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[Home] - [Criminal Justice System]
Benefits (to the Criminal Justice System) of Using Naltrexone
Backing little-used drug for addicts
By Stacey Burling / Philadelphia Inquirer Staff Writer
Posted on Mon, Jan. 24, 2005
When criminals who are addicted to heroin are sent to Gaudenzia Inc. for rehabilitation, they get a big helping of psychosocial treatment. But there's no mention of naltrexone, a medication that totally blocks the effect of opiates such as heroin and OxyContin.
Gaudenzia's approach is typical, and Charles O'Brien, a University of Pennsylvania psychiatrist who has been studying naltrexone since 1973, thinks that's a problem. He's so frustrated by the drug's meager usage 20 years after its FDA approval that he's suggesting an unusual way to get more addicts to try it: make it a provision of their probation or parole.
"We have a solution that we're not using," said O'Brien, who estimates that no more than 10 percent of the country's one million heroin addicts have tried naltrexone.
He organized a symposium at Penn this month to explore the legal and ethical implications of his idea. To sway more opinions, a transcript of the meeting will be sent to judges and probation and parole officers.
The practical aspects of requiring criminals to take naltrexone - now a pill taken at least twice a week - will become less daunting within the year if, as O'Brien predicts, the FDA approves a new injectable form that lasts a month.
A six-month pilot study at Penn in which Philadelphia probationers and parolees on naltrexone repeatedly gave urine samples found that they tested positive for opiates 8 percent of the time. Addicts receiving only standard treatment tested positive 30 percent of the time. The reincarceration rate was 26 percent for the naltrexone group and 56 percent for the others. Fifty-one volunteers participated.
Penn is now doing a larger study of the drug in this population and plans to switch to the injectable form in September.
Larry Frankel, legislative director of the American Civil Liberties Union of Pennsylvania, said requiring a drug as a condition of release, even if people can choose prison instead, is a "fairly scary precedent."
"We tend to, as a society, say the government cannot force you to take medication," he said.
But Darrell Stevens, a Superior Court judge in Chico, Calif., has been requiring people to take the drug since 1996, first in alcohol cases and more recently in the county's drug court, without any problems. He tried it, he said, because other measures weren't working. "I kept seeing the same people coming before me all the time." He now has a "raft" of letters from offenders thanking him and describing how their lives have turned around.
In Chico, offenders ordered to take the drug, always with a doctor's concurrence, must take pills while a doctor or pharmacist watches. All of the county's pharmacies participate in the program, Stevens said.
Judge Louis J. Presenza, who runs Philadelphia's drug court and is cooperating with Penn's study, is hopeful about naltrexone, though most of the people who come before him use cocaine and marijuana. "We have to try something different," he said. "If naltrexone is available, then people should have the option to use it."
O'Brien said most criminal justice officials are wary of medications for addiction. "They tend to take a philosophy which is strongly and militantly drug-free, which would be great if it worked, but it doesn't."
Studies show that 85 percent of addicts return to drug use within a year of release from prison, said Douglas Marlowe, director of law and ethics research at Penn's Treatment Research Institute. Treatment both in and out of prison reduces by 10 percent to 20 percent the chances that addicts will use drugs or get arrested again, according to different studies.
Even though it has proven effective, judges and others in the criminal justice system dislike methadone, the most widely used drug for opiate addiction, because it is addictive, O'Brien said.
Naltrexone's big advantage is that it is not addictive or even pleasurable, he said. O'Brien likened the drug, approved for treatment of heroin addiction in 1985 and alcoholism in 1995, to a "chemical chastity belt."
Unfortunately, that's also its biggest drawback. "The problem with naltrexone is it works too well," Marlowe said. "Clients don't want a drug that won't let them get high."
Naltrexone has worked for highly motivated addicts such as doctors and nurses who have a profession to lose, O'Brien said. But others quickly abandon it when they want to get high.
O'Brien said a longer-acting version of naltrexone will help with the compliance problem. Alkermes, a Cambridge, Mass., company, plans to seek FDA approval for the injectable form for alcoholics, but doctors could then use it off-label for opiates.
Naltrexone does a better job of blocking heroin's effect than alcohol's, but it seems especially good at blunting cravings and the euphoria that people with hereditary alcoholism feel when they drink, O'Brien said. A Penn study of the 30-day version in alcoholics found it reduced heavy drinking by 25 percent.
There are 14,240 people on parole in New Jersey and 28,000 on state-supervised parole or probation in Pennsylvania. An additional 213,000 people in Pennsylvania and 86,400 in New Jersey are on county probation.
Official estimates of the New Jersey and Pennsylvania state prisoners with drug problems range from 55 percent to 70 percent.
Michael Briscoe, a supervisor in Philadelphia's adult probation department, said most probation officers are indeed opposed to methadone treatment. "We see drug-free as the ultimate prize," he said.
But he encouraged staff members to attend the Penn symposium and has helped Penn researchers find addicts willing to try naltrexone. "Because it has a therapy component, we're more open to it," he said, "also because of the fact that addicts don't get high from it. It just seems like a more viable option to me than methadone."
There is no legal reason not to make naltrexone use a condition of probation or parole, said Richard Bonnie, director of the University of Virginia's Institute of Law, Psychiatry and Public Policy. "The important thing is that offenders have a choice, even if the alternative is jail."
Presenza said some addicts do, in fact, prefer prison to probation with lots of conditions.
Barry Savitz, a former Philadelphia assistant health commissioner who is now a consultant to Philadelphia Health Management Corp., warned against expecting too much from any drug treatment alone. "If it were not for the drug abuse," he said, "these would not be model citizens."
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