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- [00:01]
A
We have some people joining us here. Thanks to everyone who took time out of their busy. What day of the week is it?
- [00:07]
B
Thursday.
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A
Anyone know? Thursday. Thursday. It's so hard to tell the summer. Do you guys want to debate daylight savings time versus standard time or you want to talk about Naltrex?
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C
I mean, it's no debate. I saw a study that said daylight savings time kills, like hundreds of people every year.
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A
Does it? I'm not surprised.
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C
It might be a slight exaggeration, but it's true.
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B
How does it kill people?
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C
Well, it gets people out of their circadian rhythms, I think is the short answer. And they, like, go to bed at the wrong time and the sun isn't overhead when it's noon.
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A
And I can't explain I'm upset about this. So where I live in Washington State, if daylight saving times goes permanent in the winter, the sun will rise at 10am it's so bad. It's so bad. It's already a short day in the winter. And like, why are we doing this? Why are we doing this? Like, they've done it, They've tried it. It doesn't work.
- [01:04]
C
You want to know my biggest pet peeve? It's people who confidently say, like, we're talking at 10 Central Standard Time or Pacific Standard Time, and they just do that all year long because they think it's just standard time is standard, but
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B
time, I mean, what's wrong with it
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C
that like ⅓ or 3/4 of the year is actually daylight time? So they're, they're almost always wrong when
- [01:27]
A
they say that if we, if we could go to all standard time, I would be happy about that. Like here it doesn't get dark at night until 10pm which makes it really hard to watch TV. I had to get like, blackout curtains for my windows just to watch TV in the summertime. So we could use an hour or two less daylight on that end and more in the morning. And I realized, like, how this is a sign of aging as well, because when I was. And sobriety when I was younger and drinking all the time, like, more. More daylight at the end of the day and less in the morning was exactly what I wanted. This is what happens when you get old.
- [02:01]
C
I mean, you know, in fairness, not everyone gets up super early, but everyone is up at, like, sunset. So.
- [02:07]
A
True.
- [02:07]
C
I don't know.
- [02:09]
A
All right, well, thank you all for joining me. We are not actually here to talk about daylight savings time, and today's chat is going to be a bit different from our normal fare. So less Internet, more about drugs and drug recovery. No adult baby lifers today. Excuse me, no adult baby lovers today, unfortunately. Sorry about that everyone. But we do have two fantastic guests, Ben Westhoff and Emily Duffton. And Ben. Emily and I have a very specific common interest and that is the medication naltrexone. So this is the drug that I use to cure and yes, I do main cure my own 20 or 20 year alcohol addiction. And it's, you know, it's certainly possible I would have gotten sober without naltrexone, but I had tried many of the usual methods until including 12 step programs. Nothing worked for me long term until I got on naltrexone. And that of course is the subject of my book drink your way sober. The science based method to break free from alcohol. And naltrexone is also the subject and part of Emily's new book Addiction Inc. And Ben's new film antagonist, how a wonder drug got sidelined, which is less about naltrexone as a cure for alcoholism than for opioid addiction. So that's what we're talking about today. I'd also like to get into drug policy a bit, maybe a little politics, whatever else that comes up. So Em and Ben. Ben. Excuse me. So, Emily and Ben, first I'm going to ask you to introduce yourselves and tell me how you discovered naltrexone. So Emily, you want to go first?
- [03:33]
C
Sure.
- [03:34]
B
Hi everybody, I'm Emily Dufton. I'm a drug historian and based right outside of Washington D.C. and I just released a book like three months ago, I guess in April called Addiction Inc. Medication assisted treatment and America's forgotten war on drugs Medication assisted treatment. The name is a little bit controversial. I will note that I started writing this book back in 2018 when the term was very widely used. Now more often these days it's called mood medications for opioid use disorder which people have argued is less stigmatizing. The drugs aren't assistance to the treatment, they are the treatment itself.
- [04:07]
C
Since there being umlaud over the U, it's M u D, right, pronounced mood, I feel,
- [04:14]
B
or some people call it mode. And I was like, I don't know, it sounds like my lawn. So who knows? But it's the history of these three drugs that are currently used to treat opioid use disorder. Opioid addiction, methadone, buprenorphine, and our friend naltrexone, which is also used to treat opioid use disorder and alcohol use disorder. It's the only drug in My book, that has two indications. So it's very special. And what I argue is that these books are. Excuse me. These drugs are surprising because they're all products of Richard Nixon's White House. Surprise, surprise. And they started off as what I argue is actually a really incredible experiment in public health launched by a surprising little office that Nixon initiated that had really good people in it, like his first drug czar, who's like, no, my surrogate grandpa. And he lives outside of Baltimore and we're buddies. But I wrote naltrexone's history, which sort of leads up to why it's not being used very much today, which I think is where Ben's documentary kind of picks up.
