The Medical Journal of Australia recently published a paper entitled, Unplanned admissions to two Sydney public hospitals after naltrexone implants. The conclusion relating to the use of implants in blocking opioid receptors thus the effect of opiates such as heroin, in treating addiction, was straight forward:

An editorial critical of the TGA's failure to monitor the outcome of what is essentially exploitation of the Special Access Scheme was published in the same issue. The scheme is designed to allow access to medication not otherwise available for terminally ill patients. The medication must have a proven unique ability to manage the symptoms in question. This is not the case for naltrexone implants which are being used in unregulated settings as an alternative to other - proven - treatments for opiate addiction. Indeed, it is this legal loophole via the TGA that acts as a deterrent for naltrexone proponents to report adverse reactions. From ABC's The Health Report April 21st, 2008:

A co-authour of the editorial commented. "It is concerning that the recent research on naltrexone implants in Australia has not followed usual scientific processes," Associate Professor Robert Ali, Director of the Drug and Alcohol Services Council in Adelaide, said.

Reminiscent of Gibson, Degenhart and Hall's paper Opioid overdose deaths can occur in patients with naltrexone implants [MJA, 2007; 186: 152-153], this latest data caused similar responses and academic discussion over methodology. The responses to Gibson et al are interesting and indicate how difficult an area to clarify this is. Simply put, how does one die and what role - if any - does naltrexone play? I'd point out the following;

• If someone died "from" the implant it would require a scenario in which reasons for IC admission went untreated: renal failure, dehydration, metabolic acidosis.If someone dies from opiate toxicity due to a faulty implant, it heralds poor technology and monitoring. Eg; it's a two month wait for blood level test results in Perth, poor technique: insertion may be incomplete [not all tablets successfully inserted].

• If someone dies from opiate toxicity after cessation of treatment, then it raises questions about the treatment in total, and suggests poor follow up or ineffective counseling. Reasons for using are not addressed in full by blocking cravings.

• If someone dies from opiate toxicity with an active implant, and toxicology reveals other CNS depressants, it may go unrecorded as poly-drug toxicity can be argued as COD.

• Finally, if someone dies of obvious opiate toxicity, in circumstances familiar to emergency services, there is no reason to then confirm if an implant is active, faulty or inserted in the first place. The COD would be opiate toxicity and variables related to the implant not recorded.

Hence, anecdotally there is some confusion regarding "deaths from naltrexone treatment", as it is often noted.

However this paper did not deal with deaths - only admissions. And symptoms were quite severe, including metabolic acidosis, renal failure, dehydration, prolonged and profound withdrawal symptoms, vomiting, diarrhoea, confusion, delirium etc with some requiring Intensive Care. We can see from above we're talking about the failings of the implant, hygiene, monitoring and perhaps poor methodology in calculating naltrexone dose. It's done via Body Mass Index. Yet it may well be ambitious to think body size equates strictly to neurophysiology and genetic predisposition to neuropharmacodynamics - how drugs effect the individuals brain.

Nonetheless as with all things involving naltrexone, the opportunity to observe abstinence proponents defend an ideology, in the face of evidence, presents itself. Close, chronological examination of one vocal proponent, in light of ongoing problems and previous fatalities is cause for concern. Dr. Albert Stuart Reece has been the focus of attention in the humble Firesnake Holeplex before. On this occasion another response to the denial of evidence relating to naltrexone implants. He offers no evidence - just promises. In looking for reasons why Reece may ignore contrary evidence one finds the theme of fundamental conservative morality. It's as if Reece wants to excise "immoral" Harm Minimisation and implant morality...

In this episode, Firesnake looks at the rebuttal from Drug Free Australia to the MJA findings. Australia could be the biggest loser. You can read the response here. There's an extensive reply at the Drug Free Australia Watch blog. Citing "important contemporary evidence" and quoting Dr. George O'Neil and Dr. Stuart Reece in support of the W.A. implant trials, we are promised upcoming positive data in "the world's leading medical journals". It has actually been submitted for review and it remains to be seen as "a truly significant achievement", as Dr. Reece claims.

In fact Reece has promised these "radically superb", "brilliant" implants are the "best in the world" and "statistically powerful results" will follow. However, he said that 15 months ago in his submission to the Inquiry on the Limits of Harm Minimisation. "The outcomes of this trial are already very obvious. They will be brilliant, and in addiction medicine, as radically superb as the HPV vaccine has proven in infectious disease control in that discipline", he said in his Parliamentary Submission. Methadone itself came in for particularly vicious and unfounded criticism. Whilst Reece is prone to claim the presence of drugs other than opiates causes overdoses in naltrexone patients - when the implant fails - he's also prone to claim the opposite applies to methadone. He reasoned that 78 methadone related deaths were really 851 because the presence of other drugs meant "the figure should be clarified". [Page 5]. Or rather, dismissed.

