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Drugs not prescribed

November 20, 2006 | A version of this story appeared in Volume 84, Issue 47

Thank you for the detailed report on the development of pharmaceuticals as aids to the treatment of alcohol and drug dependence (C&EN, Sept. 25, page 21). There is much activity in this area, but as noted in the article, little by the major pharmaceutical manufacturers. There is a reason for this.

When DuPont first brought out naltrexone (ReVia), the company spent millions of dollars for two years and could not sell the drug. The potential market is huge if you consider 5% of the U.S. population could potentially use naltrexone to treat alcohol or opioid dependence, but the actual market is tiny because the vast majority of those who provide alcohol and substance abuse counseling cannot prescribe drugs and would not prescribe them even if they could. Most treatment is delivered by counselors with at most a master's degree level of training; thus, they cannot prescribe. Many counselors are themselves in recovery or trained with other counselors who were in recovery, and the treatment model is abstinence-only.

I maintain, however, that if a client goes through a treatment program and within six months is back in trouble again with alcohol, drugs, or both, then it would be unethical to apply the same treatment. Naltrexone or one of the other available drugs should be added to the next round of treatment.

An analogy is to otitis media (ear infection). The standard treatment is to prescribe amoxicillin three times a day for 10 days, then have the patient come back in two weeks. If a month later, the infection and the pain are back, you would not treat with amoxicillin again, but you could treat with Augmentin-amoxicillin combined with clavulanic acid to prevent bacterial breakdown of amoxicillin. Naltrexone would serve the same adjunct purpose to help prevent the breakdown of response to counseling for alcoholism.

Then there is the issue that physicians will not screen for alcohol and drug abuse. Primary care physicians deal with alcohol and drug problems in many of their patients with a "don't ask, don't tell" approach. Even when alcohol abuse is blatant, a physician often makes no note on a patient's chart because of the pejorative and future insurability effects such a notation can have on the patient.

The failure to develop a market has resulted in the loss of several promising drugs. One drug that I worked with in animal models for both alcohol and cocaine abuse was amperozide. This drug had gone through the one truly valid clinical trial-drug addicts in Sweden will steal this drug from pig farmers in order to get clean. Unfortunately, the veterinary use by pig farmers in Sweden will be its only approved use.

Unless there is a major change in the treatment paradigm that will be accepted by the substance abuse treatment community, and unless physicians will use screening tools and make effective referrals, it will remain difficult to develop and market a new drug for this area. The barriers to using these new drugs and vaccines as adjuncts to therapy have to be removed before any of them will become financially viable.

Brian A. McMillen
Greenville, N.C.


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