- [05:08]
C
Yeah, we both learned about naltrexone through this wonderful guy named Percy Menzies who showed up at my book reading one time. Yeah. And I. My book, Fentanyl Inc. Was about the supply chain, how fentanyl gets to the US And I went undercover in Chinese drug labs. And, you know, I thought I was pretty hot shit, you know, going to these book readings and everyone's shaking my hand and wants their picture with me. And then this guy Percy comes up. He's an Indian immigrant in his. Was he early 70s? Yeah. And he basically was like, you don't know what you're talking about in your book. Like, you got it all wrong. That was like his introduction. And I was like, nice to meet you. And because I didn't talk about naltrexone in the book, and so he just sort of like, basically like harassed me until I agreed to give naltrexone my consideration. And, you know, there's like hundreds of other journalists around the country who he is brow beaten in this way. But I answered the call and yeah, this documentary about naltrexone and Percy is. Is kind of the main character.
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A
He's a character. He's like, he's great for a sound bite. He's a funny man.
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B
It's a penicillin moment. The discovery of naltrexone could have been hailed as a penicillin moment.
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C
Yeah, I love it. I spent so much time with him and he manages to bring every single conversation back to naltrexone. It could be like, yeah, St. Louis Cardinals won an amazing victory last night. And he's like, well, but this. This reminds me of how America is not accepted naltrexone the way it should. It's like.
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A
Like it hasn't accepted the cardinals.
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C
Yeah, exactly.
- [06:45]
A
Yeah. So I know a fair amount about naltrexone and alcohol. You know, specifically I used it. I use this protocol called the Sinclair method, or tsm, which involves taking naltrexone, waiting an hour, and then drinking as normal. And the medication basically dulls the pleasure you get from drinking, so it becomes boring. And if you do this every time that you drink, you basically unlearn this behavior, this problematic behavior that being drinking. I don't know as much about its use in opioid addiction. Ben, do you want to give, or Emily, do one of you want to give? Sort of the, sort of the backstory there, how it works and how it was discovered?
- [07:23]
C
Well, basically, it was developed for opioids. It's. It's called an opioid antagonist, which means it binds to the same receptors as fentanyl or heroin or oxycontin, but it blocks them. And so you can take, you know, an naltrexone pill, and then you can shoot up as much heroin as you want, fentanyl as you want, and it will just bounce right off the receptors. So it's kind of a miracle drug. They. They literally spend millions and millions of federal dollars trying to develop it. And it's, you know, it's basically like a vaccine for fentanyl is really what it is. Mm.
- [08:02]
A
And so for people who are like, one of the things about naltrexone that differentiates it from the other, is it just suboxone or, or buprenorphine and methadone for. To treat opioid use disorder, FDA approved. So, yeah, so unlike that, you have to detox off of. Off of opioids if you have opioid. Like people who are doing tsm, if they're on, you know, they wear like a, some of them wear like a little bracelet, like a medical alert bracelet, or have something in their wallets, like on the off chance that you're in a car accident and you're. And you have to go to a, you're unconscious and you go to a hospital and your doctor gives you narcotics or, or anesthesia, I suppose it can be very dangerous in the sense of, like, you don't want. You don't want opioids in your system.
- [08:47]
B
Right.
- [08:48]
A
When you're. And I don't mean dangerous like it'll kill you. I mean dangerous like it'll suck a lot. So that's one of the differences between naltrexone and these other, these other so called gold standard treatments. What are the other sort of differences?
