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After struggling with alcoholism for decades I used Naltrexone to stop drinking five or six years ago. It wasn't a simple taper but when I had my last drink it was easier to walk away from than anything I could have ever imagined before I did it.

Thank you for posting this; it'll help me help someone who is a self destructive alcoholic.

If it helps I used the treatment program outlined in the "sinclair method" which I found online and bought his book off Amazon. In the country I now live in, using Naltrexone in this way isn't exactly unheard of but it was definitely not the status quo treatment program.

The docs that I found to prescribe it for me really wanted me to subject myself to antabuse (Disulfiram) which is a profoundly sadistic strategy that creates a major sensitivity / negative reaction to even small amounts of alcohol that can be incredibly distressing and even life threatening.

Naltrexone on the other hand simply took away most of the euphoric experience I was getting from drinking and after a 4-6 weeks of using it every time I drank, I quit after a night of heavy drinking and morning of regret. After decades of quitting only to find myself drawn back to it, it was a profoundly liberating experience to actually be sober and not want a drink at all. It still is actually (though in a different sort of way).

I have to say that drinking while taking Naltrexone was a pretty weird experience because many of the signals I'd grown accustomed to for gauging my intoxication were muted... so I "felt" kinda sober but at the same time clearly was not. I think if there is a major risk in this it's possibility of deciding to drive because of "feeling sober". So that's the thing I think people need to be really cautious about.

Furthermore, I'd imagine the cost of the naloxone alone is a small percentage of the total cost of the emergency responders + acute care given in life-threatening overdose. The article doesn't discuss a recurring theme in medicine: acute care is really, really expensive. It'd be far more cost-effective to reduce the need for acute care by providing access to addiction treatment before things get to this point. Easier said than done I suppose.

> It'd be far more cost-effective to reduce the need for acute care by providing access to addiction treatment before things get to this point. Easier said than done I suppose.

Johann Hari has pointed out that it's very effective to just give heroin addicts pure heroin and a safe place to inject it. Switzerland has 'essentially' [edit] eliminated opiate deaths with this strategy:

[edit: added 'essentially' in response to tptacek's comment below because the swiss probably haven't gotten rid of 100% of their opiate deaths]

https://www.irishtimes.com/news/health/johann-hari-heroin-in...

In reports about the Swiss strategy and in this story about Hari I see plausible claims that Switzerland has eliminated deaths due to needle-borne HIV, but no claims anywhere that prescribing heroin has eliminated all opiate fatalities. Can you cite a more rigorous source?

> but no claims anywhere that prescribing heroin has eliminated all opiate fatalities. Can you cite a more rigorous source?

I have edited the comment above to add a word.

The friend who taught me about her opiate addiction knew how to manage her dose pretty well. Then the mental health industry got her addicted to benzodiazepines, which changed her tolerance. She overdosed on me when trying to get off the benzos. The fire department revived her, then disappeared into the night. Those two doses of Naloxone stabilized her for about 2 weeks...

A lot of the deaths in the United States' present opiate overdose epidemic has to do with contamination of the heroin supply with more powerful synthetic opiates. When the supply includes elephant opiates, addicts don't know how much to use.

I see credible claims that Switzerland has reduced overdose deaths from opiates with this strategy, but none saying they've "effectively eliminated" them. I didn't look very hard, and you see familiar with the subject. Can you point me to a resource establishing this?

The thing I see reports saying Switzerland has effectively eliminated is deaths due to needle contamination. That's not hard to believe (but then, you could get that effect by giving addicts clean needles).

In the article you posted, I see Hari saying that Switzerland's practices have eliminated wounds and abscesses he attributes to drug contamination. That, too, is very plausible. But most opiate fatalities are not caused by injection site wounds; they're caused by overdose.

I think there might be some confusion. Switzerland itself claims that nobody has died from overdose of officially prescribed heroin. That, too, is totally plausible. But Switzerland still has a street opiate drug market problem!

> But Switzerland still has a street opiate drug market problem!

