naltrexone. Note the cost (retail) of oral Naltrexone is $0.74 a day — providing one a day to every addict and anyone who wanted to pretend to be an addict would cost hundreds of millions a year. This is a completely insignificant sum for the US government, so it should be done immediately. Delayed release Naltrexone is expensive (prescribing it with a $600 copay is bad practice of medicine). Here a technological improvement has made it possible for doctors to give the patients a better, but expensive option, which they don’t take.
I also have an impractical proposal that Naltrexone should be available over the counter — it can’t be abused and the reported side effects are the reported symptoms of being a person. However, I know this proposal is impractical.
My second practical proposal is phased drug assisted therapy. I think it should be
1) whatever you want for a week provided you don’t want a lethal dose (you want heroin — here’s your heorin)
2) second week whatever you want provided you take your methadone under our supervision. All the heroin you want will be none (it doesn’t do anything for someone full of methadone).
3) third week, 50% methadone 50% buprenorphine.
4) fourth week buprenorhine
5) fifth week 50% buprenorphine 50% naltrexone
6) 6th week through death do us part naltrexone.
Why not ?
This is really pointless.
OK so I don’t know anything and I can guess drug treatment specialists aren’t interested in proposals from a macroeconomist. I also guess sociologists aren’t interested in my answer to my question “Why not ?” but I am sure it is based on moralistic logic. I will try to define what I mean by “moralistic”. I mean the theory that virtue shall be rewarded (I really mean that virtue will be rewarded by God).
Pharmaceutical treatments don’t involve making a choice for Jesus, or making a profound born again choice for life, recovery, love, and solidarity. The means is unworthy of the glorious aim. It is offensive to human dignity that a shot could do what love and inspiration can’t do.
As I have made clear, I am sure that the refusal to learn from hard evidence is based on religion. The available evidence gives some support to materialism (original meaning — all that exists are atoms and the void not the translation of the Italian word consumismo into American). Another way of putting it is that it gives some support to reductionism.
People find this deeply offensive.
I think one problem is that religion is not debated or even discussed. When some people say spiritual, they mean cognitive-behavioral. Others mean pertaining to immortal souls which survive the deaths of our merely material bodies. It is hard for the two groups to reach agreement but it is even harder if they are too polite to mention that they disagree on that extremely important question which can’t be settled by science.
OK now I have to talk to my little sister (an MD certified both in internal medicine and specifically in addiction treatment).
Your practical proposal should probably include counseling or therapy at some point. The reason someone became an addict doesn’t go away when they get rid of the physical dependence. If the problem is only physical dependence, just providing enough drug to avoid withdrawal will fix the problem.
My early ’70s experience with heroin addicts while staying at the “pre-detention center” right down the block from Greenwich Village’s Washington Square Park — formally know as The Village Plaza Hotel at 79 Washington Place.
Dope users were divided between what I called “grocery bag junkies” who just came down to shoot up and party on the weekend — didn’t get hooked as far as I could see. Few years earlier had lived in East Village next door to addict who supported his heroin habit and paid his rent, etc., by selling to weekend users.
Pre-methadone, street junkies — who supported their habits by larceny — would keep increasing the dose — as their bodies got used to higher levels. Eventually they could not afford a higher dose (or their blood stream needed room for other things) and then — at a much higher level then they started out at — they would kick cold turkey so they could start all over at a low dose again.
Start getting high again. Their addiction was more psychological then physical.
A big giveaway to their psychological problems: you learned not to note they were nodding out or the next three times they saw you — this is literally true — they would come up insisting they just “hadn’t slept in three days.” IOW the didn’t want to admit they were shooting up — madly self-conscious.
I worked on a temp job around then — trucker’s helper shifting med supplies from main warehouse to satellite warehouse. We all agreed the job was fun — except when the supervisor occasionally came over to the satellite — whom we all agreed was the nicest, easiest boss we could ever have (I still remember that impression of him somehow, 45+ years later) — but when he was there we felt like we were doing the job for him, not for us, taking all the fun out — we all agreed.
Ditto for heavy dope addicts (and heavy alcohol addicts I guess). They are so pathologically self-conscious that they are doing everything for everybody else, not for themselves. Drugs are their escape from the supervisors (you and me) — the only way they can feel as good as we do.
That’s my bare bones theory anyway — what I took away from the whole experience.