One Man’s War for the Medical Treatment of Addiction
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Percy Menzies sits in his office at the beginning of each day looking at the roster of new patients. Every day is a new battle, and every day has its winners and losers. Each time he enters a room of either new potential patients or community health practitioners to discuss how he can treat alcoholism, he is ready for a fight. He has to be. Years of resistance, particularly from those inundated with meetings of Alcoholics Anonymous, Narcotics Anonymous, and failed expensive residential treatments have made him hardened and battle ready to respond to commentary from people lost and confused when hearing his suggestion. “When I tell someone that first we have to break the never-ending cycle of cravings and withdrawal in order to make the counseling more effective, patients react with disbelief that a monthly shot of a non-addicting, anti-craving medication is pivotal in helping them ‘rewire’ their brain away from drugs and alcohol,” says Menzies.
Most health practitioners aren’t qualified to speak on addiction therapy. Addiction specialists are rarely even recognized as a true billable specialty in the medical community. Most became addiction specialists through reading online journals and clinical studies, but Percy Menzies isn’t like most practitioners. This small unobtrusive man is a powerhouse of knowledge and experience on addiction drug therapy. He served as the associate product director for naltrexone with DuPont and is now the President of the Assisted Recovery Centers of America, a small group of offices dedicated to treating alcoholic and heroin-addicted patients with Vivitrol. “Quite simply, the results are astounding,” Menzies says with surprise. “I tell all the patients, I don’t care what works. If I could swing a chicken around your head 10 times and you’d be magically cured, I would do it, because I care about curing patients, not about making money, and not about some philosophical agenda. The truth is, despite so much bad press, that Vivitrol works. It works like a miracle. My clinics have been treating patients for years and if it didn’t work, I wouldn’t use it.”
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I had the pleasure of sitting down with Percy Menzies to discuss his knowledge of medical therapy for addiction and current state of the recovery community in America:
Thank you for doing this interview. Now as we previously spoke, you mentioned that Vivitrol is by far the most effective form of treatment for both alcoholism and heroin addiction. Getting right to it, what is the history of the development of Vivitrol?
Before we go to Vivitrol, we need to look at the history of the development of naltrexone almost 40 years ago. Naltrexone was developed for one specific purpose - to be a non-addicting medication to prevent detoxed heroin addicts returning from incarceration or residential treatment from relapsing when they returned home. It is the classic Pavlovian conditioning. The ‘bell’ will start ringing in the form of sights, sounds, people and places associated with past drug use and the fact that the patient has been away from his/her most favorite thing, is going to make the craving even stronger. This is called, “The Deprivation Effect.” Patients released from jails and prisons are 12 times more likely to die of a drug overdose within the first month. Most of us have heard of stories of patients returning home from treatment centers getting drunk at airports on their way home! Nothing is more frustrating for the patient and their loved ones than when relapse occurs within days of returning home.
Naltrexone was the beneficiary of Nixon’s now infamous "War or Drugs." The Nixon Administration created the Special Action Office for Drug Abuse Prevention (SAODAP) in 1971, which led to the development of naltrexone as the first non-addicting opioid antagonist. Never in the field of medical treatment did we have two drugs at the opposite end of the spectrum approved for the same treatment—the other drug was methadone. You cannot have two drugs so completely antithetical. Naltrexone has been described as a physician’s dream medication while methadone was a product of harm reduction efforts. Naltrexone was FDA approved in 1984. Vivitrol was finally introduced to solve the problem of compliance with oral naltrexone in 2006. Compliance is a major problem in treating any chronic condition and is a particularly difficult problem when it involves basic survival circuits.
The problem is naltrexone/Vivitrol is just not used in the community and the reasons are ideological rather than clinical. Imagine the drop we would see in rates of recidivism and overdoses if just 10% of patients returning home from residential treatment or incarceration were given a Vivitrol shot 3-5 days before discharge.
Can you describe what got you into this line of work and what you found to be obstacles in your struggle to cure alcoholics and addicts?
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I prefer the word ‘quit’ rather than ‘cure’ because it is an action word indicative of something you have done on your own volition. I am perturbed by people emphatically saying ‘I quit smoking ten years ago,' but in the same breath say, ‘I am in recovery for 20 years.' We have treatments that allow patients to lead near-normal lives without the drugs or alcohol. The combination of the appropriate anti-craving medications and behavioral therapy can allow people to quit for life.
Based on several studies and the fact that naltrexone had been used for almost 10 years, the FDA approved the indication of naltrexone as an adjunct for the treatment of alcoholism in 1994 – 10 years after the approval for the treatment of opioid addiction. No chronic illness that affects close to 20 million people in this country is treated episodically or experientially with complete disregard to clinical evidence, without the aid of appropriate medications, except alcoholism. I describe this as the hubris of people in recovery who claim to be ‘experts’ based on their own ‘cold turkey 12-step miracle’ recovery.
