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Hiding Opioid Addiction Treatment in Plain Sight

On my way to meet a friend, I walked through the Grand Central subway station and found myself confronted by a massive advertising campaign. Giant faces taking up much of the wall stared at me―black, white and Hispanic, all between 20 and 40 years old, looking serious and healthy. Big signs asked “What is Vivitrol?” and said “Ask your healthcare provider,” adding “There’s another option.”

But they never said what Vivitrol is for,  at least not until a final panel crowded with text revealed the condition.

Ads for Vivitrol in Grand Central Terminal, New York City

Photo by the author

Ask Your Healthcare Provider

As an internist who sees patients in an opioid treatment program, what strikes me about this ad campaign is that it barely mentions the problem the drug is used to treat. Its goals are to put the name of the drug into the minds of the public, and to suggest that Vivitrol is another (and presumably better) treatment option. Better than what? And what does it do, anyway?

Here’s what commuters in a hurry would miss: Vivitrol is a drug used to treat opioid addiction.

That’s what makes this campaign so fascinating—and distressing. The invisibility of the problem of opioid addiction reflects our society’s ongoing stigmatization of addiction and treatment for it. The ad panels with concrete information about Vivitrol―what it’s used for, side effects, appropriate and inappropriate patients―are few and far between, and written in a font far smaller than that used in the other panels.

Opioid addiction has created a national crisis. An estimated 142 people die from opioid overdoses every day in our country. In 2016, more than 1,300 people died of such overdoses in New York City alone, a huge increase from the 630 opioid-overdose deaths recorded in 2015. The White House panel commissioned to study the problem has recommended declaring a national emergency in response to the epidemic.

Despite all the publicity about recent celebrity deaths due to opioids, people with opioid addiction are reluctant to disclose their condition, even to family, close friends and doctors. They fear judgment from all those who see addiction as a sign of weakness or a personality defect, rather than the disease my colleagues and I see every day.

Examining Treatment Options

Of course, I already know what Vivitrol is, what it’s used for and what the other treatment options are. For more than 10 years I have prescribed methadone and buprenorphine to my patients, nearly all of whom suffer from opioid addiction and its many complications. I have seen methadone and buprenorphine allow people to regain control of their health and lives, find jobs and homes, repair relationships and return to their faith communities.

I don’t recall ever seeing an ad for methadone or buprenorphine outside a medical journal.

At this point there is a paucity of data to support the efficacy of Vivitrol. It appears to work better than no treatment, but that’s pretty much all we can say about it. There has not been a study that compares it to methadone or buprenorphine. Because patients must completely abstain from any opioid use for at least three days before starting Vivitrol, getting them to start the medication can be challenging. And they are more likely to leave treatment than patients on methadone or buprenorphine. Since opioid addiction is a chronic disease requiring lifelong monitoring and treatment, patients who are not being treated are likely to relapse. Methadone and buprenorphine work well; we know this from dozens of studies done over several decades. But although the evidence supports their use, these drugs are no longer under patent protection and are not profitable enough to merit significant advertising campaigns.

I have never treated a patient with Vivitrol, and out of the hundreds of patients I have seen over the years, only two have ever asked me about it. For many of my patients, most of whom are mature adults with decades-long histories of addiction, Vivitrol may never be a good option.

When the drug was first approved in 2010 to treat opioid addiction, I was extremely dubious about its utility. Early studies of oral naltrexone (the generic name for Vivitrol) did not support its use as an effective treatment for opioid addiction. My experience treating patients with methadone and buprenorphine successfully made naltrexone seem like a poor choice when better treatments were available. Since then a lot has changed, including my opinion about Vivitrol. The injectable formulation of Vivitrol improves rates of compliance with the treatment and therefore its effectiveness.

The opioid crisis has exploded in our nation, and the typical course of opioid addiction has changed. People are starting opioid use at younger ages and becoming addicted more quickly, and their lives are unraveling faster. Vivitrol may work better in people with shorter histories of addiction. We need all the treatment options we can get for patients with different histories, needs and levels of support at home. What remains largely unchanged, however, is the stigma of opioid addiction and addiction treatment.

Bias Versus Effectiveness

Methadone and buprenorphine are often disregarded as treatments that allow for “real” recovery because they are opioid agonists―medications that activate the same receptors as those activated by abused opioids. However, when used to treat opioid addiction, methadone and buprenorphine do not provide the euphoric high caused by heroin and other abused opioids. Opioid agonist drugs keep people with opioid addiction from feeling physical and psychological withdrawal and craving opioids. They are able to stabilize their often chaotic lives and focus on goals other than their next oxycodone pill or bag of heroin.

If this is not real recovery, I don’t know what is.

Still, I look forward to learning more about Vivitrol, and how best to use it to help my patients, from clinical studies—not advertising.

Also, I wish there were greater efforts to spread the word about treatments that we know help people suffering from opioid addiction. To their credit, many local health departments (including our own New York City Department of Health and Mental Hygiene) have pushed the opioid crisis into the public eye with public service announcements about overdose prevention. I look forward to seeing more public health efforts to throw some light on opioid addiction treatment and the many paths to recovery, including methadone and buprenorphine.

We need to show the public that recovery from opioid addiction is possible and to reduce the stigma attached to addiction and treatment, and expose patients to all of the effective medications we use to treat this terrible and growing problem.

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