- [09:01]
B
Yeah, I mean, they're. They're just sort of It's a fundamentally different body of drugs, right? So if you look at the three oud drugs, you've got methadone, which is the full opioid antagonist, or excuse me, opioid agonist, and buprenorphine, which is a semi, like a. I'm forgetting the word now. It's like a semi. A semi. Full opioid agonist. So what happens with these two drugs? Like an. An opioid agonist is basically any kind of opioid based medication, right? Fentanyl is an agonist, methadone is an agonist, Oxycontin is an agonist. So when you take these drugs, they fill the opioid receptors in your brain, they give you that sense of pleasure, they relieve pain, but they can also result in suspended breathing and heart rate, which is what the main drivers of overdose. So that's what kills you, right? You stop breathing on an opioid overdose and that's how you die. Naltrexone's totally different. It is derived from the T vein, a chemical derived from the opioid poppy. So it's kind of from the same home as opioid agonists like methadone or fentanyl, but it does the exact opposite. Like Ben was saying, it's kind of like a little umbrella over your opioid receptors in your brain, and it prevents any other drug like opioids or even alcohol from getting into those receptors and giving you that pleasure and giving you also the potential for overdose. So it's really helpful as like a prophylactic against alcohol or opioid use. But you're right, right? It requires this massive process of fully detoxing. Because if you have any opioids in your brain and naltrexone comes in, it's gonna kick them out and send that person immediately into withdrawal. And they're gonna be really unhappy. Because the same company that discovered naltrexone in 1963 was also the company that discovered naloxone or narcan, which is also an opioid antagonist. So think about how, like, if someone's overdosing and you shoot some Narcan up their nose and. And they immediately revive. They're like Lazarus rising from the dead. It's because that kicked all of the opioids out of their brain. But it's super short acting, right? Like it helps and then it doesn't. Like, then, then it wears off. Naltrexone is the exact same thing, but it lasts for 24 hours. Or if you get the injection bowl, the ejection, it lasts for 28 days, like a month. So think of naltrexone as super long lasting naloxone. That's kind of like, you know, to
- [11:04]
C
put into context, I think the most important thing to remember is just that methadone and buprenorphine will get you high, you know, especially if you've never had them before. Whereas naltrexone, you know. Yeah, yeah. Naltrexone doesn't. It's just. And that's why that's the best thing about naltrexone. You know, naltrexone has plenty of problems, but it doesn't get you high.
- [11:27]
A
Okay, well, let's talk about those. Yeah, let's talk about those problems. What are the, what are the negative side effects or what are the negative indications? Like who does naltrexone not work for?
- [11:39]
C
Well, the biggest problem is that like Emily was saying, you have to be completely detoxed to start naltrexone. And for a lot of opioid addicted users, that's a bridge too far.
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A
Right.
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C
So, yeah, important distinction for alcohol. You can take naltrexone anytime. In fact, that's the whole point of your book, Drink Yourself Sober is that you can and are encouraged to keep drinking while you're on naltrexone.
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A
Yeah.
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C
But for opioids, you have to be completely detoxed. And you know, that can be like seven to ten days of withdrawal. Like the worst cold, the worst flu you've ever had in your life.
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B
Right, right.
- [12:15]
C
So but once you get past that withdrawal period, then you can start naltrexone. And you know, another thing is just like, if someone's been addicted for years and years to heroin or fentanyl or whatever, everyone gets detox at some point. You know what I mean? Along their journey, everyone tries to. And so the key is to kind of start them. You know, if they want to do naltrexone, do it right then. Or if they're in prison. Most people get sober in prison. So when they're leaving prison, that's another really good time to start on naltrexone.
- [12:48]
A
Yeah, I can imagine. So one of the things that I found when I was working on my book and just from my own experience, like, I'm not sure that naltrexone would've worked for me when I was 25 years old. Like, it worked for me at a very specific time in my life when I was highly motivated, stable, you know, I. I Was married, I owned a house. Like, I, I just, I didn't have. And I really wanted to get sober at that point, as, like, I had tried many times before and it hadn't worked. But at that point, like, everything sort of lined up for me. And it was also during COVID So in some ways, like, you know, Covid accelerated my drinking, but also I didn't have all this sort of external draw of like, going out to bars and seeing friends and that and that sort. Um, and what. You know, I interviewed a lot of people who did. Who did the sinclair method and it 10. And I also talked to people who worked in public health who were very skeptical of naltrexone and that what they said basically was like, this works for people who are highly motivated to take the drug every day. And there is a. There is an injectable Vivitrol. You can't really do the Sinclair method on Vivitrol. It just sort of doesn't work the same way because with the. The oral form, it's this very targeted use. You only take the pill in anticipation of drinking to try to create that association between basically a lack of pleasure, boredom, and drinking in your brain. Is that true of opioids as well? Like, do you need it? Does it work? Is it better for like or more effective for, like, the popula? I'm sure every population that is highly motivated is going to have and stable is going to have better luck with. With drug treatments. But is that. Is that a real barrier for. For naltrexone with opioid use?
