Over the last few decades, the opioid epidemic has moved close to the forefront of national health news.
Since the late 1990s, opioid use disorder and opioid related drug overdoses began to rise to unprecedented levels.1 In response, medical professionals increasingly turned to methadone, an opioid agonist, as a method of opioid addiction treatment. Methadone has been used as an effective treatment for opioid addiction since the 1960s. However, with the increase in methadone came an unexpected after effect. As an opioid agonist, methadone activates the opioid receptors in the brain, thereby creating addictive properties itself. Despite strict and widespread regulation of methadone as a treatment for opioid abuse, there was an increase in the number of patients who were abusing methadone treatment, resulting in methadone addiction, and in some cases overdoses on methadone. While the number of overdoses due to methadone remained significantly less than that of opioids, addiction medicine specialists have been left crestfallen by this negative side effect.
A Variety of Options
To prevent abuse and overdoses as a result of methadone while still treating patients’ underlying opioid addiction, medical specialists have recently turned to other medication-assisted treatment methods. Examples of alternative medication-assisted treatment methods to methadone include partial opioid agonists like buprenorphine, which still trigger the opioid receptors in the brain like methadone does, but to a lesser degree. Other alternatives to methadone are opioid antagonists like naltrexone. Unlike methadone or buprenorphine, naltrexone blocks the opioid receptors in the brain, thereby preventing the patient from experiencing a euphoric high. Both buprenorphine and naltrexone have been successful in treating opioid addiction in recent years.2
As the number of patients who use medication-assisted treatment for opioid use disorder increases, and the number of medication-assisted treatments increase, addiction specialists will encounter more patients seeking to alter their treatment plan from one medication to another. Medical professionals should be cognizant of the fact that when instituting a treatment plan with buprenorphine or naltrexone, they are precipitating withdrawal in order for the medication to be effective. This is due to the fact that with either drug, the patient is transitioning from a full opioid agonist to either a partial agonist or antagonist, thereby inducing less opioid receptor stimulation in the brain, if not preventing it entirely. Accordingly, it is important for medical professionals to discuss the potential symptoms of withdrawal with the patient. Addiction specialists should also consider other medications, such as an anti-nausea or anti-diarrheal medication, as part of the treatment plan to ease a patient’s discomfort due to the precipitated withdrawal.
When formulating a treatment plan with buprenorphine or naltrexone, whether in combination with other comfort medications or not, it is important for medical professionals to conduct a thorough and detailed history of the patient’s family, medical and addiction histories to establish an appropriate treatment plan. Such a history would include prescription and illicit opioid use, past inpatient and outpatient rehabilitative measures, and social history. In addition, it is important for medical providers to regularly review the applicable state Prescription Monitoring Program to further determine the patient’s history of controlled substance use.
Overall, it is hopeful that buprenorphine and naltrexone will continue to be beneficial in treating opioid use disorder. It is important to remember that these medications are fairly new additions to the range of available treatments for opioid addiction. Their administration involves precipitating withdrawal and its associated symptoms. This different approach to addressing opioid addiction has the potential to give rise to litigation in the future. Documentation surrounding the formulation of each patient’s treatment plan, as well as of the discussions of the plan with the patient, will be the most paramount defense for any such future litigations.
Michael A. Sonkin, Partner, and Alexandra M. Lopes, Associate, are attorneys at Martin Clearwater & Bell LLP where they focus their practice on the defense of medical malpractice matters. For more information, visit mcblaw.com.