The Reply

Abstract

I appreciate the comments by Silverman, MD and Akerman, MD in response to my editorial. They highlight the importance of including opioid antagonist therapy as a treatment option for patients with opioid use disorder.1Wakeman S.E. Using science to battle stigma in addressing the opioid epidemic: opioid agonist therapy saves lives.Am J Med. 2016; 129: 455-456Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar I agree that all treatment decisions must be patient centered and that naltrexone should be an available option. There are select patient populations in whom extended-release naltrexone may be considered preferentially, such as younger patients with a shorter duration of use, those with a high likelihood of abstinence, or people wanting to transition off of opioid agonist therapy after successful treatment.2SAMHSAClinical use of extended-release injectable naltrexone in the treatment of opioid use disorder.http://store.samhsa.gov/shin/content/SMA14-4892R/SMA14-4892R.pdfDate: February, 2015Google Scholar In addition, qualitative research has found that because of our unfortunate lack of effective opioid agonist therapy within correctional facilities, individuals who are involved in criminal justice may prefer to avoid agonist therapy for fear of forced withdrawal on incarceration.3Fox A.D. Maradiaga J. Weiss L. Sanchez J. Starrels J.L. Cunningham C.O. Release from incarceration, relapse to opioid use and the potential for buprenorphine maintenance treatment: a qualitative study of the perceptions of former inmates with opioid use disorder.Addict Sci Clin Pract. 2015; 10: 2Crossref PubMed Scopus (52) Google Scholar A recent randomized clinical trial found extended-release naltrexone to be more effective than no medication in preventing relapse among individuals under correctional supervision.4Lee J.D. Friedmann P.D. Kinlock T.W. et al.Extended-release naltrexone to prevent opioid relapse in criminal justice offenders.N Engl J Med. 2016; 374: 1232-1242Crossref PubMed Scopus (212) Google Scholar However, it is important to note that the study excluded individuals with a recent history of overdose and those who preferred agonist therapy. All treatments should be available to patients who have this deadly disease. There are currently no direct comparisons of extended-release naltrexone with buprenorphine or methadone; however, the existing literature suggests that treatment retention with antagonist therapy is inferior compared with agonist therapy.5Bart G. Promise of extended-release naltrexone is a red herring.Lancet. 2011; 378 (author reply 663-664): 663Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar On the basis of the current evidence, opioid agonist therapy is considered first-line treatment as recommended by the World Health Organization.6World Health OrganizationsGuidelines for the psychosocially assisted pharmacological treatment of opioid dependence.http://www.who.int/substance_abuse/publications/opioid_dependence_guidelines.pdfDate: 2009Google Scholar The first trial directly comparing extended-release naltrexone with buprenorphine is ongoing in the United States, so we may soon have new data to inform care.7Lee J.D. Nunes E.V. Mpa P.N. et al.NIDA Clinical Trials Network CTN-0051. Extended-Release Naltrexone vs. Buprenorphine for Opioid Treatment (X: BOT): study design and rationale.Contemp Clin Trials. 2016; 50: 253-264Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar Until then, our treatment decisions must continue to be patient centered, to be guided by existing research, and to include patient education about the likelihood of treatment success with different pharmacotherapies. Last, it is worth noting that the stigma around pharmacotherapy is greater for agonist therapy than antagonist therapy. This may be due to mistaken notions that buprenorphine and methadone are “addictive.” These stigmatizing beliefs misunderstand the definition of addiction and perpetuate the false notion that the goal of treatment is to be drug and medication free rather than in remission. The goal of diabetes treatment is not to stop insulin, but rather euglycemia and prevention of negative consequences; the goal of opioid addiction treatment is similar. Antagonist therapy is a useful treatment option, but we must be cautious to not allow stigma and a greater willingness to embrace a “blocker” rather than a “replacement” therapy to skew interpretations of the evidence. Treatment decisions and policies around addiction treatment and choice of medications always should be driven by science and not by belief. Antagonist Treatment for Opioid Use DisorderThe American Journal of MedicineVol. 130Issue 3PreviewIn the editorial “Using science to battle stigma in addressing the opioid epidemic: opioid agonist therapy saves lives,”1 Sarah Wakeman astutely emphasizes the current underutilization of medication-assisted treatments for opioid use disorders, despite the striking evidence behind their effectiveness. The editorial, however, focuses solely on agonist therapy, without mention of US Food and Drug Administration (FDA)-approved antagonist therapy (ie, extended-release injection naltrexone [XR-NTX]), available in the United States as VIVITROL. Full-Text PDF