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Dopey Doctors and Naltrexone Prescriptions

 Alexander DeLuca, M.D. February 27, 2003; Last revision: February 1, 2005. Modified: 2005-12-30
 
 
[Identifier: http://www.doctordeluca.com/FAQ/DopeyDocs.htm]


Question:
"I have attempted to obtain a prescription for Revia (naltrexone) from my primary care doctor with the intention of moderating/eliminating my alcohol consumption. I take no drugs. My doctor is only slightly familiar with Revia and will not educate himself sufficiently to prescribe it to me. Rather, he suggests that I go to a "drug rehab" type of place, even though he has confirmed via blood tests that I don't take drugs. He also states that he requires a "special license" to prescribe Revia, which I'm not sure I believe. Can you recommend a doctor who can and will prescribe Revia?"

Executive Summary:
Any doc that "refuses to educate himself" does not deserve to have you as a patient. He/She is suppose to help you by rendering expert advice tailored specifically to you based on specific knowledge of your body, your psychology, and YOUR goals. Anything less is a failure to live up to his/her end of the bargain. If they can't or won't do this, dump them and find doctor able and willing to practice up to this most fundamental standard of care.


Dear Mr. X,

I sincerely apologize for taking so long to get back to you.

I don't know whether you'd benefit from a rehab treatment or not, but "rehab" is often a knee-jerk response to any and all sorts of substance abuse problems regardless of degree and of the needs/history of the individual. Often people who really don't know much at all about the addictions only know the word "rehab" which they then advise instead of saying something like, "I don't know a lot about all the different options available these days, but let me investigate and then we'll talk over your options." I do know, from a decade of running a treatment center, that rehab is NOT for everybody or for every sort of degree of substance abuse problem, and sending a person to rehab when that is not what is called for can do way more harm than good.

[Please excuse my angry tone -- you are literally the third person I'm responding to tonight who has been given misleading, pig-headed, and just plain wrong information from a physician who they are paying to provide them with expert assistance, and that makes me embarrassed for my profession, and angry at the way people with alcohol problems get the run around so often. I get so tired of docs spouting gibberish when they could so easily RTFM [Read The < very Fine> Manual :-)].

Any doc that "refuses to educate himself" does not deserve to have you as a patient. He's suppose to help you by rendering expert advice tailored specifically to you based on specific knowledge of your body, your psychology, and your goals. Anything less is a failure to live up to his end of the bargain. Suggestion: dump him and find doctor able and willing to practice up to this most fundamental standard of care.

As to recommending a doctor, I might be able to help... What city/county/state are you in? It's possible I might personally know an addiction medicine specialist in your area. Or you can go to the American Society of Addiction Medicine website at http://www.asam.org/ where you can get a list of docs by county/state who will at least be (able to spell 'naltrexone') aware of the basics of naltrexone therapy and of the varieties of treatment options and who will actually want to work with you on this most important life problem that you have taken such admirable initiative around.

Simple Truths About Naltrexone (Revia):
No special license is required to prescribe naltrexone; if a doctor can write a script for penicillin, he can write one for naltrexone. Assuming your doctor is not just incredibly lazy, he's probably confusing naltrexone with buprenorphine which, as a treatment for heroin addiction, does require special training and an addendum to one's DEA license (the license needed to prescribe morphine, amphetamine, and other controlled substances), but this has nothing whatsoever to do with naltrexone.

Just so you know, naltrexone is not habit forming, and has zero abuse potential. It has very little toxicity. Some physicians will caution about liver toxicity and indeed, in one published paper where naltrexone was used in at 5X the usual dose in an experimental protocol as a treatment for eating disorders, it did cause a reversible inflammation of the liver. (Reversible meaning that when the naltrexone was discontinued, the liver returned to normal). However, I have reviewed the literature this virtually never happens with doses in the usual range of 50-100 mg a day.

If you have a history of hepatitis or other liver damage, or if you and/or your doctor just want to be super-safe, you might want to get a blood test ("liver function tests") to make sure your liver is functioning OK and to establish a baseline - then check it again in a few months after being on the medication.

Naltrexone doesn't have many drug-drug interactions to worry about either, but your physician (or you) would easily be able to check that if you are in fact taking any other meds.

The most important thing to understand is that naltrexone is a "pure opiate antagonist," which means that it occupies opiate receptors in your brain and holds on to them tight. So tight, that if you were to be given a dose of any opiate medication (morphine, percocet, vicodin, methadone, heroin, oxycontin, etc, etc) it would have NO EFFECT.

In the normal course of life for those of us who are neither chronic pain patients or heroin addicts, this is no big deal. But if you were knew you were going to need pain meds or surgery, you need to stop taking naltrexone at least three days earlier. Then opiates will work as advertised. I strongly recommend you place an index card in your wallet with a message to any emergency medical person you might happen to "meet" if you were unconscious after a train wreck or the like, to the effect that you are taking naltrexone, and what dose and regimen you're on. This way, the clinicians in the ER or the anesthesiologist will know to compensate for the presence of the drug.

Also really important: if you are ever on opiate medications daily for some pain or post-op, DO NOT TAKE NALTREXONE UNTIL YOU'VE BEEN OFF THE OPIATES FOR A WEEK - otherwise you might experience several hours of withdrawal symptoms; this wouldn't kill you, but it is VERY uncomfortable.

