Naloxone for Chronic Pain

My trusty Google search bot fleet turned up this recent article highlighting a recent piece on NPR (radio) that I had not heard or heard tell of as we say in the South since I work and cannot listen to it as much as I would wish. It concerned a trend in utilizing naloxone in treating chronic pain.

This is somewhat significant as naloxone is about as far away from using opioids to treat pain as you can get. Naloxone is used to treat addictions and simply cannot be viewed at all in the same pejorative light as opioids.

Naloxone, without boring the reader with a brainy, academic, overly pharmacologic explanation of the in’s and out’s of this area of “medication-assisted treatment” (MAT in the new parlance of addictionology), is a blocker of effects of opioids and helps to blunt the effects by which opioids and even alcohol induce and sustain addiction. It is both a generic (not a brand name, i.e., not expensive) drug and a brand name form drug, Vivitrol (super expensive and highly promoted by its parent manufacturer.

Naloxone has been around for decades. It has a well-established place in the pantheon of tools to treat addictions, along with, of course, the cognitive therapies and my sentimental favorite the 12 Step programs that I view as all-important in the journey of anyone in recovery.

As an aside, I will never forget my first patient with alcohol addiction as a naive, dumb, unschooled psychiatry resident over 45 years ago at Duke. He was not my then biased stereotype of a problem drinker, someone who had lost almost everything, came into the hospital inpatient service in alcohol withdrawal, etc. On the contrary, he was a professional, respected in his circles, accomplished, educated and showing almost none of the physical issues or stigmata of the ravages of alcoholism. He had relapsed. His treating Duke psychiatrist, my instructing attending was wise enough to ask this man to educate me about his disease. And this was in the days when moral opprobrium still reigned supreme toward alcoholism and addictions. the concept of addiction as a disease was just making headway into the lingua franca of our world then as the new enlightened way to view and approach addictions courtesy of two of then past giants in addictions, the recently late Dr. Herbert Kleber MD then of Columbia University Dept. of Psychiatry and UNC-Chapel Hill School of Medicine’s Dr. John Ewing, a giant in alcoholism research and treatment, founder of the Center for Alcohol Studies.

My patient above told me his ‘story.’ I had the sense to listen to him for as long as he wished to talk. He took me through his life account for well over an hour. I was astonished at how open he was with me about his failings, drinking, failures, and relapses. When I intimated that I would have to digest all that he had told me, he surprised me further. He asked me if I knew about A.A., Alcoholics Anonymous. I answered honestly that I knew very little. I recounted that I remembered my parents taking in geologists and mining engineers from my father’s international mining teams when I was a kid, who had been alcoholics and helping them get back on their feet. I said I only knew that my father had helped them go to AA and that it helped them but that was about the sum total of my knowledge.

My attending’s patient then proceeded to tell me of his years’ involvement with AA and gave me an introduction I would not forget. He helped me to see it as one of the most accepting, supportive organizations ever. I kept thinking to myself while he told me of AA, why weren’t most of our social organizations more like AA? Churches, fraternal orders, etc. I marveled at the trust he felt he was able to place in persons in AA.

However, what blew me away was one of the final points he left me with. He was a traveling professional, who worked in other professional centers somewhat regularly. He told me of how AA saved him from his core internal loneliness and depression that he struggled with. He spoke of his long past pattern of drinking to salve his loneliness in hotels away from home and family in the evenings after he had completed his consultations.

AA helped him to break that many year pattern by going after supper in hotels or restaurants to local AA meetings. He told me that he knew wherever he found himself, there would be an AA fellowship of persons in which he could find acceptance, support and positive booster inoculation against drinking. He described as the western world’s largest support community. I was flabbergasted as I grasped what he was conveying. And I never lost that sense of AA.

Back to naloxone. The article that set off all this in me, “In Tiny Doses, An Addiction Medication Moonlights As A Treatment For Chronic Pain,” from just days ago (Sept. 23, 2019) is well worth the reader’s attention.

One of the issues that might not strike the reader right off is that this long generic, out of patented brand name status, money-making status, has only modest research behind it to explain its now anecdotally reported effectiveness in unrelated pain syndromes. But reports are continuing to surface in some number and frequency that this medication is making perhaps a more and more solid case for more clinical investigation of it in pain control.

But, and it is a BIG but, it has not much potential as a MONEY MAKER. No drug company appears likely to pick it up and develop it as a pain modifying medication. The company marketing Vivitrol is not going to do so as documented in this NPR article.

So this possible more desirable medicine will be left to the backbench of interventions. It is not addictive in and of itself at all, like buprenorphine can be which is also used as an “MAT” medication in the treatment of opioid addiction.

This medication has little support for its use and ‘development.’ By development, I mean good clinical, nationally coordinated research that would establish its “place” in pain control clinical practice.

I think that generic medications such as this with a clearly very valuable social medical potential should be ‘adopted’ by the national research and clinical research arms that be. Monies to support and drive the clinical research that should be devoted to a medication such as this, ought to be easily devoted to its cause. A new mechanism of initiating, driving, funding and sustaining the R&D of such a lowly generic medication ought to exist. I would even propose a policy of supporting monetarily pharmaceutical companies to jointly share somehow monetarily in the sale of a naloxone category of medicine so that the use of naloxone or medicines like it, would not be a marginal effort but part of mainstream medical practice to benefit the huge cohort of pain patients who need an effective non-addicting medication intervention.

Just because a medication would never make BILLIONS for companies as the Oxycontins of this world have done, does not mean it should not be developed in a way that paves the way for its mainstream use and establishes its scientifically based modes of action in the mysterious world of pain.

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