- [14:30]
B
I mean, I would say so. Historically, certainly, yes. Like, some of the first clinical trials were done in the 80s, and some of them were with, like, VA hospitals. A lot of drugs are tested in VA hospitals. So you had like, you know, a population that maybe isn't as stable, maybe isn't as sort of in that mental place where they're prepared for this. Whereas when it was tested with, I think they were called for the. For the highly motivated addict. Right. This was a population of, like, business executives and pilots and all this other stuff, like, oh, and. And like, doctors who had lost their license. So these people really did need to, like, approach sobriety with, like, a real driving force. Like, you're going to lose your license or your spouse is going to leave you, or, like, you can't fly the plane anymore. You're going to lose your livelihood. And for people like that, you know, the doctor running the clinical trial was like this thing's magic. These people have transformed. They've gotten their lives back, they've gotten their medical licenses back. This is amazing. But for most other populations, compliance is the number one issue. You know, especially for a pill that like when it comes to opioid use disorder, like to stay out of withdrawal, like you gotta be using multiple times a day, every day because like, yeah, you're really like highly processing heroin or even more short acting opioids like fentanyl, like you gotta, you gotta keep using. So naltrexone is a pill you take like once a day, like your daily vitamin. And it will prevent your brain from absorbing those other chemicals, but it wears off after a day. So like, if you don't feel like doing this anymore, you know, it's pretty easy to quit. The, the shot overrides that a little bit. But the pill format really requires on like that daily sense of adherence, which for a lot of patient populations is like the hardest. The hardest for me.
- [16:04]
A
Yeah. When I talked to a guy who worked in public health, you know, his, most of his clients were, he was a, a physician, most of his patients were homeless. And when I asked him what to do about that population, this was more for alcohol than, although I'm sure there was lots of, they were using lots of other drugs and also had, you know, mental health issues or whatever. He said, I said, you know, what do you do for that pop? What do they need? And he said a place to go. And I don't think he even terms like in terms of getting clean, just in terms of like having something to eat, having a place to sleep. Do you guys have a. Yeah, go ahead.
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C
Then I would push back just a tiny bit because, you know, like Emily was saying, the naltrexone pill, you have to take it every single day. Like, who can even remember? I can't even remember to take my B12 shot every, you know, like spray every day.
- [16:49]
A
Yeah.
- [16:50]
C
But the vivitrol shot, that's 30 days, that's almost a full month. And you know, it's a big old shot. It's like a horse, you know, I've
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A
heard it's very painful right in the ass, right?
- [17:02]
C
Yeah. So if you can get someone to do that though. And Herbst Clinic, for example, deals like largely with unhoused people, you know, marginalized people, and he gets them to take it and it's so much better for them going out into the world, you know, like 30 days of protection and who knows if they're going to come back. If they come back. That's amazing. But still, 30 days of protection is like, an incredible start. And, you know, I think it does work, I think for a lot of people in this world, for sure.
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A
So what happens if someone. If someone has the Vivitrol shots? And so Vivitrol is the. Is the injectable form of naltrexone. What happens if someone has the shot in their system or takes the pill and smokes fentanyl? What. What physically happens to them?
- [17:48]
C
So should really be nothing, you know, like some people that I've heard reports about taking insane, crazy amounts and overriding it, but really it doesn't get them high and it shouldn't really.
- [17:58]
A
Could you still overdose on a. If you took a massive amount of fent on. On Vivitrol or Naltrexone, would you overdose or would just. Nothing would happen.
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C
I've heard that, like, in crazy, crazy cases, maybe, but I think for the vast, vast majority of people, nothing happens.
- [18:14]
B
Yeah. Okay, so take like a pretty enormous amount to override the naltrexone, you know? Cause it binds, like, pretty, pretty tight to the brain. It really does.
- [18:21]
A
Yeah. Okay. So we have this drug that. It does act in. In many ways like a vaccine against. Against opioid use, or at least the. The fun part of opioid use, the part where you actually get high. Why isn't everybody. This is the question everybody has. Why doesn't everybody know about it? Why have we all heard of methadone and Suboxone? Why isn't Line of defense.
- [18:43]
B
Who.
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A
Who wants to take that? Ben?
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C
Well, yeah, that's the subject of my film. So basically right off the gate, there was this sort of misinformation campaigning against it. And there it was determined that it caused liver disease. Okay. And so there was this big black box warning on the packaging that said, if you have, like, a compromised liver, you can't take this. And there was like, it was on the front page of the New York Times, like, this new incredible drug debuts. But you can't take it if you have a compromised liver. And when you think about people who drink in excess and people use opioids, that's like everyone practically, you know, they. They have like, liver issues. And so that turned out to be not true at all. They had to. They took off the black box warning.
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A
How did the. How did the black box warning get put on the. Put on the drug in the.
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C
It was based on this study that was basically irrelevant. It was like naltrexone for obesity. They were testing it out and found this tiny little indication it was just bad science that got away from the people doing the study. And so.
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A
And what year are we talking about here when the New York Times. Okay, so this drug has been around for a long time.
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C
Yeah, yeah, yeah, yeah. So that. So that was one problem. And then one thing I talk about in my film is basically the. The methadone lobby, so.