The planet's various governments created the street drug marketplace by making desired substances illegal. The United States government created the country's drug culture by lying to people about the actual hazards of these desired substances.

Perhaps Switzerland has not eliminated opiate deaths, as my comment originally indicated, but the Swiss are doing better than everyone else in making progress at helping people with opiate addictions.

  Results from the Swiss studies, however, show that 
  mortality among patients in heroin assisted 
  maintenance programmes is low, and lower than for 
  patients in other maintenance programmes.14 In 
  addition, the wider safety concerns could not be 
  empirically confirmed in Switzerland or the 
  Netherlands.15 Finally, the incidence of heroin 
  dependence has decreased greatly in Switzerland 
  since the start of the trials, and currently 
  heroin has a more negative image than it did 15 
  years ago.16

- http://www.bmj.com/content/336/7635/70?variant=full

ref #14 (above) says:

  CONCLUSION: Mortality in heroin-assisted treatment 
  was low compared to the mortality rate of Swiss 
  opioid users 1990s (estimated to be between 2.5 
  and 3%). It was also low compared to mortality 
  rates of opioid users in other maintenance 
  treatments in other countries as reported in the 
  literature. The SMR was also lower than that 
  reported in the only meta-analysis in the 
  literature: 13.2 (95% C.I. 12.3-14.1). The low 
  mortality rate is all the more noteworthy as 
  heroin-assisted treatment in Switzerland included 
  only refractory opioid addicts with existing 
  severe somatic and/or mental problems.

- https://www.ncbi.nlm.nih.gov/pubmed/16002023?access_num=1600...

Not quite "eliminated", and I don't have a source in English, but drug overdose deaths fell by about two thirds between 1995 (Heroin prescriptions started in about 1994) and 2012:

http://www.suchtmonitoring.ch/de/3/7.html?opioide-mortalitat

In 2015, there were about 10 cases of needle-borne HIV infections in Switzerland, out of a bit more than 500 overall.

Vancouver is doing this too:

http://www.cbc.ca/beta/news/canada/crosstown-clinic-heroin-a...

Hari is a self-admitted liar.

I don't know how long this country can survive with this rampant corruption and profiteering. When do we hit a breaking point, and what does that look like?

I mean I read your response and think, "wow, that's horrible." Then realize absolutely nothing is going to be done about it.

> I don't know how long this country can survive with this rampant corruption and profiteering.

So far it has been 241 years.

100 years ago, politicians were tricked into trusting organized crime to tend to the health of people who are drawn to opiates. Those politicians are dead & gone, but we're still stuck with their mistake.

My mother broke her wrist 6 months ago, and was given opiates to deal with the pain of having a plate put in her wrist. She did not become an opiate addict. I presume she managed to avoid becoming a junky because she has a pretty stable day-to-day life.

When the drug war started, politicians had a problem: banning someone from ingesting wasn't something the US government had the power to do. We were a free country after all. They had to bend the constitution by implementing a tax rather than a ban, and simply never issued tax stamps. Fast forward 100 years, the federal, state and local governments can ban anything they damn well please with little to no resistance, confiscate our property with no recourse and a myriad of other things we accept as normal.

Where would we be if they hadn't circumvented the constitution and just let people use the drugs they wanted? We would probably (maybe) have more drug deaths, but we wouldn't have this 1984 like society. I think I want a do-over.

Would there be more deaths? Surely legalisation/decriminalisation of some drugs gives a guide has to what happens when people can get what they want. Obviously the drugs that are becoming more freely available are of the safer variety but the scare mongers told us horror stories about what was going to happen, and it hasn't worked out as they stated.

By "organized crime," I assume you mean something other what's traditionally thought of as organized crime, e.g. the Mafia, but I can't tell what.

> I presume she managed to avoid becoming a junky because she has a pretty stable day-to-day life.

While circumstance and upbringing are factors for addition, I think it's accepted that there is also a biological component; your mom may be inherently less prone to becoming addicted to opiates.

