I got exposed to the field of addictive disorders rather accidentally.  I have to admit I knew little about addictions, especially growing up in India. Yes, we saw people getting drunk at parties, drunks getting into brawls on the streets and people smoking opium and marijuana (called by chaaras). Several family members died of alcoholism and their families suffered greatly and we accepted this as ‘part of life’.

I emigrated to the US in 1977 and started working as a pharmaceutical sales representative for a relatively small company that had developed a number of highly effective opium-based medications. Opioid medications like oxycodone, hydrocodone, oxymorphone, nalbuphine and naloxone.  Every one of these medications is still in clinical use and remains the standard of care.

In the 1970s and 80’s scientists were beginning to understand the complex neurochemical relationship between neurotransmitters like endorphins and the opiate receptors. The drug that most fascinated me was naloxone, better known by the brand name NARCAN. Narcan was the first pure antagonist that reversed the effects of opioid drugs like heroin and saved lives. Physicians were astonished to find a drug that was so safe and acted so rapidly in reversing the respiratory depression cause by heroin and thus saving lives. Narcan has been a life-saver and many cities are giving out syringes of naloxone to heroin addicts as a way to save drug addicts from overdosing and dying. More about Narcan in my subsequent commentaries.

In 1984, DuPont Pharmaceuticals introduced naltrexone as the first non-narcotic drug designed to prevent detoxed heroin addicts from relapsing when they returned home to their ‘natural’ environment of previous drug use. Naltrexone is in the same class as naloxone, but is longer acting. Naltrexone was marketed as TREXAN. As a pharmacist with a strong understanding of pharmacology, I was most enthused about this medication that finally offered an alternative to methadone which was in use for over ten years as the only treatment for heroin addiction.  We naively felt confident that the medical and treatment community would whole-heartedly welcome a dramatically different medication. Boy was I wrong! The indifference and hostility towards naltrexone stopped us in our tracks. Naltrexone was quickly pigeon-holed as a drug appropriate only for motivated patients like physicians, pharmacists, and business executives – people who had something to lose. We could not make any progress in marketing Trexan and within a few years gave up all efforts to market the drug.

Yet, naltrexone remained as a molecule of great interest for researchers and they started experimenting using this medication for all sorts of problems ranging from binge eating to schizophrenia. Researchers at the University of Pennsylvania and Yale found naltrexone to be effective in treating alcoholism and based on these NIH-funded studies, the FDA in 1994 approved naltrexone as a treatment for alcoholism. Naltrexone was marketed for the alcoholism indication under the brand name REVIA.

My dormant enthusiasm revived and we felt very confident that the first medication in over fifty years to treatment alcoholism would be widely accepted and used by the medical community. To our utter surprise and chagrin, the indifference and hostility was front and center, based on the belief that alcoholism should not be treated with medications. There was little or no interest in learning about the pharmacology of this medication and not even the intellectual curiosity to try it in patients who have repeatedly relapsed to alcohol use. Used correctly, naltrexone worked very well, but few were willing to try it. The reason most often cited was poor compliance on the part of the patient and this was a legitimate issue.

After spending millions of dollars to market ReVia, DuPont Pharmaceuticals pulled the plug on marketing it.

Rarely, have I felt such a passion for a drug that can, when used correctly have such a melodramatic effect on patients devastated by alcohol and opioid drugs.  In the year 2000 I took voluntary retirement and made it my mission to introduce evidence-based treatment for alcoholism and drug addiction which has remained marginalized and stigmatized to this day. It has not been easy, but after twelve years I feel a sense of fruition, especially in the St Louis area that we are indeed changing lives. My treatment center is called the Assisted Recovery Centers of America and is based in St Louis. We have an associated clinic in Durban, South Africa and the plans are to open centers in more geographic locations.

My goal is to elevate the debate on the treatment of addictive diseases. We are caught up in the very acrimonious debate on the wisdom of the War on Drugs and on drug legalization; the near-epidemic use of prescription pain medications, and the surge in heroin use. I am shocked at the societal indifference towards this problem and the solutions often are likely to do more harm than good. In a nutshell – the politics of drug and alcohol treatment is worse than the disease.

My plan is to write a weekly commentary/essay and invite a healthy and hopefully civil debate on issues related to our field. I may invite others as guest commentators and post reprints of articles that may be helpful to our field.

By way of disclosure, I have consulted with several pharmaceutical companies in the past and presently speak and consult with Alkermes, Inc., the company that markets VIVITROL, the monthly injection of naltrexone for the treatment of alcoholism and opioid addiction.

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