BACKING LITTLE-USED DRUG FOR ADDICTS

When criminals who are addicted to heroin are sent to Gaudenzia Inc.
for rehabilitation, they get a big helping of psychosocial treatment.
But there's no mention of naltrexone, a medication that totally blocks
the effect of opiates such as heroin and OxyContin.

Gaudenzia's approach is typical, and Charles O'Brien, a University of
Pennsylvania psychiatrist who has been studying naltrexone since 1973,
thinks that's a problem. He's so frustrated by the drug's meager usage
20 years after its FDA approval that he's suggesting an unusual way to
get more addicts to try it: make it a provision of their probation or
parole.

"We have a solution that we're not using," said O'Brien, who estimates
that no more than 10 percent of the country's one million heroin
addicts have tried naltrexone.

He organized a symposium at Penn this month to explore the legal and
ethical implications of his idea. To sway more opinions, a transcript
of the meeting will be sent to judges and probation and parole officers.

The practical aspects of requiring criminals to take naltrexone - now
a pill taken at least twice a week - will become less daunting within
the year if, as O'Brien predicts, the FDA approves a new injectable
form that lasts a month.

A six-month pilot study at Penn in which Philadelphia probationers and
parolees on naltrexone repeatedly gave urine samples found that they
tested positive for opiates 8 percent of the time. Addicts receiving
only standard treatment tested positive 30 percent of the time. The
reincarceration rate was 26 percent for the naltrexone group and 56
percent for the others. Fifty-one volunteers participated.

Penn is now doing a larger study of the drug in this population and
plans to switch to the injectable form in September.

Larry Frankel, legislative director of the American Civil Liberties
Union of Pennsylvania, said requiring a drug as a condition of
release, even if people can choose prison instead, is a "fairly scary
precedent."

"We tend to, as a society, say the government cannot force you to take
medication," he said.

But Darrell Stevens, a Superior Court judge in Chico, Calif., has been
requiring people to take the drug since 1996, first in alcohol cases
and more recently in the county's drug court, without any problems. He
tried it, he said, because other measures weren't working. "I kept
seeing the same people coming before me all the time." He now has a
"raft" of letters from offenders thanking him and describing how their
lives have turned around.

In Chico, offenders ordered to take the drug, always with a doctor's
concurrence, must take pills while a doctor or pharmacist watches. All
of the county's pharmacies participate in the program, Stevens said.

Judge Louis J. Presenza, who runs Philadelphia's drug court and is
cooperating with Penn's study, is hopeful about naltrexone, though
most of the people who come before him use cocaine and marijuana. "We
have to try something different," he said. "If naltrexone is
available, then people should have the option to use it."

O'Brien said most criminal justice officials are wary of medications
for addiction. "They tend to take a philosophy which is strongly and
militantly drug-free, which would be great if it worked, but it doesn't."

Studies show that 85 percent of addicts return to drug use within a
year of release from prison, said Douglas Marlowe, director of law and
ethics research at Penn's Treatment Research Institute. Treatment both
in and out of prison reduces by 10 percent to 20 percent the chances
that addicts will use drugs or get arrested again, according to
different studies.

Even though it has proven effective, judges and others in the criminal
justice system dislike methadone, the most widely used drug for opiate
addiction, because it is addictive, O'Brien said.

Naltrexone's big advantage is that it is not addictive or even
pleasurable, he said. O'Brien likened the drug, approved for treatment
of heroin addiction in 1985 and alcoholism in 1995, to a "chemical
chastity belt."

Unfortunately, that's also its biggest drawback. "The problem with
naltrexone is it works too well," Marlowe said. "Clients don't want a
drug that won't let them get high."

Naltrexone has worked for highly motivated addicts such as doctors and
nurses who have a profession to lose, O'Brien said. But others quickly
abandon it when they want to get high.

O'Brien said a longer-acting version of naltrexone will help with the
compliance problem. Alkermes, a Cambridge, Mass., company, plans to
seek FDA approval for the injectable form for alcoholics, but doctors
could then use it off-label for opiates.

Naltrexone does a better job of blocking heroin's effect than
alcohol's, but it seems especially good at blunting cravings and the
euphoria that people with hereditary alcoholism feel when they drink,
O'Brien said. A Penn study of the 30-day version in alcoholics found
it reduced heavy drinking by 25 percent.

There are 14,240 people on parole in New Jersey and 28,000 on
state-supervised parole or probation in Pennsylvania. An additional
213,000 people in Pennsylvania and 86,400 in New Jersey are on county
probation.

Official estimates of the New Jersey and Pennsylvania state prisoners
with drug problems range from 55 percent to 70 percent.

Michael Briscoe, a supervisor in Philadelphia's adult probation
department, said most probation officers are indeed opposed to
methadone treatment. "We see drug-free as the ultimate prize," he said.

But he encouraged staff members to attend the Penn symposium and has
helped Penn researchers find addicts willing to try naltrexone.
"Because it has a therapy component, we're more open to it," he said,
"also because of the fact that addicts don't get high from it. It just
seems like a more viable option to me than methadone."

There is no legal reason not to make naltrexone use a condition of
probation or parole, said Richard Bonnie, director of the University
of Virginia's Institute of Law, Psychiatry and Public Policy. "The
important thing is that offenders have a choice, even if the
alternative is jail."

Presenza said some addicts do, in fact, prefer prison to probation
with lots of conditions.

Barry Savitz, a former Philadelphia assistant health commissioner who
is now a consultant to Philadelphia Health Management Corp., warned
against expecting too much from any drug treatment alone. "If it were
not for the drug abuse," he said, "these would not be model citizens."