Stemming disability and deaths from opioid use disorder is a major public health challenge, and medication has become the treatment of choice to help people with addiction. The study reported in this CNN story compares two available drugs—buprenorphine/naloxone (Suboxone) and naltrexone (Vivitrol)—that can blunt or block cravings and reduce illicit opioid use.
The clinical study found that people with opioid use disorder were far more likely to begin taking one (Suboxone) than the other (Vivitrol), principally because Vivitrol requires patients to have first gone through detoxification. That’s an important difference, the article notes, as effectiveness is more likely if a physician can choose a drug that fits her patient’s circumstances. The story does a nice job of making this point, although it gives less attention to another sobering pattern unearthed by the study: Among the subjects who started the drugs, fewer than half were still taking them six months later. Also, more needed to be said about the potential harms of the medications–both carry risks–as well as their general availability and cost.
We wanted to point out two things with the story that don’t fall within the realm of our review criteria:
We know that opioid agonist treatments (Suboxone and methadone) are the current gold standard for treatment of opioid use disorder. However, riding on a wave of marketing and lobbying, injectable Vivitrol has become a commonly prescribed medication for this disorder. Vivitrol does not induce physical dependence, as does methadone or Suboxone, so it is attractive to people and policymakers who dislike the notion of medications that are difficult to stop taking. This study is the first to address whether Vivitrol is as effective as Suboxone in a head-to-head randomized trial. Having a third medication that acts via a different mechanism than the other two would be an important addition to the arsenal.
For readers coping with opioid use disorder in their lives, this story will help them understand important differences between the two drugs, at least in terms of starting treatment.
Cost does not make an appearance. This is a problem for a comparative story, as the prices for these two drugs seem quite different, with Vivitrol looking by far the more expensive.
The story describes duration of staying on the treatments and rates of relapse, reporting that the rates are roughly equal. The story is also clear that that those randomized to Vivitrol did not do nearly as well as those randomized to Suboxone–because over a quarter did not tolerate or receive the first dose of Vivitrol. If a person is hardy enough to tolerate detoxing in preparation for Vivitrol, then their likelihood of abstaining from opioids may be similar to those getting Suboxone (a little less than half of all people in the trial were still taking the drugs after six months).
Both Vivitrol and Suboxone have side effects that are not compared—or even mentioned—in this story.
The story offers some methodological detail about the clinical study, although we cannot tell if individuals were randomly assigned to conditions (they were), if the study was blinded (it was not). Also readers should have been informed of the major limitations of the study.
One interesting thing to note: The study did not look at how many of the subjects used the very potent drug fentanyl, which is involved in over half of overdose fatalities currently.
CDC death estimates from opioid overdose in the United States are included, and the story did not disease monger the problem.
Although the sources are clearly identified, funding information is missing in action, as are any references to possible conflicts of interest. For example, lead author Dr. Joshua Lee has accepted grant money from Alkermes, the manufacturer of Vivitrol. This should have been disclosed.
The story compares two treatment drugs, as well as methadone. That’s sufficient, although non-medication-assisted alternatives were not discussed.
All three drugs mentioned in the story are available, though more could have been said about how accessible they are to people who are trying to overcome addiction.
The lead touts the study as “the first large head-to-head comparison of two opioid treatment drugs.”