This addiction treatment case involves a young woman in Oregon who was addicted to opioids and consequently enrolled in an accelerated opiate detoxification program at a clinic. During the first week of her treatment, the patient saw her doctors at the clinic every day. During the end of the week, a doctor in the clinic inserted a drug containing patch under the patient’s skin. Shortly after the treatment was administered, the patient was discharged from the clinic and returned home to continue her recovery. While at home, the patient began to experience extreme weakness, cold sweats, and tremors. After calling for emergency services, the patient lapsed into a coma. The patient was transported to the hospital, where she remained in a coma for an extended period of time. She eventually recovered, however she continues to suffer complications from her extended unconsciousness.
Question(s) For Expert Witness
- 1. Are you familiar with the subdermal Naltrexone patch in the treatment of patients with opioid addiction?
- 2. What constitutes an accelerated opiate detox program?
- 3. What criteria is used to determine if the patient is a candidate for such a program?
- 4. Is coma a known risk of subdermal Naltrexone patch and/or accelerated opioid detoxification program?
Expert Witness Response E-068745
I am very familiar with the medications utilized in a detoxification protocol, used in treating opioid dependence. This is one of my primary areas of expertise, and an area I lecture on regionally, nationally, and internationally is the treatment of opioid dependence, opioid withdrawal and detoxification. I have written extensively and published articles, abstracts and presented at meetings on this topic including abstracts involving complications of naltrexone-induced precipitated withdrawal. I have reviewed protocols involving certain ‘modified’ accelerated detoxification protocols including rapid induction of naltrexone from buprenorphine and other opioid agonists and even conducted certain of these modified protocols in various settings including the hospital and a medically managed detoxification program. Certainly, the addiction medicine provider should have a detailed discussion with the patient and his representatives regarding the risks, benefits and the alternatives to this type of procedure. There should be a consent detailing the procedure and known risks/complications and a very clear plan for monitoring and contact with the provider given any questions or side effects that are identified – in particular if part of the procedure involves home monitoring or is ‘ambulatory’ in any way.
Expert Witness Response E-112211
There is no such thing as an FDA approved subdermal patch. There is injectable Vivitrol from Alkermes, and an implantable naltrexone insert from Titan/Braeburn. Anything else is not FDA approved. 10 days is needed from last opiate use until use of a long acting naltrexone formulation. A week long accelerated program is experimental and could involve a wide variety of interventions. Some of these in the past have been associated with fatality and those MDs were prosecuted and went to prison as well as lost their license. The experimental programs that I and others have developed and used over the past 20 years for rapid opiate detox have clear and approved criteria. That being said, death has been described from some ultra-rapid detox programs.