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The Pharmaceutical Journal Vol 267 No 7173 676-680
10 November 2001

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Letters to the Editor

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Naltrexone implants

Value in treatment questioned

From Dr C. B. Chapleo

It was with dismay that I read the recent "Broad Spectrum" article by Dr Colin Brewer entitled "Naltrexone implants for opiate addiction: new life for a middle-aged drug" (PJ, 25 August, p260). To state that naltrexone "is an obvious alternative to methadone" reveals a lack of understanding of what opiate addiction treatment is about and of the psychological and emotional state of patients seeking treatment. The article also totally ignores the aspect of how to transfer a patient on to naltrexone, which in itself is not straightforward and can cause considerable discomfort to the patient resulting in many of them discontinuing this form of treatment. I am not against naltrexone, which for some individuals (likely to be a minority) might well be the correct treatment. As such it is right that naltrexone is included in the armamentarium of medicines available to physicians to treat opiate addiction, but its role needs to be put into perspective.

Naltrexone is viewed by many as somewhat of a failure because it has not been well accepted by physicians and patients. Additionally, some patients view naltrexone suspiciously as an imposition and yet society by and large would be in favour of it because it is as close to "no medication" as we can get.

Clearly, naltrexone does have a role to play (route of administration is an extra consideration) but I suggest only in the minority of patients who are committed to remaining abstinent. However, here lies the difficulty and danger. Dr Brewer correctly points out that this population of patients is "ambivalent about giving up the drug in question". In those patients who relapse for whatever reason, naltrexone implants represent a significant danger and this has been recognised in Australia, where the implants have been developed and have been in trial. There is considerable debate and controversy over the use of these implants, not only because of the way they were being used and prescribed but because of the inherent danger of patients attempting to overcome the effect of the implants — trials with the implants are on hold because some addicts used lethal doses of heroin in an attempt to overpower the implant, and others tried to remove the implants surgically by themselves.

Is this then the "obvious alternative to methadone"? I think not. Treatment of opiate dependence is a serious matter. We are referring here to what is medically accepted now as a chronic relapsing disorder and such a condition reserves a responsible approach to treatment. Unbalanced reporting has no role to play and does a disservice to the medical profession in this area.

C. B. Chapleo
Director of Buprenorphine Business,
Reckitt Benckiser Healthcare (UK) Ltd

Dr COLIN BREWER, medical director, Stapleford Centre, responds:

Naltrexone is an obvious alternative to methadone in the same sense as an intrauterine device is an obvious alternative to oral contraceptives. Nothing in my article was intended to imply that naltrexone was in any sense "better" than methadone (which I prescribe for many of my patients) but it is without doubt an alternative and one which many of my patients ask me to prescribe for them. I am a general psychiatrist who has specialised for over 30 years in the treatment of patients who abuse alcohol and other drugs. I am also the author of numerous papers — some of them invited reviews — published in the leading journals of my specialty. It is likely that I know at least as much as Dr Chapleo about the nature of addiction and its treatment and about the psychological and emotional state of my patients.

I do not "totally ignore" the matter of how to transfer patients on to naltrexone. Indeed, I specifically mentioned it as one of the difficulties of naltrexone treatment.

Although the Stapleford Centre offers both opiate and naltrexone maintenance, our current waiting list includes far more patients requesting detoxification and transfer to naltrexone than patients requesting methadone or buprenorphine. Furthermore, if they relapse after a period of naltrexone, most of them request further naltrexone treatment, having learnt from their experience not to stop it too soon, rather than returning to long-term opiate maintenance.

There is certainly debate in Australia about naltrexone implants, but it is not true that implants in general were developed there. As my article made clear, the most widely used model was developed in the United States and is used in at least a dozen countries to my knowledge, including one state in Australia. Because, as I pointed out, all implants so far are "unofficial and have no product licence", this has certainly caused bureaucratic anxieties in some Australian states, but the locally produced implant continues to be used with official permission in Western Australia.

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