Crazy Idea.....but what do you think?

[VentJockey]

I just admitted a patient to my internal medicine service who I have treated many times before. His is the same story, over and over again: he comes in with complicated alcohol withdrawal, we dry him out, and then he leaves the hospital and goes directly to the bar. We keep seeing him over and over. He's been to rehab, 12 steps, etc etc.

I think its time for the nuclear option. Except that we don't really have the nuclear option. Already I know I'm going to send him out on Disulfiram. I'll make sure he takes it before he leaves the hospital...but after that, he's going to stop taking it.

So why am I posting a thread about alcoholism on a pain forum? Because you guys have experience with drug delivery systems/pumps. Systems like Synchromed, and I'm sure there are plenty of others. I have a bright idea that may be totally crazy, but I want to see if perhaps someone out there thinks its possible:

1) Get a compounding pharmacy to compound up some disulfiram to some form that it is acceptable to the pump. Should be pretty easy to accomplish this part.

2) Get a surgeon or one of you guys to implant this pump for an off-label use in the patient, full of Disulfiram.

3) Get the patient to sign over his disability check to a rep payee, such that he gets no cash unless he shows up to get the pump refilled.

I'm not crazy, I don't think I'm actually going to get this to happen for this patient during this admission. But I see guys like him all the time. There is no salvation for them. They have failed all the "help" that they can get, and they have no meaningful life left.

So, you guys who use these pumps every day: is this technically feasible? Is it worth hunting down the pain management guys at my shop and talking to them about the possibility? Where could I learn more about how these pumps work? Any suggestions for how I may pursue this idea in an academic way? Or is it just totally out there and begging for a lawsuit?

---

Members don't see this ad.

 

[lobelsteve]

I just admitted a patient to my internal medicine service who I have treated many times before. His is the same story, over and over again: he comes in with complicated alcohol withdrawal, we dry him out, and then he leaves the hospital and goes directly to the bar. We keep seeing him over and over. He's been to rehab, 12 steps, etc etc.

I think its time for the nuclear option. Except that we don't really have the nuclear option. Already I know I'm going to send him out on Disulfiram. I'll make sure he takes it before he leaves the hospital...but after that, he's going to stop taking it.

So why am I posting a thread about alcoholism on a pain forum? Because you guys have experience with drug delivery systems/pumps. Systems like Synchromed, and I'm sure there are plenty of others. I have a bright idea that may be totally crazy, but I want to see if perhaps someone out there thinks its possible:

1) Get a compounding pharmacy to compound up some disulfiram to some form that it is acceptable to the pump. Should be pretty easy to accomplish this part.

2) Get a surgeon or one of you guys to implant this pump for an off-label use in the patient, full of Disulfiram.

3) Get the patient to sign over his disability check to a rep payee, such that he gets no cash unless he shows up to get the pump refilled.

I'm not crazy, I don't think I'm actually going to get this to happen for this patient during this admission. But I see guys like him all the time. There is no salvation for them. They have failed all the "help" that they can get, and they have no meaningful life left.

So, you guys who use these pumps every day: is this technically feasible? Is it worth hunting down the pain management guys at my shop and talking to them about the possibility? Where could I learn more about how these pumps work? Any suggestions for how I may pursue this idea in an academic way? Or is it just totally out there and begging for a lawsuit?

Informed consent might be a problem. Just shoot and kill him.

 

[deleted185747]

Yes, you would have to do the informed consent when he is not intoxicated and when he is not at your mercy.

Try once a month vivitol/naltrexone to try to decrease his cravings. Also give him baclofen as this helps to decrease cravings.

Your pump idea is crazy but I like it. Why not just put alcohol in the pump?

 

[VentJockey]

Thanks for the input. You are right that informed consent for something like this has to be extremely thorough. If I were to actually try to pull it off it would take a year to get all the proper procedures through the ethics committee, I think. But, am I to infer from these responses that the technical part, with these implantable drug delivery devices, is in fact feasible? Like we could take one of these pumps and instead of putting the catheter intrathecally, that we could deliver the drug to the peritoneum, and that we could possibly fit enough of the drug into the pump?

 

[ampaphb]

I think you might be missing the consent issue. It seems unlikely that an addict would ever agree to having a pump containing a reversing agent implanted.

 

[101N]

Why not something more orthodox like depo naltrexone?

 

[jettavr6]

I think you might be missing the consent issue. It seems unlikely that an addict would ever agree to having a pump containing a reversing agent implanted.

You'd be surprised. Many of these patients want to be done with alcohol/drugs, etc., but have too difficult a time doing it. Some of them would consent to extreme and unorthodox remedies to help keep them away from their habits. A good and thorough psych eval would be worth getting as part of the consent process.