Naltrexone as an aid to controlled drinking:
Finally, though you wouldn't know it by going to most U.S. docs or reading the U.S. literature, there is a body of research on the use of naltrexone specifically as an aid to controlled drinking. Instead of taking the medication every day, this research suggests that people carry Nal with them at all times, and take a pill before entering into a drinking situation, or whenever craving for alcohol occurs. This ends up being a lot cheaper, as you are not taking it every day. In the US, where an 'abstinence uber-alles' mentality rules, docs only think of naltrexone as an aid to not drinking, and the usual regimen is 50mg daily, with some patients responding to 100mg if 50mg is only partially or not effective. While this will do no harm to a person with a goal of moderate drinking, and might actually work best for some people, you should know about the 'as needed' dosing, which has good support in the (non-US) literature, and which can save you a lot of money.

Know that naltrexone works even better for people practicing controlled drinking than it does those practicing abstinence, and this should be encouraging to you. (You'll find that most US docs will not be aware of this literature - see "References / Links" below; also: "Naltrexone for Patients who Wish to Moderate or Control Their Drinking" <http://www.doctordeluca.com/AbuseDepNal.htm>).



..alex...

Alexander DeLuca, M.D.
adeluca@doctordeluca.com
http://www.doctordeluca.com/

April 7, 2003; Major revision: 5/20/2003; Minor formatting: 7/18/2004


REFERENCES / LINKS:
Page of naltrexone references:  http://www.doctordeluca.com/AbuseDepNal.htm

Updated! (2005-12-30) - Does Naltrexone Cause Permanent Liver Disease? (No); Can Naltrexone be Used in the Presence of Liver Disease (Carefully). [References with Abstract from Medline Search for 'naltrexone' and 'hepatotoxicity']:  http://www.doctordeluca.com/Library/References/Nal_Hepatic_Tox.htm  

Naltrexone, buprenorphine, controlled drinking, and GHB references: http://www.doctordeluca.com/Ref-Search.htm

Collected experiences of Moderation Management members (from an MM listserv) with naltrexone (ReVia) as an aid to moderate drinking. http://www.doctordeluca.com/library.htm#MM&Nal

"Putting the Patient Back into Treatment; Collaborative Determination of Treatment Goals" <http://www.doctordeluca.com/Documents/FR_Goals.htm> by Fred Rotgers, Psy.D., written back when we were both at Smithers before I got fired in a media firestorm and he was later found guilty by association with me. (The summer of 2000 was brutal for us 'Moderate thinker' types in NYC and nationally - but we (MM, and Fred and me and us) have emerged stronger and will have the last laugh <Ha!>

See also: "The Harm Reduction vs. Abstinence Wars of Summer 2000!" <http://www.doctordeluca.com/Documents/PrimaryDocuments.htm>

HTML slide show by DeLuca: "Alcohol Abuse vs. Dependence and the Evolving Role of Naltrexone as Adjunctive Pharmacotherapy <http://www.doctordeluca.com/Library/SlideShows/RH2002A_files/frame.htm>"

"Evidence About the Use of Naltrexone and for the Different Ways of Using It in the Treatment of Alcoholism" <http://www.doctordeluca.com/Library/AbstinenceHR/NalUsefulModNotAbs-Sinclair01b.pdf> by David Sinclair, Alcohol & Alcoholism, Vol. 36, No. 1, pp. 2-10. From Abstract: "Naltrexone is most effective when paired with drinking but ineffective when given during abstinence ... naltrexone should be administered to patients who [are] still ... drinking ... and when drinking [is] anticipated; this treatment should continue indefinitely."

Targeted naltrexone treatment of early problem drinkers. Addictive Behaviors, Vol 22, #3, pg 431 - Henry Kranzler. <http://www.doctordeluca.com/Library/PsychoPharm/TargetedNalRxProbDrinkers97.pdf>

Naltrexone and Cognitive Behavioral Therapy for the Treatment of Outpatient Alcoholics: Results of Placebo-Controlled Trial. American Journal of Psychiatry, Vol. 156, pp 758-64. - Richard Anton. <http://www.doctordeluca.com/Library/PsychoPharm/Nal&CBT-1999.pdf>

Problem drinkers, endorphins, naltrexone and testosterone - by DeLuca, originally posted to the Main MM listserv a few years back. <http://www.doctordeluca.com/Documents/EndorphNalTestos1.htm#TopOfPage>

Medications that can Help Us Avoid Relapse in Early Recovery - by DeLuca, written in 1996 for my patient at Smithers, this is oriented towards abstinence, but I've never been able to say this stuff any better that I do in this handout. Good info about Antabuse here, too. <http://www.doctordeluca.com/Documents/SobrietyMeds.pdf>


Five Year Clinical Course Associated with DSM IV Alcohol Abuse or Dependence in a Large Group of Men and Women. American Journal of Psychiatry, Vol. 158, No. 7, pp 1084-90. - by Shuckitt (HTML version: http://www.doctordeluca.com/Library/DetoxEngage/NonProgAlcAbuse.htm). From the Conclusions section of this paper:

The data suggest that over 5 years the DSM IV diagnosis of alcohol dependence predicts a chronic disorder with a relatively severe course, while DSM IV alcohol abuse predicts a less persistent, milder disorder that does not usually progress to dependence." Meaning that alcohol abuse isn't always or even usually just 'early alcoholism' as the disease theorists have chanted all these many years, but is rather a different beast with a natural history of it's own.

<Whoops!
 


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Dr. DeLuca's Addiction, Pain, & Public Health website - Originally posted: 2/27/2003; revised: 2/1/2005.