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New Treatment With No Street Value Shows Promise; Can It Reduce Daily Area Methadone Traffic?


This story is part of an ongoing series about the effect of methadone treatment on individuals and the neighborhood. Part I gave an overview  of methadon treatment and the Goldman Clinic; Part II examined the Ramonita De Rodriguez Library; Part III took a close look at the issues surrounding the intersection of Front Street and Girard Avenue; Part V looked at how police and politicians handle these problems:

Broken Windows part IV

A long line of men and women standing outside a nondescript, concrete building is a common sight in some neighborhoods—  folks wearing t-shirts, sweat pants, and Timberlands in the spring or fall, their cigarette smoke rising up and rolling around flat-brimmed baseball caps.

Tattoos peek out between the boots and a pulled up pant leg, maybe something tribal, sports-related, or a R.I.P. message. In the winter, the group bobs up and down on the balls of their feet to stay warm, their frosty breath subbing for the warmer-weather cigarette smoke.

The people are recovering addicts waiting for their daily dose of methadone so they can continue on with their day. But does it have to be that way?

Some local clinics are trying out an alternative drug named Vivitrol (naltrexone in an extended-release form), which was approved by the FDA for treatment of opioid-dependent patients in October 2010. It had previously been approved for treatment of alcohol dependence.

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The two most important differences between Vivitrol and methadone or Suboxone are the new drug requires only one dose a month and does not have the potential for abuse.

Representatives of the Goldman Clinic at 8th Street and Girard Avenue confirmed they began a Vivitrol pilot project about one year ago.

Laura Boston Jones, vice president of Behavioral Health Services at North Philadelphia Health System, said they are “bringing on another medication that one could use instead of methadone.”

Initially, Vivitrol was seen as a breakthrough. “This drug approval represents a significant advancement in addiction treatment,” said Janet Woodcock, M.D., director of FDA’s Center for Drug Evaluation and Research, in the FDA’s press release at the time of the drug’s approval.

A local doctor agrees with FDA’s Woodcock.

“This is the perfect drug,” said Dr. Richard DiMonte, who practices in Delaware County. DiMonte started administering Vivitrol even before it was approved for opioid-dependent patients. He also works with Suboxone but said it is falling by the wayside in the last few years.

“My practice went from 70 percent Suboxone and 30 percent Vivitrol to 90 percent Vivitrol and 10 percent Suboxone,” DiMonte said.

DiMonte cites the drug’s non-addictive nature as key. He said the patients who choose Vivitrol are more committed to their recovery.

“They can’t get high on it,” he said. “[Therefore] it has no street value.”

A fact sheet provided by the manufacturer of Vivitrol, Alkermes, reads, “Vivitrol is an antagonist therapy for opioid dependence and blocks opioids from binding to the receptors, thereby eliminating all effects of external opioids.”

Thomas Foley, who lives in Northern Liberties, is a certified drug and alcohol addiction counselor and clinical director at a practice in Bucks County. He said the problem with treatment of all diseases relates to compliance.

“Probably only 30 percent of patients are 100 percent compliant with the [doctor prescribed] treatment,” Foley said. “This goes for everything from diabetes and hypertension to addiction.”

Foley believes the daily treatment of addiction can lead to low compliance levels. “It’s just not realistic for people with jobs [and] people looking for jobs,” Foley said.

Jones noted this advantage with respect to the Goldman project. “[With] certain disease states, individuals are known to be non-compliant,” she said. “If they’re non-compliant with an oral medication they have to take everyday then they end up back in the hospital.”

DiMonte saw a difference at his practice. “Now it’s more like 60 percent compliance [with the once-monthly Vivitrol],” he said.

That figure is important to Foley, who cited data about reaching various lengths of time with abstinence and the correlation with relapse rates.

“We start to see success at the three-month mark,” Foley said. “But the six-month mark is a big improvement. If we can get someone to go a year, preferably 12-14 months, the success rate is extraordinary.”

Don’t miss the final part of this series. Read PART V now

 

Nicole Kapulsky of Delaware County credits Vivitrol for her success in her personal battle with addiction. “It made me feel normal,” she said.

Kapulsky refused to take anything other than Vivitrol after going through a five-day methadone taper, in which she started at a 20 mg dose, and went down to 5 mg.

“I’ve done a lot of research,” she said. “Since methadone is addictive you need to detox from that too. Detox once was bad enough.”

But Jones at North Philadelphia Health System does not think it is time to abandon methadone. “I am a believer in methadone,” she said. “I have done the research. There is nothing more researched in the field of addiction than methadone and its effectiveness.”

But Jones does see another positive with Vivitrol. “It is not a narcotic so it does not produce a dependency of any type,” she said.

While the lack of dependence was a huge selling point for Kapulsky, she noted another benefit. “It gives the brain time to heal,” she said. “[Addiction] is about repetition. Addicts do that with [the drug they abuse]. With methadone you’re doing that all over again.”

Kapulsky’s current job requires her to work three long days each week. Daily treatment would be impossible, given the strict restrictions on methadone, requiring  patients visit a clinic daily to receive it, not any particular property of the drug.

Another benefit she found was getting her kids back.

“My whole thing was my kids,” she said. “I needed to be clean to get them back. Being on methadone is not being clean. Vivitrol is considered clean.”

Kapulsky stopped taking Vivitrol more than a year ago. She has been clean for four years and one month now. And she got her three kids back.

“It really is a miracle drug,” she said.

Both Foley and DiMonte caution against labeling the drug a “miracle.”

“You still need to come in for counseling,” Foley said. “This replaces one part of the puzzle. It’s a significant piece, but there’s more to it.”

Kapulsky continues to attend counseling twice a week, despite stopping the Vivitrol.

Foley said that’s now more the norm than the exception.

Hurdles do exist for implementing Vivitrol, however. The cost of an injection ranges from $1000 to $1200. Insurance reimbursement varies.

“My insurance covered it,” Kapulsky said.

Goldman’s project took extra time as it began with a focus on insurance costs.

“Initially, it was very slow … in terms of who we could enroll,” Jones said. “So we started with one set of individuals who were insured [by a company] who was looking to see some of the cost benefits of moving to this versus … methadone.”

DiMonte said most insurance covers the cost but the manufacturer provides a $500 voucher for uninsured people. “It runs about $600 to $700 a month for someone without insurance with the company rebate,” he said. “That may sound high, but it’s not as high as the cost of heroin.”

Another issue is the recommendation that the addict abstains from opiate use for a week or so before using Vivitrol. Foley said that is why it remains only one piece of the puzzle and the counseling is so important. “You can’t force someone to do this,” he said. “They have to want to do it.”

“The medicine is an ally,” Foley said. “Think of it like this: The addict is Batman, [Vivitrol is] Robin, and I’m Alfred.”

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