Maybe I'm not understanding your post, but Naltrexone for detox opiate treatment is cruel and unscientific, you would just precipitate opiate withdrawal.
No, I'm talking about detox first, then transition patients to naltrexone only as a strategy for opiate dependent patients. This is considered an "abstinence only" treatment because there's no agonist in the system.
There's no treatment published trial for this strategy compared to standard buprenorphine/methadone maintenance strategy. All trials are on-going.
I do agree that genetic testing may help with Naltrexone, however, it is unlikely that insurance companies or the Affordable Healthcare Act will pay for a thousand dollar lab test to search for a modest 19% improvement in Heavy Drinking Days (24% improvement for Vivitrol), keeping in mind that Naltrexone does not improve overall abstinence or alcohol free days.
The cost effectiveness of genetic testing is unclear, and without advocacy the test itself may not be paid for, and it's not clear that it will continued to be so costly. Thinking in terms of what's going on now in policy instead of what SHOULD happen is somewhat shortsighted, in my mind.
Your second point is somewhat politically driven. Why is overall abstinence or alcohol free days a better outcome measure than heavy drinking days? Are you arguing that all drinking behavior is ipso facto bad? Also, the second result is not as simplistic as you say. While Naltrexone is generally not believed to increase the total days of abstinent days in the long run, it increases the time it takes to get to the first relapse (COMBINE). The total alcohol free days is also a poor measure because the noise is much larger in that signal by survey methodology. I would argue survival analysis is the better measure.
Instead of relying on an expensive genetic test, what may be just as helpful is knowing that Naltrexone's effectiveness in Women and African Americans are not proven/effective.
I disagree. Because, it's very possible that in SOME women and SOME African Americans it IS effective. It's just that in some current trials, there's suggestion that this effect over placebo is less than in white male population. It's incorrect to approach clinical practice by using potentially incorrect subgroup analysis. The correct clinical practice is to give it to everyone because don't know who's going to benefit and the side effect is small. This is, in fact, the current evidence based guideline.
By the way, this is the same way antidepressant effectiveness trials are being misused to argue an incorrect point. Antidepressants are OFTEN shown to be less effective in minority populations, and these results are distorted to mean that minorities don't benefit from antidepressants, which is false--they do sometimes, it's just that there is a larger variance in the effect in minority subjects, and usually it's a smaller sample, and therefore the signal doesn't reach statistical significance.
Absence of evidence is not evidence of absence.
"If science continues to look at addictions through the lens of neurotransmitters and "reward pathways" in the brain, then we will achieve nothing more than partial success in treating substance dependence."
While I agree that the approach of using neuroscience to treat addiction is not the entire story, the general principle of using evidence and the scientific method instead of political axe grinding is a much better approach than the faith based method various interest groups propound. PROJECT MATCH, for instance, showed that there's no superiority for any specific psychotherapeutic paradigm (i.e. intense AA is NOT better than CBT) and no easy way to match patients to the right therapy. Things are very complex, and to simplistically say this works or not work for this or that person is, in my opinion, not responsible.
Both vivitrol and naltrexone are backed up by solid evidence in terms of overall group effect for treatment of alcohol dependence. The fact that it's possible to develop a MEDICATION for treatment alcohol, to me, strongly argues that there is at least a component of substance abuse that is NOT just a "human weakness" or "social injustice," but actually driven by biology.
Addiction is a complex, multifaceted phenomenon, which makes it fascinating and a great field to go into. But I caution against simplistic, and politically motivated ways of approaching data.
