Extended-Release Naltrexone and Harm Reduction Counseling for Chronically Homeless People With Alcohol Dependence

ABSTRACT

Background: Abstinence-based alcohol interventions are minimally desirable to and effective for chronically homeless individuals with alcohol dependence who have multimorbidity and high publicly funded service utilization and associated costs. Lower-barrier, patient-centered combined pharmacobehavioral interventions may more effectively treat this population. Harm reduction counseling involves a nonjudgmental, empathic style and patient-driven goal setting that requires neither abstinence nor use reduction. Extended-release naltrexone (XR-NTX), a monthly injectable formulation of an opioid receptor antagonist, reduces craving, is safe and effective for active drinkers, and may thereby support harm reduction goal setting. The aims of this 12-week, single-arm pilot were to initially document some aspects of feasibility, acceptability, and alcohol outcomes following XR-NTX administration and harm reduction counseling for chronically homeless individuals with alcohol dependence. Methods: Participants were currently/formerly chronically homeless, alcohol-dependent individuals (N = 31) from 2 community-based agencies in the US Pacific Northwest. Measures included self-reported alcohol craving, quantity/frequency, problems, and biomarkers (ethyl glucuronide [EtG], liver transaminases). XR-NTX and harm reduction counseling were administered monthly over the 3-month treatment course. Results: Of the 45 individuals approached, 43 were interested in participation. The first injection was received by 31 participants, and 24 complied with all study procedures. Participants reported the treatment was acceptable. Participants evinced decreases in alcohol craving (33%), typical (25%) and peak (34%) use, frequency (17%), problems (60%), and EtG from the baseline to the 12-week follow-up (Ps < .05). Conclusions: XR-NTX and harm reduction counseling are promising means of supporting reductions in alcohol use and alcohol-related harm among chronically homeless, alcohol-dependent individuals.

Keywords:

• Alcohol dependence
• extended-release naltrexone
• harm reduction
• homelessness

ACKNOWLEDGMENTS

We would like to thank the following individuals for their contributions: staff and management at the 2 collaborating agencies who helped us identify, transport, and track participants, especially Julie Carlson, Jeff Clemmons, Kelley Craig, Trevor Evans, Noah Fay, and Chloe Gale; Dr. Joseph Merrill, who served as independent safety monitor; Megan Kirouac for her assistance in setting up and managing the study organization; Emily Taylor and Katy Thysell for their assistance with data management; Samantha Chalker, Laura Haelsig, Jennifer Hicks, Gail Hoffman, Jennifer Holttum, Ami Kanagawa, Maya Nehru, Anthony Olds, and Morgan Quick for their help with data entry; Dr. Anthony Floyd, Dr. Karen Moe, and Hamideh Razazi for their assistance with our human subjects applications; and Dr. Patt Denning for her consultation and expertise in harm reduction interventions. We would also like to thank our supporters at Alkermes, Inc. (especially Karen Lutz), Dutch Shisler Sobering Support Center, King County Mental Health Chemical Abuse and Dependency Services (MHCADSD) (especially Dan Floyd and Amnon Shoenfeld), the Washington State Health Care Authority (especially Charles Agte, Kathy Cleeves, Amy Irwin, and Dr. Jeffery Thompson), and the Washington State Division of Behavioral Health and Recovery (especially Deb Cummins). Most of all, we would like to thank the study participants for their role in this research and for helping us understand the meaning of harm reduction.

FUNDING

This research was supported by small grants from the Alcohol and Drug Abuse Institute (Principal Investigator [PI]: Collins) and the Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations (CHAMMP; PI: Collins) as well as a Career Transition Award from the National Institute on Alcohol Abuse and Alcoholism (K22AA018384; PI: Collins). These agencies were not directly involved in the work reported on in the article or in the composition of the submission. Dr. Saxon serves on the Scientific Advisory Board for Alkermes and as speaker for Reckitt Benckiser. Dr. Ries serves as speaker for Alkermes, Janssen Pharmaceuticals, and has served in the past as speaker for Reckitt Benckiser. All other authors declare that they have no conflicts of interest pertaining to this article.

AUTHOR CONTRIBUTIONS

Dr. Collins codeveloped the study idea. She led the study and intervention design, conducted the primary statistical analyses, and served as the lead author. She has had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Duncan and Smart served as study physicians on the study and contributed to intervention design and interpretation of the findings. Dr. Saxon, Mr. Malone, and Mr. Jackson contributed to study design and interpretation of the findings. Dr. Ries codeveloped the study idea and contributed to study and intervention design as well as interpretation of the findings. All authors critically reviewed, provided edits for, and approved the final article. There is no one else who fulfills these criteria but has not been included as an author.