In 2000, I left DuPont Pharmaceuticals and followed my calling to start evidence-based treatment centers that integrated anti-craving medications with relapse prevention counseling. Opening a clinic in St. Louis was no easy task. I was repeatedly reminded that St. Louis is a very conservative city and not open to unconventional treatments, particularly with medications like naltrexone that have been rejected by 12-step and psychology leaders. I had to deal with the dominance of the 12-step groups and the methadone clinics. Somebody once jokingly said that if these two groups were business organizations they would be charged with violating antitrust laws.
Things changed rapidly for the better with the introduction of Vivitrol in 2006, the once-a-month, long-lasting injection of naltrexone. The issue of compliance was over and now we could create a ‘drug free-zone’ within the patient’s brain for a month! Look at it as a monthly vaccine; calming the storm of the never-ending cycle of cravings and withdrawal. This finally allowed the patients to focus on their long-term recovery through counseling and psychiatric services.
The Assisted Recovery Centers of America (ARCA) model worked well because the patient was getting well within his/her natural environment that was filled with cues and triggers. In the past, these led to relapse, but now helped with Vivitrol, the patient could quit. This has to be the goal of every treatment program – extinguish the conditioning that caused and sustained the addiction.
The benefit of this treatment approach is that the patients don’t have to spend weeks in residential treatment. The treatment is individualized and most can go back home in 10-12 days and continue long-term treatment on an outpatient basis. The state is tracking outcomes and at least one study has been published and several more are ongoing.
How well do patients fare at your clinics? Does insurance typically cover the expensive cost of Vivitrol? How long does a patient need to stay on it? What is the treatment regimen and what typically happens after a patient ends their therapy?
The ‘cure’ or ‘quit’ rate is entirely dependent on the patient staying with the treatment regimen. We tell our patients that if they continue on the medications like naltrexone or Vivitrol, attend counseling sessions and are drug or alcohol-tested, relapse is not likely. Unfortunately, patients are very ambivalent about recovery. They fall victim listening to the wrong voice (such as anti-medication, 12-step sponsors) and stop taking the medications, stop attending counseling sessions, often leading to relapse while trying to stay sober in AA.
Our formal program is treating the patient for six months or longer and keeping them on naltrexone or Vivitrol for a year or longer. We are pleasantly surprised that just about every insurance company is paying for Vivitrol so the rumors that it is inaccessible are entirely false. The issue of the cost of the Vivitrol is most often raised by counselors and therapists opposed to using any medications. Be suspicious of this. We have medications and therapies that can cost tens of thousands of dollars and yet we find ways to pay for those drugs. Why is it that we in America want to treat addictions on the cheap? We have to change our mindset. There are several well-designed studies on Vivitrol that show better treatment outcomes and, yet, the ideological barriers trump evidence-based treatment.
There are those, such as Dr. David Sinclair, "The Godfather of Naltrexone," who claim that drinking on naltrexone is much more effective than using it for abstinence. Do you agree with him? What do you find occurs in patients who do drink on your therapy?
I have known Dr. David Sinclair for many years and don’t agree with his approach. The patients that come to our clinics have gone through other programs with little to no success. Most of the patients have attempted to moderate their drinking with no success. Controlled or social drinking for a patient who has developed full-blown alcoholism is an oxymoron. AA is correct on this point. Most of my patients started on naltrexone and will test the drug by either drinking or using opioids. They will come back and admit that they did not experience a high from the alcohol or the heroin had no effect. We tell our patients that they should consider alcohol or opioids as causing an ‘allergic’ reaction, similar to AA. Using alcohol or opioids will prime the pump and you are likely to breakout into drinking or using drugs. We convince our patients that they can lead a very normal, healthy life without alcohol or drugs being the center of gravity.
One of the biggest controversies of low-dose constant naltrexone therapy such as Vivitrol is that it up-regulates the opioid receptors in the brain of the alcoholic causing even bigger relapses after treatment. How do you respond to this?
This is brought up quite often as a reason for not using naltrexone. There is some fascinating work done by Dr. Shepard Siegel at McMaster University in Canada on Pavlovian conditioning and drug overdose. Pavlovian conditioning leads to tolerance. In response to the drug cues, the patient will use drugs and then over a period of time tolerance develops. This is called down-regulation. In response to the tolerance the patient needs increasingly larger doses of the drug. If this patient were taken away, say to jail or prison for a period of time, the Pavlovian conditioning will gradually cease, as it is not followed by drug use. Over time, the tolerance diminishes and the patient attains a drug naïve state, i.e. the patient has not used drugs. Now, if this patient was released and was to use the same dose that he/she last used, there is the strong likelihood of an overdose and even death. This is the reason patients being released from incarceration are 12 times more likely to overdose and die. Many state prisons are now releasing heroin addicts on an injection of Vivitrol 3-5 days prior to release.
