March 20, 2024
ALLISON BALLARD/USA TODAY NETWORK
A nationwide shortage of oral naltrexone, a medication used to treat alcohol dependence, has been destabilizing to people using it to assist in their recovery, according to addiction specialists. Pictured here are a selection of wines at Vinofiore in Shallotte, North Carolina.
For a long time, she drank every day, starting at 5 p.m. Eventually, she began drinking at 3 p.m.
"There were days near the end where I would decide, 'Today, I'm taking the day off,' and I would drink all day," said the 64-year-old Narberth resident, who requested to remain anonymous to protect her privacy.
As her health and her relationship with her daughter deteriorated, the woman agreed to detox and to strive again for sustained recovery, this time taking the oral form of naltrexone, a medication that reduces cravings for alcohol and its euphoric effects. Now, she has more than four months of sobriety.
But as a largely unexplained nationwide shortage of naltrexone tablets winds on, the woman has been unable to fill her prescription for the medication since February. Although she has maintained her sobriety and is doing well overall, she had not planned to stop taking naltrexone and has been experiencing more thoughts about drinking since she went off the medication, she said.
The shortage of oral naltrexone, one type of medication-assisted treatment, has had a palpable destabilizing effect on her patients, said Dr. Aviva Zohar, a board certified addiction medicine provider who runs Thalia Medical Center in Narberth. Medication-assisted treatment is the use of medications like naltrexone in conjunction with other forms of support and therapies to treat substance use disorders.
"People are coming in with more cravings," Zohar said. "Even the feeling of, 'I don't know when my medicine is coming in,' is a huge struggle. It's horrific." People "...can't get their medicine, and it's causing a lot of stress."
The pharmaceutical companies that produce the tablets have offered scant information about the shortage that has been going on for several months. The U.S. Food and Drug Administration's drug shortages database shows that some pharmaceutical companies are starting to report naltrexone tablets as available. But others are still listing them as unavailable or on backorder until late March or early April due to increased demand for the drug or a shortage of an active ingredient presumably needed to manufacture the medication.
"It's kind of like running out of penicillin," said Leyla Ozer, intake coordinator and treatment placement specialist at Thalia Medical Center. She said that approximately 30% of their patients take oral naltrexone – which was first synthesized in 1963 and FDA-approved in 1984 to treat opioid addiction.
Naltrexone comes in two forms: as daily tablets to treat alcohol use disorder and as Vivitrol, a monthly extended-release intramuscular injection, given by a practitioner, to treat alcohol and opioid use disorders. Naltrexone binds to the endorphin and opioid receptors in the brain, blocking euphoric effects, reducing cravings and the amount of alcohol or opioids used.
The Mayo Clinic defines alcohol use disorder as a "pattern of alcohol use that involves problems controlling your drinking, being preoccupied with alcohol or continuing to use alcohol even when it causes problems." Approximately 29 million adults and 750,000 youth ages 12 to 17 have alcohol use disorder, according to the National Institute on Alcohol Abuse and Alcoholism.
Statewide alcohol retail sales were up 3.5% and e-commerce sales up 6.8%, according to a report released last month by the Pennsylvania Liquor Control Board. Allegheny, Philadelphia and Montgomery counties accounted for 35% of statewide sales.
Anecdotally, Zohar and Ozer said they have noted a marked increase in people struggling with their use of alcohol and other substances since the COVID-19 pandemic.
"The hallmark of active substance use is loss of control," Zohar said.
Naltrexone and other forms of medication-assisted treatment help people regain control of their lives so they can heal – just as "if you break your leg, and you go to an orthopedic doctor, they might put you in a cast and give you time to heal it," Zohar said.
The Narberth woman said that since she has not been able to take naltrexone, she has been thinking more about alcohol. She gets "thoughts like, 'Oh, I can do this, and nobody would know," she said. "Before I wasn't getting those."
During the shortage, Zohar has been offering patients the option of monthly Vivitrol shots in lieu of the oral naloxone. Research has shown that people who had the extended-release injection stuck with their treatment longer compared with patients using oral medications that must be taken daily.
Acamprosate, another FDA-approved oral medication to treat alcohol dependence, reduces cravings, but it must be taken three times a day. Antabuse, also an FDA-approved medication, produces unpleasant side effects and sensitivity to alcohol. Research has shown that the anticonvulsive medication, Topiramate, helps reduce cravings and increase abstinence.
Pharmaceutical companies often give Zohar free samples of Vivitrol injections for patients, she said. A once-a-month naltrexone shot costs about $1,100, while a monthly supply of naltrexone tablets is about $48.
Although the injections provide a dependable 30-days of coverage, and tablets require the health care professional to rely on a patient's willingness and ability to take them daily, some people aren't ready for the "commitment" of a Vivitrol shot, Zohar said. She takes a harm reduction approach with her patients, meaning that she meets people "where they are" and works with them to find a variety of tools for their recovery.
The 64-year-old Narberth woman doesn't like needles and would prefer not to have naltrexone injections, if possible, she said. But if she feels she is in danger of relapsing, she will get the shot, she said.
"I think it's a shame many people aren't aware of the choices there are in medication" to help them in their recovery, said Zohar, who also offers outpatient detox.
During her recent months in recovery, partly with the temporary help of naltrexone, the Narberth woman said she has been enjoying being "clearer and more aware. I was tamping down my feelings before." She has been learning to talk to herself through all the ramifications of picking up even one drink that "can lead to many more."
If someone were to say to her that taking naltrexone to assist her recovery was a crutch, she said she thinks it "...would be a stupid argument because if there is something that would help, why not (use it)?"
