Treatment for patients struggling with opioid addiction is often a multi-faceted approach. Medication can help ease the patient’s symptoms of withdrawal and cravings. And the counseling portion of treatment helps to address the root causes of why a person became addicted and for them to learn coping mechanisms to manage the disease.
The treatments go hand-in-hand at Quannacut Inpatient Addiction Services, the behavior health services program in Greenport that is now part of the Stony Brook Medicine network.
Part of that treatment over the past decade has involved the use of a medicine called Vivitrol, a brand name for the drug naltrexone.
The drug works to effectively block the effect of opioids by binding to the opioid receptors in the brain. The medicine was first offered as a pill and now is available as a shot known as Vivitrol.
“Just like Narcan throws opiates out of the brain and reverses an overdose, the naltrexone attaches to the receptors and prevents people from getting high or overdosing if they try to use opioids,” said Dr. Lloyd Simon, the medical director of Quannacut who recently retired from his role at Southold Internal Medicine.
Naltrexone can also be used to treat alcohol addiction by decreasing cravings.
While Vivitrol has proven effective, its use comes with a major caveat. Before the drug can be administered, the recipient must be off the drug they had been using for a minimum of seven days. That includes not only the illegal drugs, but even prescription medication like Suboxone that is used to treat opioid dependence. The Vivitrol website even recommends patients be off any drugs for as many as 14 days.
Dr. Simon said during that window, the drug a person had been using is still bound to the receptors in the brain.
“Just the same way as Narcan would automatically get rid of the drug, so would naltrexone or Vivitrol,” he said.
That could trigger symptoms of opioid withdrawal.
“During that time, we know that on the outside if patients are not in the hospital, during that time when they’re on no medication and they are feeling still even the mild withdrawal effects, that’s a very high-risk time for patients to relapse,” Dr. Simon said.
The team at Quannacut, which includes the new outpatient facility in Riverhead, is taking part in a national study that could lead to a breakthrough in how Vivitrol is administered, potentially shortening that seven-day window and providing more hope to patients during a vulnerable and crucial time period.
Quannacut at Stony Brook Eastern Long Island Hospital is the only location in the northeast selected as part of the National Institute for Drug Abuse Vivitrol Study.
Dr. Richard Rosenthal, the director of addiction psychiatry for Stony Brook Medicine, approached the team at Quannacut about joining the study, Dr. Simon said.
The study is scheduled to last 90 weeks and provides a path for naltrexone to be administered within two days on a very small dose, Dr. Simon said.
A typical dose of Vivitrol is 380 milligrams and is designed to last four weeks. Under the protocol in the study, a patient would begin by receiving 1 milligram of naltrexone per day.
“It’s actually such a small dose that we have to have a compounding pharmacy prepare it for us,” Dr. Simon said. “There is no 1 milligram pill.”
A patient must be cleared of withdrawal symptoms before beginning the process. Once they receive a first dose, they are assessed two hours later to see if it made them feel better or worse. The dose gradually increases over the next few days before the Vivitrol shot is administered, possibly as soon as the fifth day.
Dr. Simon noted that Quannacut has not yet gotten that far in the study, which is being done in two separate treatments known as “Standard” and “Swift.” The Standard treatment provides a baseline with the typical detox period and seven-day required abstinence period before Vivitrol is given. The Swift treatment is when the new method is applied.
The study is considered random, so every six weeks another site is added to the Swift treatment and the goal is to eventually get to five sites using the Swift treatment and one remaining on the Standard. Only one site is currently underway with the Swift treatment.
Dr. Simon said that even for patients in a hospital setting, the long waiting period sometimes leads them to change their mind about trying Vivitrol.
“If we can give them the Vivitrol faster, we’re going to be more successful at giving it to more patients,” Dr. Simon said.
If a patient completes the study locally, they would move on to the outpatient facility in Riverhead under the care of Dr. Jarid Pachter.
The goal is for a patient to receive two additional Vivitrol shots to complete a three-month study.
It’s a rigorous process for a patient to begin the study. The medical team must identify a patient as a potential candidate. Personnel would then discuss in detail the process and the patient must agree to take part. If they agree, a more in-depth consent process and education will begin. A patient must even pass a test that confirms they understand the process.
“If they don’t do as well on the test as we like, we reeducate them to try to make sure they do understand every aspect of the study that’s important to them,” Dr. Simon said.
He added that if the method proves effective, it would be “extremely helpful,” and could be transitioned to outpatient services as well, which could drive down the cost of the process.
“Right now a patient would have to stay in the hospital the entire time for this study to be effective,” Dr. Simon said. “If a patient can be stabilized in the hospital for even a day or two and then complete the rest of their treatment protocol as an outpatient, that’s a huge amount of savings.”
Vivitrol does come with some significant risk, mainly if a person goes back to using the same amount of drugs four weeks after receiving the shot. The body would become more sensitive to drugs as their tolerance would have dissipated.
Dr. Simon noted that that’s part of the lengthy educational process.