Date:         Thu, 11 Apr 1996 16:50:55 -0500
Reply-To: "Academic & Scholarly discussion of addiction related topics."                             
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: "Anne M. White" 
Subject:      Re: Naltrexone was(WHAT I SEE HERE)
To: Multiple recipients of list ADDICT-L 
Status: RO

>
>I know that you didn't ask me, but we have been using Naltrexone for some
>time here, with selected clients.  We have had quite a positive response
>from it.  They have tended to stay in treatment, and lapses/slips, etc.,
>seem to be reduced (anecdotal info, so far).
>
>I think the "trick" is to be selective with who gets it.  I am also a firm
>believer that what you say (e.g., how you 'set up' the drug trial) is quite
>important - what you actually tell the client about what to expect; how it
>works; what else they will need to do, etc.
>     Ned
>
>
>Edward M. Rubin, Psy.D.
>Sinai Samaritan Medical Center
>2000 W. Kilbourn Avenue                    voice: (414) 937-5070
>PO Box 342                                   fax: (414) 937-5422
>Milwaukee, WI  53201-0342                  email: erubin@facstaff.wisc.edu
>

Ned , could you give a brief outline of your selection criteria that seem to
work for your program. We're only just starting to use this regularly in
Canada and I could use some practical information.
Thanks
Anne



Date:         Thu, 11 Apr 1996 21:24:30 -0500
Reply-To: "Academic & Scholarly discussion of addiction related topics."
              
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: George Davidson 
Subject:      Re: WHAT I SEE HERE
To: Multiple recipients of list ADDICT-L 
Status: RO

>I have a qquestion for you concerning naltaxone. I'm batting zero with it.
>Two patients so far. first one stopped after two days. No real reason given,
>just didnt like it. the second stopped after a week, told his counselor and
>his doctor that he was experiencing wild mood swings. Have you seen the
>latter in any of your patients?
>Jim.

        I have tried it on a dozen or so, and plan on a lot more in the
near future. A couple of people had very unpleasant side effects, a couple
found no effect whatever, and a few found a miraculous relief from craving,
producing a kind of "no longer hitting the head against a brick wall"
euphoria. I have been astounded by the results, and I think my own
reservations and hesitancy about this drug preclude much a placebo effect.
Bottom line, I am cautiously escited about naltrexone, and plan to use it a
lot more so I can speak with more anecdotal authority! I'll post my results
as they come in.

Heu, modo itera omnia quae mihi nunc nuper narravisti, sed nunc Anglice
George S. Davidson  MB BS FRCPC      gsdavids@niagara.com

=====================================================
Date:         Thu, 11 Apr 1996 21:24:32 -0500
Reply-To: "Academic & Scholarly discussion of addiction related topics."
              
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: George Davidson 
Subject:      Re: Naltrexone
To: Multiple recipients of list ADDICT-L 
Status: RO

>I think the "trick" is to be selective with who gets it.  I am also a firm
>believer that what you say (e.g., how you 'set up' the drug trial) is quite
>important - what you actually tell the client about what to expect; how it
>works; what else they will need to do, etc.
>     Ned
        If you tell me how you decide who to try it on, I'll tell you my
criteria (this may give me time to think what they are). Frankly, I don't
have a feel for this yet, and I'm not likely to get one in a hurry because
the drug is (a) ridiculously expensive, and (b) not on most drug plans or
the government drug plan in my area.

Heu, modo itera omnia quae mihi nunc nuper narravisti, sed nunc Anglice
George S. Davidson  MB BS FRCPC      gsdavids@niagara.com

========================================
Date:         Fri, 12 Apr 1996 00:02:01 -0400
Reply-To: "Academic & Scholarly discussion of addiction related topics."
              
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: Pmh Prison 
Subject:      Re: WHAT I SEE HERE
To: Multiple recipients of list ADDICT-L 
Status: RO

In a message dated 96-04-11 10:31:45 EDT, Maia asks:

>Hi Ned...
>
>If what you say to the client and how you set up the use of naltrexone is
>so important, then why not just use placebo?
>
>At least you know placebo won't have the negative side effects that can
>hapen with naltrexone, even if you don't inform your pts that they are
>possible.