> By "organized crime," I assume you mean something other what's traditionally thought of as organized crime, e.g. the Mafia, but I can't tell what.

The Mafia and other manifestations of "traditional" organized crime is exactly what I was referring to.

Two years ago, when a new friend was teaching me about her addictions, I bought Johann Hari's book, Chasing the Scream: The First and Last Days of the War on Drugs [2]. Hari says that after heroin was made very difficult to obtain (circa 1915), organized crime became the supplier for most addicts.

The Los Angeles Times Op-Ed A 1930s California story shows why the war on drugs is a failure also covers how the Mafia swooped in to supply the needs of addicts [2]. This is the primary article I was thinking of when I wrote the quip you responded to.

[1] http://chasingthescream.com/

[2] http://www.latimes.com/opinion/op-ed/la-oe-hari-california-d...

> > I presume she managed to avoid becoming a junky because she has a pretty stable day-to-day life.

> While circumstance and upbringing are factors for addition, I think it's accepted that there is also a biological component; your mom may be inherently less prone to becoming addicted to opiates.

My mother is inherently less prone to becoming an addict because she has meaningful things to do: job, family, friends, trips, etc. My friend who taught me about addictions (mentioned above) was vulnerable to the street pharmacy because she was exposed to meth amphetamine as a pre-teen, and her brain chemistry never fully recovered. She says she was very depressed as a child/teen, and was made suicidal by her doctor when he injected her with Depo-Provera around age 20 (this is a chemical castration drug used for 3 months of "birth control"). This friend is doing well now because I provided the "connection" that Johann Hari says is so important for helping addicts out of their pit.

Describing criminal drug peddlers as "tending to the health" of people is a very odd way of putting it. It's also rather beside the point when talking about today's epidemic.

Having meaningful things to do is not "inherent."

I never heard of Depo-Provera before but calling it "chemical castration" and putting "birth control" in scare quotes seems like hyperbole and inflammatory. The drug is a progestin, a synthetic hormone that is administered in a number of forms. Depression is one of the possible side effects of the shot, but that doesn't necessarily mean it would exacerbate an existing condition and you've not mentioned whether the doctor was also treating her depression.

https://www.plannedparenthood.org/learn/birth-control/birth-...

> Describing criminal drug peddlers as "tending to the health" of people is a very odd way of putting it.

The intention is to point out the absurdity of our situation, where much-desired plant-based substances can only be obtained with the assistance of organized crime.

> It's also rather beside the point when talking about today's epidemic.

The point is that the epidemic is entirely artificial. It is created and maintained by stupid politicians. It could be ended in a few months by implementing the same solution as is used in Switzerland.

> I never heard of Depo-Provera before but calling it "chemical castration" and putting "birth control" in scare quotes seems like hyperbole and inflammatory.

The same drug is given to male sex offenders [1] explicitly for the purpose of chemical castration. Many women lose their libido when they're put on this drug. No hyperbole is enough to warn about the dangers of this FDA-approved substance.

[1] https://en.wikipedia.org/wiki/Medroxyprogesterone_acetate#Ot...

You're ignoring the fact that the current situation has been created by prescription pill misuse (in proscribing and taking) and the death toll has exceed that of automobiles largely because of Fentanyl and other synthetic opioids. Of course, a lot of the attention being paid is not because of the relative scope but because the affected population is whiter and less poor.

But synthetic vs. plant-based doesn't mean shit, plenty of plants can kill you. I'm all for treatment over criminalization but you sound more like you're advocating for legalization of heroin.

> No hyperbole is enough to warn about the dangers of this FDA-approved substance.

Sure, if you're willing to ignore all the other information on that Wikipedia page. Every patient should be well-informed about possible side effects before starting a medication. The injection form is longer lasting so it may take longer for bad effects to subside but loss of libido for a few months is not the end of the world.

The worst thing about chemical castration of sex offenders is it's forced.

> You're ignoring the fact that the current situation has been created by prescription pill misuse (in proscribing and taking) and the death toll has exceed that of automobiles largely because of Fentanyl and other synthetic opioids.