"Therefore the problem is not one of evidence or safety assurances - those determinations have already been made by the many reputable and highly skilled clinicians who have used the devices, invariably with superb results". [Pages. 14-15]  How is progress going? Well, despite DFA's claims, Norman Swan noted on April 21st, 2008;

Firesnake has taken interest in the moral conservatism of the religious right and it's propensity toward abstinence. It's argued that fundamental religious beliefs can have an adverse effect in the public health domain in the quest to enforce morality over evidence. It's further argued the global involvement of certain naltrexone proponents in anti HM propaganda is well demonstrated and this conflict of interest makes for poor integrity and objectivity from DFA and their "fellows". Drug Free Australia don't so much present evidence on Harm Prevention successes, as present attacks on Harm Minimisation as the self evident cause of our drug problem. Attacking the signifiers of Harm Minimisation as malignant is done over and again, rather than promote the socially unpopular strict conservative moralism, that is the assumed alternative. We follow the loyal devotion to abstinence of Dr. Stuart Reece from 1990 quotes beloved by the International Abstinence Association on the moral decline of society [bold mine];

Enduring the "hedonistic delirium" of modern democracies, Reece threatened the QLD government, claiming they'd "have blood on their hands" if he couldn't prescribe naltrexone - September, 1999. He got his way. By the last week of May 2001, 25 patients were dead and the QLD medical tribunal launched an inquiry into "gross negligence", also noting his breaching guidelines regarding pregnancy.

From ABC The 7:30 Report - 4 June 2001:

ANNE REYNOLDS: He was very, very passionate. He was very enthusiastic about his program. He was very adamant that it was The best thing available, nothing else was as good as Naltrexone.
SIMON ROYAL: Anne claims Naltrexone treatment left her son with chronic depression and a new addiction to antidepressants.

Six hundred days after his course of Naltrexone tablets, Paul Reynolds took heroin again.
It killed him. Anne is flying back to London after interring her son's ashes.

ANNE REYNOLDS: He's doing it without the right - enough support.
He's sending them back into the world with just the families to care for them without the rehabilitation process in place. He seems to think that he has all the answers and he doesn't. He's one man. [Source].

He was defended by Dr. David Hunt who, claimed the death rate was similar to methadone. But a 2005 study at NDARC noted over 2000 - 2003 naltrexone had a death rate associated with it, four times that of methadone [Page 49]. Hunt, along with Reece and O'Neil, appears in a thank-you list in the anti methadone, pro naltrexone, pro "bible classes" Trophy of Grace. Written by Bronwyn Healy who now holds a place on Youth for a Drug Free Australia.

Total Mortality per 1000 Episodes, 2000 - 2003 [Source]:
Methadone: 102,615 treated. 282 related deaths. Total Mortality = 2.7
Naltrexone: 3,169 treated. 32 related deaths. Total Mortality = 10.1

Two years later the Inquiry was indefinitely adjourned, Reece had hurt feelings and claimed "vindication" from a "conspiracy between drug addicts and The Courier Mail". Three months later on September 14 2003, he was on Sunday Nights with the ABC, claiming Dr. God was the one in control and that "faith cures addiction". Remember, it's not what one believes we're noting. It's what one does with it.

In Februrary 2007 Dr. Reece introduced himself to the Inquiry into the impact of illict drug use on families. He glossed over his tragic past with naltrexone;

At least 25 dead and 1,800 rapid detoxes - each taking days and requiring intensive medical support - in eight years. And he "knows the science"? Asked about naltrexone fatalities;

On August 7th 2007 Reece wrote to the Commissioner of Health in New Jersey, USA, lobbying against needle exchange programmes and also painted his experience with naltrexone as authoritative and positive. He also again attacked Wodak;

We also note the support of certain overlapping elements of the religious right in Australia. Firesnake looks closely at this approach toward addiction "treatment" and asks just where the morality lies. How is it "morally correct" as some supporters claim, to place ones superstitions ahead of another's health in making clinical choices?

It seems plain that ideology is what defines policy and procedure for certain practitioners. At some point we must ask ourselves which dynamic is really dominating here? The health of the individual or the cosmic duty of the practioner to expunge the aforementioned off-shoots of progressive societies "hedonistic delirium"? And ensure society finds "the way back" as the way forward solution to modern day problems? I must submit dear reader, that the latter is plainly demonstrated. When the gains of democratic society are so insouciantly insulted, we may conclude the signifiers of Harm Minimisation must terrify the morally conservative and appear as invitations to debauchery.

More so, it is also plain identities associated objectively with Harm Minimisation, are justly discredited in spectacular evidence vacuums, by dent of their professional leanings. Naltrexone is the emergency adjunct to faith based education and general "just say no" abstinence, employed when they fail. Evidence to the contrary is simply ignored as is the option of respecting the best of both approaches.

The conflict of interest here is clear. Faith and superstitious belief cannot be allowed to intercede in the treatment of vulnerable at risk community members. When we consider also what certain proponent will gain from "success" and lose from failure, we must remain highly skeptical. The last word should go to Professor John Saunders who said in 2001 referring to the Reece deaths;

The first tragedy is that now a large number of young people have reportedly died having had treatment with Naltrexone.
The other tragedy is that the adverse publicity that Naltrexone has received recently will prevent there being a proper research and development program into Naltrexone treatment, including Naltrexone implants. I have a real concern that a useful, the availability of a useful form of treatment, will actually be compromised by all the drama which is occurring at the moment.

All articles mentioned in the episode are here.

Music thanks to Garageband.

Gags.
1 hour. 3 min.
25 MB.