Maia -

This is unkind.

Ned makes the point that good medicine, and good treatment, need to be
tempered with respect for the patient and the patient's needs, fears,
concerns and hopes.

Naltrexone has been touted as the magic bullet, the perfect pill that will
"cure your ills" - money back guarantee.  Giving the patient information
about the drug and settting the frame of mind to give the prescription the
best possible chance -- meaning the patient will take it and take it
according to directions -- seems better than saying "Here.  Take this.  Call
me if it does not work", especially if there is some question of how the
patient will know the medcine is working.

I thought you were for better, more humane, and more understanding treatment.
 Did I miss something?

Paul

=================================================
Date:         Fri, 12 Apr 1996 07:09:54 -0400
Reply-To: "Academic & Scholarly discussion of addiction related topics."
              
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: Frederick Rotgers 
Subject:      Re: Naltrexone
To: Multiple recipients of list ADDICT-L 
In-Reply-To:  George Davidson  "Re: Naltrexone" (Apr 11,
              9:24pm)
Status: RO

George,

        Ned will obviously send along his criteria for using naltrexone with
alcohol dependents, here are mine.

        1. Client has history of failed attempts that seem directly due to
subjective cravings, or reports strong subjective cravings early in an
abstinence-goal program

        2. Client is highly motivated and committed to abstinence, at least for
the near term (next year or two).

        3. Client is active and working well in psychosocial treatment.

        4. No liver disease/ other medical contraindication to naltrexone.

        5. As with antabuse, client is relatively stable otherwise, with
reasonable social and economic supports (i.e. not homeless, unemployed, etc.)

        #1 is not a *necessary* criterion, but the research suggests that these
are the folks most likely to benefit from naltrexone, so I lean toward using it
with them, being pharmacologically conservative.

Fred

Frederick Rotgers, Psy.D.
Center of Alcohol Studies       Voice: 908-445-0941
Rutgers University              FAx: 908-445-5944
PO Box 969                      e-mail: frotgers@rci.rutgers.edu
Piscataway, NJ 08855-0969

In Vino Veritas

===================================================
Date:         Fri, 12 Apr 1996 08:05:48 -0400
Reply-To: "Academic & Scholarly discussion of addiction related topics."
              
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: Maia Szalavitz 
Subject:      Re: WHAT I SEE HERE
To: Multiple recipients of list ADDICT-L 
In-Reply-To:  <960412000200_468000894@mail06> from "Pmh Prison" at Apr 12,
              96 00:02:01 am
Status: RO

Hi Paul...

You missed something.  I was not being unkind, and Ned will get that.  I
was asking a research question-- plus, Ned knows that I have problems
with naltrexone as a treatment because it can create anhedonia and block
natural opiate highs like runner's high.

i feel like people in early recovery need access to these highs, though I
recognize that naltrexone works for some people.

The question of whether or not to inform people about the potential
dysphoric effects of the drug is a sticky one-- it will obviously reduce
compliance if people know, and could create negative placebo effects.
OTOH, the people could feel they are nuts for having the side effects if
they have them and were't warned.  Or they will feel betrayed if they
hear about them in literature or on the street.

So, what do you do?  I say tell the truth and let the pts sort it out!


=================================================

Date:         Fri, 12 Apr 1996 15:42:28 -0400
Reply-To: "Academic & Scholarly discussion of addiction related topics."
              
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: arlene 
Subject:      Re: WHAT I SEE HERE
To: Multiple recipients of list ADDICT-L 
Status: RO

At 12:02 AM 4/12/96 -0400, you wrote:
>In a message dated 96-04-11 10:31:45 EDT, Maia asks:
>
>>Hi Ned...
>>
>>If what you say to the client and how you set up the use of naltrexone is
>>so important, then why not just use placebo?
>>
>>At least you know placebo won't have the negative side effects that can
>>hapen with naltrexone, even if you don't inform your pts that they are
>>possible.
>
>Maia -
>
>This is unkind.
>
>Ned makes the point that good medicine, and good treatment, need to be
>tempered with respect for the patient and the patient's needs, fears,
>concerns and hopes.
>
>Naltrexone has been touted as the magic bullet, the perfect pill that will
>"cure your ills" - money back guarantee.  Giving the patient information
>about the drug and settting the frame of mind to give the prescription the
>best possible chance -- meaning the patient will take it and take it
>according to directions -- seems better than saying "Here.  Take this.  Call
>me if it does not work", especially if there is some question of how the
>patient will know the medcine is working.
>
>I thought you were for better, more humane, and more understanding treatment.
> Did I miss something?
>
>Paul
>
I feel as though if a drug is going to have negative side effects, the
patient should be told.  However, since I'm not an addictions counsellor, I
could be wrong on this.
But, oh, do I have stories to tell about doctors giving pills and insisting
that the patient use them no matter what.  Sorry if it does not pertain to
this thread.

