November 28, 2017

How do the 2 primary medications for opioid misuse stack up?

Daily Briefing

    Two of the primary medications for treating opioid misuse, Suboxone and Vivitrol, are similarly effective, according to a recent study published in The Lancet.

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    According to the New York Times, the study, funded by the National Institute on Drug Abuse (NIDA), affirms the findings of a smaller, shorter study, conducted in Norway, that was published last month.

    Details on treatment options

    Suboxone, made by Indivior, is a daily oral medication that contains buprenorphine, an opioid, and naloxone, which causes a withdrawal if a patient tries to snort or inject the medication. According to the Washington Post, the medication "essentially replaces" the high offered by other opioids without generating a high—which means people who misuse drugs do not have to detox before starting a Suboxone regimen. The medication can create a dependency, the Wall Street Journal reports, and patients using it often remain on the drug for years, sometimes for a lifetime.

    Vivitrol, made by Alkermes, is a monthly injection of naltrexone, a non-opioid drug that blocks the brains' opioid receptors to prevent opioids from triggering a high. The drug, approved by FDA in 2010, can be taken only after a patient has been fully detoxed from opioids, a process that takes at least a few days and which can make it difficult for people who misuse drugs to start the treatment.

    Study details

    For the study, researchers assessed 570 adults who were dependent on opioids—primarily heroin—and who received either Suboxone or Vivitrol as part of inpatient treatment at eight different facilities between 2014 and 2017. The researchers observed the study participants for six months, collecting self-submitted reports of opioid use, level of opioid craving, and side effects, in addition to weekly urine samples.

    The researchers found that at the end of a six month period, the relapse rate for those treated with Vivitrol was 65% compared with 57% for those treated with Suboxone. However, the researchers also found it was more difficult for patients to initiate Vivitrol treatment (72%) than it was for patients to initiate Suboxone treatment (94%). Many of those who were unable to start Vivitrol had relapsed before they could start the treatment, according to the researchers.

    Discussion

    While acknowledging that Vivitrol was more difficult to initiate, the researchers said the focus should be on the comparable efficacy of Vivitrol and Suboxone once initiated, as the difficulties of detoxing are already well established, the Times reports.

    For instance, John Rotrosen, a psychiatry professor at New York University School of Medicine and one of the lead authors on the study, said the study demonstrated "the relatively equivalent safety and effectiveness of these two medications." He added, "What we were really hoping, and what we found was ... the two medications would be sufficiently equal, so providers and patients and families really recognized they have a choice."

    Nora Volkow, director of NIDA, said she hopes the findings debunk the "widespread belief" that patients "don't do as well on naltrexone as they do on buprenorphine." She recommended that providers tailor the treatment options for each patient. For instance, according to Volkow, a provider might prescribe Vivitrol for a patient who lives in a rural area that might make it difficult to access a daily medication and prescribe Suboxone for patients with chronic pain, as the medication blocks pain receptors.

    Separately, Joshua Lee, an associate professor at NYU's School of Medicine and one of the lead authors of the study, said, "The problem is not enough people are getting into treatment ... and when they do go into treatment, they don't get any of these treatment options."

    However, some experts expressed concern about the gap in the rates of how many people were able to start Vivitrol compared with Suboxone. For instance, in an editorial accompanying the study, David Lott, a professor at the University of Illinois College of Medicine, expressed concerns about the difficulty of getting through detox in order to be treated by Vivitrol. While the study adds "to [the] growing scientific literature supporting the effectiveness and safety" of Vivitrol, Lott wrote, the "substantial induction hurdles for (Vivitrol) continue to present challenges."

    Separately, Sarah Wakeman, the medical director of the Substance Use Disorders Initiative at Massachusetts General Hospital, said the study confirmed it's much easier to initiate Suboxone treatment with patients and that patients remain on Suboxone longer than Vivitrol. "The take-home from this study is that … (Suboxone) is more effective," she said.

    Ultimately, Volkow called for further research, noting that neither drug is "perfect — in this trial, 50% of the patients relapsed after six months. … So it behooves us to research more and develop more medications" (Blau, STAT News, 11/14; Goodnough and Zernike, New York Times, 11/14; Bernstein, Washington Post, 11/14; Whalen, Wall Street Journal, 11/14).

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