I don't think that an intrathecal or intraperitoneal device is necessary. Titan pharmacetuicals is trying to get Probuphine (buprenorphine) subdermal implanted device approved by the FDA. They are facing some hurdles, but I think that eventually they will be approved. Antabuse can be delivered in a similar way.

 

[joshmir]

There are apparently some methadone clinics which mix in antabuse into the methadone, and it is frowned upon by others in the harm reduction/addictionology realm

I have also heard that sometimes antabuse is not completely effective even on the day its taken; ie it possible to get sick but not so sick that drinking alcohol is inconcievable; so they get drunk but just feel really bad, and thats not enough of a deterrent; ie it doesn't always make you violently ill; not sure if this is true

I would look into whether there are halfway houses which require drunks to take a daily witnessed dose of antabuse in return for food and shelter and how that works

 

[floam]

I have a family member that probably would have accepted an "Antabuse pump", they were so desperate. Turns out though that they could drink on disulfiram 250mg/day just fine, it was learned through a relapse. Just got a little red-faced. Naltrexone + gabapentin/lyrica ended up working for them.

 

[callmeanesthesia]

I have my own built in genetic Antabuse - acetaldehyde dehydrogenase deficiency. Maybe there’s a gene therapy out there to splice in the mutant gene in place of a functional copy.

 

[Orin]

In theory, intrathecal baclofen would treat this but yes, you technically can deliver anything anywhere with a Synchromed/Prometra. Look at 5-FU for metastatic cancer to the liver!

The drug compounding part would be another separate issue.

This is a bad idea though as the devices are a lot of work. Just go with DBS

 

[painfree23]

where do you get these patients to fill naltrexone? also how do you dose them PO?

 

[floam]

where do you get these patients to fill naltrexone? also how do you dose them PO?

Can be filled wherever they'd normally pick up their meds, grocery store or whatever. 50mg qd

 

[painfree23]

Can be filled wherever they'd normally pick up their meds, grocery store or whatever. 50mg qd

I tried a few times and got pushback from their insurance company, another time from their pharmacy. Any ideas on cash prices? Most cvs will have it ?

 

[iwumd07]

I tried a few times and got pushback from their insurance company, another time from their pharmacy. Any ideas on cash prices? Most cvs will have it ?

It’s usually between $22-30 for a month supply without insurance using GoodRx.

 

[Orin]

I tried a few times and got pushback from their insurance company, another time from their pharmacy. Any ideas on cash prices? Most cvs will have it ?

To be precise, this is the naltrexone pill and not the compounded low dose stuff.
50 mg cuttable tablet
There's also a liquid out there but harder to find and harder to keep usable

 

[joshmir]

IMG_0272.HEIC

 

[joshmir]

 

[Baron Samedi]

Gabapentin is actually used off-label to decrease alcohol cravings.

Unfortunately, it has a bit of abuse potential itself.

 

[Ferrismonk]

When I tried to write for Naltrexone 50mg tablet for someone, it was close to $300. Maybe should have given them the GoodRx card.

 

[deleted993114]

I just admitted a patient to my internal medicine service who I have treated many times before. His is the same story, over and over again: he comes in with complicated alcohol withdrawal, we dry him out, and then he leaves the hospital and goes directly to the bar. We keep seeing him over and over. He's been to rehab, 12 steps, etc etc.

I think its time for the nuclear option. Except that we don't really have the nuclear option. Already I know I'm going to send him out on Disulfiram. I'll make sure he takes it before he leaves the hospital...but after that, he's going to stop taking it.

So why am I posting a thread about alcoholism on a pain forum? Because you guys have experience with drug delivery systems/pumps. Systems like Synchromed, and I'm sure there are plenty of others. I have a bright idea that may be totally crazy, but I want to see if perhaps someone out there thinks its possible:

1) Get a compounding pharmacy to compound up some disulfiram to some form that it is acceptable to the pump. Should be pretty easy to accomplish this part.

2) Get a surgeon or one of you guys to implant this pump for an off-label use in the patient, full of Disulfiram.

3) Get the patient to sign over his disability check to a rep payee, such that he gets no cash unless he shows up to get the pump refilled.

I'm not crazy, I don't think I'm actually going to get this to happen for this patient during this admission. But I see guys like him all the time. There is no salvation for them. They have failed all the "help" that they can get, and they have no meaningful life left.

So, you guys who use these pumps every day: is this technically feasible? Is it worth hunting down the pain management guys at my shop and talking to them about the possibility? Where could I learn more about how these pumps work? Any suggestions for how I may pursue this idea in an academic way? Or is it just totally out there and begging for a lawsuit?

Playing with addicts will always end in tears.