My friend did not transfer her addiction from pills, she was a good old-fashioned heroin addict. The present body count stems from the synthetics. Many fewer people died when the street pharmacy's products were purer.

> I'm all for treatment over criminalization but you sound more like you're advocating for legalization of heroin.

I don't think legalization is necessary, just an acknowledgement that present policy is actually a make-work program for organized crime.

As for your comments about Provera, I say that doctors should not play Russian Roulette with women's health.

From what I understand, the current state of the epidemic was exacerbated by the crackdown on pills and the current deaths is from heroin more than anything. Heroin used by people who can no longer get pills of which they know the dosage of.

Yes, restrictions on prescriptions, meant to stop people from getting hooked and cut down on illegal distribution, plus some crackdowns on pill mills have driven people already addicted to cheaper, more available opioids.

"Heroin-related deaths more than tripled between 2010 and 2015, with 12,989 heroin deaths in 2015. The largest increase in overdose deaths from 2014 to 2015 was for those involving synthetic opioids (other than methadone), which rose from 5,544 deaths in 2014 to 9,580 deaths in 2015. One of these synthetic opioids, illegally-made fentanyl, drove the increase. It was often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge." [0]

But the rate of increase for death by prescription opioid has been greater than non-prescription so they are nearly half of all deaths.

[0] https://www.cdc.gov/drugoverdose/epidemic/index.html

Addiction is fundamentally about not being able to regulate ones nervous system and looking for external triggers for dopamine release.

This is almost always linked to developmental and shock trauma earlier in life.

That doesn't account for the genetic component.

You may have a person who is more sensitive in some ways, but you don't get addiction without some form of developmental or shock trauma - I've never seen it, and haven't met any professionals who have either.

> You may have a person who is more sensitive in some ways, but you don't get addiction without some form of developmental or shock trauma

I wish the justice system would consider this factor when deciding whether to send people for gratuitous punishment...

Rather than a revolutionary movement you see mass implosion, addiction, suicide and people falling apart under the weight of triple time hours or being excluded from work altogether .

I guess one way it could play out is that as the corruption becomes more and more obvious, together with increasing differences in political ideology between red and blue states, an appetite for seceding from the United States could develop in some states, and if that sentiment becomes common enough, it could become a reality?

The problem is that the stratified cultures that form the arbitrary two sided political dichotomies (see Britain for another great example - given current norms it would make perfectly good sense for Scotland, London, and Northern Ireland to secede from the more conservative England and Wales).

But they are arbitrary. The talk radio in the rural conservative parts and the Internet circlejerks in the liberal ones have divided peoples way worse than they were a hundred years ago by putting the soft-reds and soft-blues into echo chambers of the most ardent idealogues and turning many into adherents that place their personal identity into their politics.

The other problem is those of us guilty of that - the framing of our identity on high-brow concepts like ideology - don't want to change. Who wants to revert back to ignorance on how you personally think the world is best ordered?

The rift will only grow until dissolution does happen unless all participants admit that they want to preserve solidarity in society. They will not be able to change themselves, but they can train future generations to not base themselves so heavily in politics such that they do not segregate themselves such. But it would take everyone agreeing on something nobody wants to have happen. So... yeah right.

It's IMO more likely than most people think. I really hope we don't see a civil war in our lifetime, but historically democracy's are highly unstable. This time it might be different, but then again it might not.

A Civil War today would look like Afghanistan or Iraq, not like the one we had before. It won't be pretty and will probably end in authoritarianism the likes we've never seen.

~50% of all US war casualties occurred during the Civil War. It was very nasty, even if only 3% of the total US population died in direct fighting.

Yes, it was a gruesome war. By Afghanistan and Iraq, I meant more insurgent type war rather than sanctioned armies fighting. Liberal states would have insurgent right wingers and Conservative states would have insurgent left wingers. Insurgents would be fighting the opposite faction of insurgent, and everyone will be armed to the teeth. We saw a glimpse of how that would play out in rural areas with the Oregon stand off. I suspect the cities would be something like we saw in Ukrane with their stand in the main square with the firewall, except a lot more shooting. There would be massive food shortages. It would be crazy and unpleasant and not a damn thing will have been resolved.