arlene.

===========================================
Date:         Fri, 12 Apr 1996 19:16:29 EDT
Reply-To: "Academic & Scholarly discussion of addiction related topics."
              
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: "David F. Duncan" 
Subject:      Re: WHAT I SEE HERE
Comments: To: addict-l@KENTVM.KENT.EDU
To: Multiple recipients of list ADDICT-L 
Status: RO

Arlene,
    Failure to inform a patient that a drug has a side effect is a crime
if the patient is a subject in a research study, otherwise it is only
malpractice.  If the side effect is fatal and the patient dies, then it
could be the crime of negligent manslaughter.  In any and all cases it is
unethical and unjustifiable no matter why a clinician might consider doing
it.

=============================================
Date:         Fri, 12 Apr 1996 19:50:16 -0400
Reply-To: "Academic & Scholarly discussion of addiction related topics."
              
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: "Gwen Olitsky, MS" 
Subject:      Re: WHAT I SEE HERE
To: Multiple recipients of list ADDICT-L 
Status: RO

Arlene,

In a research study...and I'm familiar with the CSAT and CSAP programs..
there is an extensive "human protections" section, where researchers must
outline all methods of protecting the patients or clients.  If the study
looks good enough to fund, but the "human" piece isn't up to snuff, there
are demands for correction, and no funding until they are in place.  There
should also be a description of *how* the human subjects will be
informed...that must be "okay" too.

Not that this means everyone will get what is promised in the grant application!

As a reviewer, I know that we spend a great amount of time on "protecting"
human subjects.... at least in the committees I'm familiar with.

Gwen

>Arlene,
>    Failure to inform a patient that a drug has a side effect is a crime
>if the patient is a subject in a research study, otherwise it is only
>malpractice.  If the side effect is fatal and the patient dies, then it
>could be the crime of negligent manslaughter.  In any and all cases it is
>unethical and unjustifiable no matter why a clinician might consider doing
>it.
>
>
>Gwen Olitsky, MS
>The Self-Help Institute for Training and Therapy
>Philadelphia, PA

=========================================
Date:         Fri, 12 Apr 1996 22:59:07 -0600
Reply-To: "Academic & Scholarly discussion of addiction related topics."
              
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: Ned Rubin 
Subject:      Re: WHAT I SEE HERE
To: Multiple recipients of list ADDICT-L 
Status: RO

In message Thu, 11 Apr 1996 10:27:46 -0400,
  Maia Szalavitz   writes:

> Hi Ned...
>
> If what you say to the client and how you set up the use of naltrexone is
> so important, then why not just use placebo?
>
> At least you know placebo won't have the negative side effects that can
> hapen with naltrexone, even if you don't inform your pts that they are
> possible.

Maia,

Because I think that ReVia works...that is not to say that the placebo
effect isn't there, but I suspect (not a lot of data to support this yet)
that ReVia plus placebo gets better results than placebo alone.

I also agree with what you posted earlier...the person considering taking
the medication needs to be given all of the facts (e.g., side effects, etc)
and then make up their own mind about what they want to do.  For any one
person, only they can determine if the gain outweighs the cost.

I agree with Arlene, also, that to NOT inform about all the effects is
malpractice, which is why, as you already know, CSAT and CSAP (as Gwen
mentioned) take sooo much time with truly informed consent.

BTW, not just national or Federal research.  The research I am conducting at
SSMC is locally funded through the medical center itself, and has the same
stringent informed consent procedure as is required for a huge, Federal
grant.


