| There is more information coming in all the time on this and related subjects. There have now been a number of deaths and some morbidity reported in dependent patients who were started on naltrexone treatment. Two people died after naltrexone was prescribed in a North American study of 162 patients over a 15 month period. One was apparently a suicide in a known depressive while the other was a young lady who died of an apparently accidental overdose after ceasing the drug. From an epidemiological point of view, these may still be considered 'naltrexone deaths' (the drug and treatment 'did not work').
In another study by Miotto and Ling, of 81 patients who began naltrexone after traditional detox, 13 had overdosed, four fatally, at the end of a 12 month trial.
Dr O'Neil from Perth has reported that there have been six deaths in 600 heroin addicts taken into treatment over a nine month period.
It would appear that mortality is far higher than with patients who are on methadone treatment (>1% pa for naltrexone and <1% pa for methadone prescribed patients). The place of naltrexone in the scheme of things is therefore becoming clearer.
It should never be recommended in preference to methadone and it is unsuitable for pregnancy, HIV, active hepatitis, infectious endocarditis or severe injury cases in opioid dependent people. Naltrexone is only indicated for patients who have already detoxified from opioids.
Where all other treatment options are exhausted and/or methadone is unacceptable or contraindicated in a non-depressive patient who desires a chemical treatment of their dependency, naltrexone is an option. Since it is an unregistered drug, there should be no other therapeutic alternative and the patient should have detoxified completely before starting treatment. Before individual approval, the TGA in Canberra (02 6232 8444) requires patients be informed of this and of the possibility of side effects or even death.
For novel treatments, ethical practice would dictate that any outcomes of note such as particularly good or particularly bad results should be reported to colleagues in the usual ways.
There are an increasing number of methadone failures who still need assistance and naltrexone may help some of these (we know that buprenorphine and possibly long acting morphine will also help a proportion). I believe that any doctor who has sufficient knowledge of dependency (and therefore who prescribes methadone for appropriate cases) should be permitted to prescribe naltrexone for patients who have already proven to have detoxified. The drug is unlikly to be registered in Australia until mid-1999 under normal processes.
It would be inappropriate for a doctor prescribing naltrexone to have to transfer a patient elsewhere for methadone, a simple treatment that can be given in any suitably accredited general practice. It would be like one doctor prescribing insulin, but referring patients elsewhere for oral hypoglycaemic agents, basic dietary advice or other simple diabetes treatments.
Rapid and ultra-rapid opioid detox using naltrexone is another matter entirely and, I believe, should be avoided altogether in general practice. It may be appropriate in formal, funded research protocols in the specialist setting. Doctors who are currently charging large sums of money for this 'service' are taking risks both with their practices and with their patients lives in my opinion.
Dr Andrew Byrne
Email: ajbyrne@ozemail.com.au
Andrew Byrne is a medical writer and practising GP, specialising in drug and alcohol medicine. He practises in Redfern, Sydney. He is author of: "Methadone in the Treatment of Narcotic Addiction" and "Addict in the Family".
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