I realized I was being vague.

A civil war in a nuclear armed country could be considerable worse than that. Just consider what would happen if a faction of the army with control over nuclear weaponry took a non-neutral stance...

You mean unregulated Capitlism? It will wake up when we realize we need some middle ground between Capitalism and Socialism.

Most everybody already realizes this. We have exactly such a system in place. The argument is about exactly where the balance is to be found.

If you totally discount the good manufacturing practices and traceability that pharmaceuticals have to follow, sure you can hack together a cheap substitute that might not work when the chips are down

Except for biologics, many drugs are not that expensive to manufacture. The cost is in proving they will do what they say they do on the package.

Do you really believe that it costs upwards of 4000 dollars to track a little box with medication in it? For that money I hope each box comes with a solar rechargeable smartphone that sends a gps beacon every half hour.

To actually put some numbers to the argument, literal aircraft grade bolts from spruce and specialties or spencer are super handwavy about twice the retail cost of similar low/single quantity bolts sold at home depot. I've done a couple ham radio antenna projects where I don't wanna climb up there again anytime soon nor do I want to clean up a failure and literal aircraft grade fasteners are surprisingly cheap and available and extremely reliable. Good enough for a 747, good enough to hold up my ham radio antenna.

With modern technology, trace ability and all that is really not that expensive for commodities. Returning to the topic, it would be predictable if OPs re-invention of the concept of generic drugs were maybe 1/10th the price of name brand. Oddly enough that's not unusual for generic pharma to be shockingly cheaper than name brand. The real question is why aren't generic overdose drugs incredibly cheap? I would guess profiteering, but who knows. Maybe they're not shelf stable, perhaps extremely temp or UV sensitive?

It's not the tracking, it's the super long and expensive regulatory process, and the cost of researching the drugs. Remember that for every successful drug, there are probably many that the company spent lots of money working on, and didn't end up working out. Someone has to pay for those failed ones as well.

How does that explain that the autoinjector was $690 in 2014 but $4500 today?

I don't know about the autoinjector, but for a lot of medication the list price is there simply so that when the insurance company negotiates a lower price, the manufacturer will get a reasonable amount. in many cases expensive drugs can even be free if your income is low enough.

This is a good point as well. List price doesn't mean the price that people end up paying. Some of these products are discounted 80-90%.

As noted by others, the cost of Evzio is up from $690 to $4500.

So, yes, there always is some reason. The pharma company needs to cover the costs to their whole business with the revenues from their whole business, and they'll play whatever games help them do that. The price for a drug does not correspond to the cost to produce (or develop or get approval for) that particular drug, the price corresponds to maximum revenue for that drug.

With all the max revenue from all drugs, they need to cover research for a bunch of drugs that won't work out, marketing, board of directors, and other expensive hires to power the rotating door between regulation and industry, etc.

It would obviously be better if prices paid for long-existing well-known drugs did not mostly go to cover inept big-business shenanigans. "Real competition" would fix this, but the health care industry is fucked up in 10 different ways and we can't agree which direction to go to fix it. (In this case I'd say the problem is that the end-user is not paying for it, so bureaucracy and politics decide how much of which brand to buy, and the result is so bad the end-user would never pay for it, so we're stuck - it's unfixable.)

It's clear enough that the manufacturer is enjoying their market position rather than having their costs spiral out of control as demand increases.

Alternate access: https://outline.com/R36DZt

NB: I have no association with outline.com, nor do I even know who's running this, though if anyone has information on that, I'd like to know.

It is ... staggeringly useful.

Big Pharma has found a way to jack the price of this generic drug too.

Take a look at what companies make these generic drugs. It's not big Pharma at all. It's small companies. Most big pharma give up on a drug once it goes generic.