Naltrexone does the same thing. It extinguishes the Pavlovian conditioning and allows patients to achieve a drug naïve state. If a patient who has been on Vivitrol for a period of time and uses a large dose of heroin, theoretically an overdose can occur. We caution the patient about this. The greater benefit of naltrexone is the restoration of the endorphinic homeostasis, which allows patients to enjoy the pleasures of everyday life, from the food, friends, healthy sex, etc. We have known for a long time that opioids, including methadone, suppress testosterone levels and many of these patients are either asexual or have significantly diminished sex drives. Our patients are pleasantly surprised by the long-term benefits of naltrexone.
What have been the biggest obstacles you have encountered in the recovery community in getting the message out about Vivitrol?
I cannot think of a community so stuck in the past and rejecting of every advance in the treatment of addictive behaviors. The treatment landscape is dotted with silos. There is the AA and NA silo, methadone silo, buprenorphine silo, psychiatry silo, research silos and the list goes on. Schools of social work teach little or nothing about pharmacotherapy. I am disappointed by the psychiatric community’s ignorance of anti-addiction medication. With the explosion of new medications and demand for psychiatric treatment, addiction treatment has been on the receiving end. It is not unusual to have a 2-3 month waiting period to see a psychiatrist and when they do see a patient it is for a relatively short time. Drug addicts are experts in describing their symptoms to obtain drugs totally inappropriate in recovery. I call them the Three Horsemen of the Apocalypse—Suboxone, Xanax, and Adderall. It is virtually impossible to get psychiatrists interested in addiction medicine. They are so focused on just the psychiatric symptom that they ignore the addictive disorder.
What has been the most stifling and damaging part of the American recovery movement in your opinion and how do we fix it?
The refusals to change, accept, and embrace the advances in the treatment of addictive disorders. A good example is Betty Ford. The adamant refusal to use medications ultimately led to their demise. Betty Ford is now part of Hazelden because insurance stopped paying and people stopped coming. Changes will come when insurance companies insist on the use of evidence-based treatments. I just read an article that under Obamacare, 12-step treatment is not evidence-based and therefore, is not eligible for reimbursement. I totally and emphatically agree.
How do you feel about harm reduction approaches such as naloxone and needle exchanges? Are they helpful in reducing the problem of drug addiction?
This is a subject that throws me into a rage. Harm reduction and legalization is being promoted by wealthy misguided individuals who are influenced by Milton Friedman. He believed that legalization decreased the lure to use drugs. I believe in decriminalization and education. During the AIDS epidemic, needle exchange programs were promoted as a way to reduce infection. I have nothing against it. But you cannot promote needle exchange as the only solution. It did nothing to decrease the heroin epidemic. Look at what is happening in poor countries like Pakistan and Afghanistan with the needle exchange program. The drug addicts share and continue to use the disposable syringes until the needle cannot puncture the blood vessel. Used disposal syringes are sold and resold to other addicts.
I was once talking to a staunch harm reduction guy and asked him why he talked about methadone and buprenorphine, but not naltrexone. With hesitation he replied, “Naltrexone takes away the freedom to use drugs.” I told him that I have no problem with what he is advocating, but if a heroin patient came to me saying that he was tired of his life and wants to be drug-free don’t you think ethics demands that I offer him options?
In response to the overdose deaths, naloxone is being promoted as a wonder drug that saves live. This medication has been on the market for almost 40 years. It is a life-saver and should be made freely available. But it is not a panacea. It provides a window of opportunity for the patient to be rushed to the hospital and into treatment. We still don’t see any talk about medical treatment.
What do you say to those who claim alcoholism and drug addiction naturally resolves itself and that direct medical treatment shouldn’t be the first line of defense since it isn’t a medical problem?
Just about everyone knows someone who spontaneously stopped using drugs, alcohol, or quit smoking. Indeed, quite a few people do it. Others responded to price increases and decreased availability and quit. We have to make every effort towards prevention. Unfortunately, the message does not get to everyone. Look at the drop in smoking rates. Twenty years ago the smoking rates were 50%. Now, they are down to 19%. Similarly, we have the die-hard alcoholics and drug addicts who have tried repeatedly to quit and have failed. This group needs medical intervention combined with behavioral therapy just like those who needed smoking cessation medical assistance. Why is this such a hard concept to understand?
How do you intend to change the face of the recovery community in America?
Over the last 15 years, the ARCA treatment model has been recognized as the standard of care. What is this model? Medical detox followed by appropriate anti-craving medications and behavioral therapies in the patient’s natural work and home environment. This model has worked for the broadest spectrum of patients from street addicts to CEOs. I keep fighting for the change that will help addicts. It’s time the recovery community embraced what works.
Matthew Leichter is a writer based in Baltimore, Maryland. He is a senior statistician, and lead epidemiologist for the financial and healthcare consulting firm Cognilytics, LLC. He last wrote about how Obamacare is killing AA and why smart recovery will never replace AA.