Dr. DeLuca's Addiction Website


The best time to start naltrexone therapy is now.

Alexander DeLuca, M.D., FASAM - 8/14/01

Question:  "My therapist said that he would not ReVia (naltrexone) unless I was abstinent for two months and intended to stay that way. I'm confused; does this make any sense?"


No.

The old idea, based on anecdotal experience, not research, was that:
'everyone coming into treatment scores high on depression and craving
scales - if they stay sober ("just don't drink and go to meetings
dear") that over a period of 6-12 months they will no longer rate
diagnosis as 'depressed' and therefore were never depressed, just
alcoholic, and therefore never needed treatment for depression in the
early months of recovery. This exact same logic (we like to 'keep it
simple in drug and alcohol treatment') was applied to insomnia and
anxiety. It's all just alcoholism; buy 28 days of rehab, then don't
drink and go to meetings, and you'll be fine.

This sort of thinking made at least some little bit of sense, when the
drugs we had for insomnia were the barbiturates which really were
dangerous, and the drugs for anxiety and depression (the tricyclics
and antipsychotics) had lousy side effect profiles and were difficult
to use. What I mean is, when your treatment options are limited, and the
symptoms to be treated will, in the majority of cases go away by just
staying sober, withholding treatment for anxiety, depression, insomnia
and sexual dysfunction made some sort of medical sense.

On top of this sliver of medical sense, the treatment industry threw a
wet blanket of "drugs (including medicines) are BAD for recovering
alcoholics, period." This is why, when I first started working at
Smithers in 1990, nurses would literally call me at 3AM for permission
to give a patient an aspirin or Tylenol, and nurses and counselors would
spend hours talking to people about learning to live life without
aspirin. I mean, sheesh, pick your battles, you know? The problem with
the 'drugs are bad, doctors are stupid, just don't drink and go to
meetings (after paying us for a 28 day inpatient rehab)' is that
the number one cause of relapse in the first 3 months of sobriety is
insomnia, and that depression and anxiety untreated for 6-12 months in
a newly sober person is a recipe for return to drinking. Not treating the
symptoms of early recovery does much more harm than good.

All of this is way more absurd these days. We now have safe
and easy to use antianxiety and antidepressant medications that
relieve symptoms in early recovery even if the person would have
eventually gotten over them anyway in 6-12 months (IF they could have
stayed abstinence despite the symptoms). We have benzodiazepines,
which, while they have some (grossly exaggerated) abuse potential
can be used in the first weeks for anxiety while we wait for the Prozac
to kick in. And it turns out those nasty old tricyclics antidepressants,
used in low doses, make pretty good sleeping pills - without abuse potential
and without tolerance production. So now the 'drugs are bad, doctors
are stupid, just don't drink and go to meetings' starts to feel like veniality
instead of mere ignorance.

The best time to start naltrexone is NOW, if you are interested in
trying it at all - there is no particular reason to wait for two weeks
or abstinence. Hell, it's supposed to help you achieve two weeks of
abstinence if that is your desire.

The physician's job is to help people through the negative mood states
and insomnia that are so common in early recovery. This often means
frequent visits and/or phone calls so I can ask the patient if he/she
is having depression, anxiety, insomnia, etc, because I can almost
always treat these symptoms! Using sleeping meds (preferably
tricyclics but Ambien or benzos for a few weeks if necessary), using
antianxiety meds, using antidepressants if warranted in the particular
case are good things to do.

The object of the medical part of early recovery is make the patient
feel as comfortable and cared for as possible while they start to pick
up the pieces of their family, occupational and legal lives.


 

 

Alexander DeLuca, M.D., FASAM.
Copyright 2001. All rights reserved.                            [Top of Page]
Revised: October 9, 2001.
Dr. DeLuca's Addiction Website