Ten years ago, we summarized nearly 40 years of research and clinical work involving the over-representation of physicians with opioid use disorder, primarily from diversion or prescription misuse (Merlo & Gold, 2006). Some of my initial outcome studies, using clonidine and switching detoxified patients to naltrexone, showed excellent opioid treatment success for physicians. Over the years we looked at psychiatric diagnoses and other risk factors common among physicians, especially in specialties with easy access to these opioids, such as surgeons and anesthesiologists. Physicians, like other professionals in safety sensitive careers, are considered by Boards of Medicine and citizens as a drug-free occupation. While not closely monitored via random drug testing, they are tested for cause, e.g., accidents, incidents and suspicious behavior.
When suspected, or identified, as having a substance use disorder, physicians are evaluated and treated in collaboration with the Board of Medicine and State Physician Health Programs, which offer intervention and treatment support and an unprecedented five years of monitoring and accountability. The outcomes were excellent. As a result, the 5-year outcome data in Florida and other states with similar programs was documented and easily attained. For physicians with opioid addiction, these data reveal that over 80% fully recover (evidenced by spouse and other interviews and by drug testing), and most returned to work. Yet for some opioid dependent doctors, particularly among those in high risk specialties, relapse is more common and the first sign of relapse was often overdose.
Extended Release Naltrexone
The use of adding extended release naltrexone to an already successful program to treat MDs is especially encouraging for two reasons. First, Naltrexone is a full opioid antagonist which blocks opioid induced euphoria. Second, while Boards of Medicine have been reluctant to recommend methadone as a maintenance opioid, Naltrexone was thus considered a viable alternative and recommended for anesthesiologists who returned to their workplace—the operating room.
Moreover, recent research demonstrated an association of Naltrexone injections with long-term recovery among nurses (Earley, et al, 2017). Specifically, investigators reported that the use of Naltrexone had improved retention and outcomes among 38 opioid addicted nurses and nursing assistants, whom received at least 1 Extended-Release Naltrexone (XR-NTX) injection, while more than half (n = 21; 55.3%) received 12 or more injections. None of the study participants relapsed to pre-treatment morbidity, overdosed, or died during the 24-month study. As expected, opioid craving scores fell 45.2%. In a smaller study of addicted anesthesiologist and anesthesiology residents, (Merlo, et al, 2010) with histories of multiple relapse on opioids, the addition of extended release Naltrexone decreased the risk of relapse by nine-fold, while improving the return to professional work by 11-fold.
Why Does This Matter?
The short-term efficacy of XR-NTX is well-documented; the drug is well tolerated and not associated with any new safety concerns. Longer, five-year or oncology-like outcome studies are needed. Random assignment, direct comparison to other treatments is necessary. Compared with similarly designed, short-term studies of non-medical personnel, the rate of retention in treatment was higher, the percent of participants who tested positive on urine drug screens was lower, the prevalence of opioid craving and participants reporting mental health issues were also significantly less among those on the XR-NTX protocol. Moreover, patient quality of life scores, and re-employment rates were equal to, or better among those on the XR-NTX protocol compared to controls.
The Bottom Line
The relapse rate for all substance use disorders is unacceptably high. There are numerous clinical and non-clinical reasons for this, many of which are beyond the control of clinicians. Thus, any advantage we can provide may be the difference between life and death. Treatment with a MAT is not an either or, but should be in addition to. Injectable XR-NXT offers advantages for some patients over shorter duration MATs.