     Ned


Edward M. Rubin, Psy.D.
Sinai Samaritan Medical Center
2000 W. Kilbourn Avenue                    voice: (414) 937-5070
PO Box 342                                   fax: (414) 937-5422
Milwaukee, WI  53201-0342                  email: erubin@facstaff.wisc.edu

===============================================
Date:         Fri, 12 Apr 1996 23:02:10 -0600
Reply-To: "Academic & Scholarly discussion of addiction related topics."
              
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: Ned Rubin 
Subject:      Naltrexone
To: Multiple recipients of list ADDICT-L 
Status: U

Hi all,

One of the groups that I present in our Intermediate Care Program is
educational in nature.  I have developed a menu of possible topics from
which the clients can choose, if they attend that group.  One of the groups
of topics that are included is medications that can impact on addiction.
This includes Naltrexone.

First, there needs to be some interest expressed by a patient(s) in the
particular group in which this was discussed.  During this group, ReVia is
explained, and a bit of the theory of how it may work.  It is also explained
in the total context of treatment, and as only one possible adjunct (so that
clients do not "place all their eggs in one basket," and look for the
medication to take care of everything for them.

In addition to the interest expressed in the group, and then subsequently in
individual meetings with the psychiatrist who will prescribe, the individual
needs to have talked about struggles with cravings, urges and slips.  Not
everyone has the same experience with these various phenomena.

Finally, we try to assess the client's motivation to engage in using this
medication.  ReVia seems to be most effective in motivated clients.
Actually, Fred has recently posted some of the apparent general criteria for
successful use of ReVia.

We have used ReVia judiciously, but going through this process seems to have
had a positive impact on our, and our clients, particular experience with
it.  I think you can see how the steps we use add to the positive valence of
the medication, and impacts the client's expectations of just how it will
work (e.g., in the context of the total treatment; what effects they can
anticipate; what it can and cannot do, etc.)

Hope this helps a bit...what I have described is not any sort of formal
assessment process, but one that tends to emerge as a joint function of
client interest, and staff meetings where the suggestion might also be
raised by staff.


     Ned


Edward M. Rubin, Psy.D.
Sinai Samaritan Medical Center
2000 W. Kilbourn Avenue                    voice: (414) 937-5070
PO Box 342                                   fax: (414) 937-5422
Milwaukee, WI  53201-0342                  email: erubin@facstaff.wisc.edu

==========================================
Date:         Sat, 13 Apr 1996 00:33:00 EDT
Reply-To: "Academic & Scholarly discussion of addiction related topics."
              
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: Lucy Letton 
Subject:      Re: Naltrexone
To: Multiple recipients of list ADDICT-L 
Status: RO

This is odd.  The clients we most often use naltraxone with are:

*    chronic relapsers and/or
*    desire to stop drinking --  (good motivation) and
*    prone to impulsivity and/or
*    co-morbid bipolars

We've had a fair number who cannot tolerate the side effects, though, and
frankly, I think a good antidepressant works as well accomplishing the same
feat.

Lucy

=============================================
Date:         Sat, 13 Apr 1996 07:23:36 -0400
Reply-To: "Academic & Scholarly discussion of addiction related topics."
              
Sender: "Academic & Scholarly discussion of addiction related topics."
              
From: Frederick Rotgers 
Subject:      Re: Naltrexone
To: Multiple recipients of list ADDICT-L 
In-Reply-To:  Lucy Letton  "Re: Naltrexone" (Apr 13, 12:33am)

Lucy,

        Obviously, ability to tolerate side effects is an important part of any
medication regimen for a particular individual. Unfortunately, that can't be
assessed without trying the meds. Even well-done informed consent about side
effects doesn't always prepare particular individuals for how the drug will
feel to them. And some people have difficulty tolerating any side effects at
all--even minimal ones that will go away in a few days. So, as we've discussed
many times here--meds are not yet a universal magic bullet, and IMHO, never
will be.

Fred

Frederick Rotgers, Psy.D.
Center of Alcohol Studies       Voice: 908-445-0941
Rutgers University              FAx: 908-445-5944
PO Box 969                      e-mail: frotgers@rci.rutgers.edu
Piscataway, NJ 08855-0969

In Vino Veritas

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