Vivitrol

[psych]

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Hi. It's been awhile since I've been on here.
Today I was informed my patient passed away (likely from opioid OD- unclear if intentional vs accidental).
I've been working as the sole psychiatrist at an ACT program that started from the ground up two years ago.
When I met the patient a year ago he came out of jail after a long hx of gang involvement/past prison terms, and probation mandated a residential substance abuse treatment program. He has a history of extensive substance use and kept testing + w/his PO at that time. The patient would use pretty much anything.
Initially I told him, no naltrexone or Vivitrol because of his recent substance use (in particular PRUNO while in jail and heroin was his DOC on the streets)…
Well 6 months later (and allegedly 6 months sober, per the residential tx program who was drug testing him) his interest in naltrexone/Vivitrol was still pretty adamant. I counselled him about using on the injection and the risks if he were to require painkillers due to a broken arm ect.. I told him explicitly that heroin may not work if he leaves his program and tries to use. I warned him of the risks of overdosing if he tried to overcome the naltrexone effects... I told him he could get sick if he were to drink ETOH and Vivitrol was in his system.
He still wanted it and I prescribed it.
Well fast forward another 6 months of being on Vivitrol. He graduates from the residential program. He says Vivitrol works great and he has no cravings. He was placed in a sober living house with mandatory AA/NA groups as well as an ancillary substance abuse treatment team who meet with him 2-3x a week (AND drug tests him).
I found out today that he apparently had been testing + with the ancillary treatment team, was kicked out of his sober living, apparently refused his *past due* Vivitrol last Thursday with my RN, and passed away this last weekend (of a suspected opioid overdose).
I have been troubled with this ever since I heard.
He is the only patient with opioid use disorder I have ever given Vivitrol to and I wonder if I'll ever prescribe it again to those with this condition. I have had some limited success in ETOH use disorder but normally I tell my opioid patients I'm not comfortable prescribing it.
This patient was very organized, seemingly high functioning, at one point was working full time and applying for better jobs.
I will probably take patients off Vivitrol before they leave a controlled environment in the future. It should have been a major red flag to the nurse that he refused the Vivitrol (but she is new and probably has no idea...).
Anyway I am trying to process what happened and since I'm the sole psychiatrist I don't have colleagues to talk about this with.

 

[Neuro111]

It certainly is very difficult when you lose one of your patients. So I am really sorry that you're going through it. Although it hurts, I really hope you do not take it personally. There is only so much we can do as providers for these patients. I tend to stay away from vivitrol for OUD as much as possible, and I tend to encourage most of my patients to stay on bupe or methadone (esp bc i'm in a city with LOTS of heroin/fentanyl). That said, when the patient insists on one medication over the other, all three of which are approved for the treatment, what can we do? You can only prescribe what they are willing to take, and if they are not willing to take bupe or methadone, it is either no prescription or vivitrol. If he had not been on vivitrol, there is no guarantee that your pt wouldn't have over dosed earlier. I've also seen people who really push to come off MAT when they are not fully stable who relapse and overdose. It is an uphill battle against fentanyl/heroin. it sucks. I really hope you absolve yourself from any guilt, and I am sorry again that you are going through this.

 

[psych]

It certainly is very difficult when you lose one of your patients. So I am really sorry that you're going through it. Although it hurts, I really hope you do not take it personally. There is only so much we can do as providers for these patients. I tend to stay away from vivitrol for OUD as much as possible, and I tend to encourage most of my patients to stay on bupe or methadone (esp bc i'm in a city with LOTS of heroin/fentanyl). That said, when the patient insists on one medication over the other, all three of which are approved for the treatment, what can we do? You can only prescribe what they are willing to take, and if they are not willing to take bupe or methadone, it is either no prescription or vivitrol. If he had not been on vivitrol, there is no guarantee that your pt wouldn't have over dosed earlier. I've also seen people who really push to come off MAT when they are not fully stable who relapse and overdose. It is an uphill battle against fentanyl/heroin. it sucks. I really hope you absolve yourself from any guilt, and I am sorry again that you are going through this.

Neuro, ty.
I sincerely appreciate you responding & reminding me how huge & challenging this epidemic is.
I suppose I’m doing hindsight is 20/20 in the midst of the shock, when I considered this person one of my most ‘stable’ patients (granted without being fully informed). I certainly deterred him from Vivitrol in our first meetings, given his history.
I know I can’t blame myself for this but it’s just so hard grappling with being the prescriber and knowing this happened after being several days late/then refusing the Vivitrol. Off course I’ll talk to the nurses and my ACT team about this but I’m pretty sure it won’t be something I’ll consider for future patients with an opioid use hx.

 

[splik]

Vivitrol has its place. in some states where its nigh impossible to provide opioid substitution therapy it may be the only option. there is data supporting its use. It can be helpful for pts with comorbid alcohol and opioid use disorder or those who have failed methadone and suboxone. you were very thoughtful about the potential risks in this patient, counseled him about it, engaged in shared decision making and gave it to him. It is usually a good sign if patients are asking for it (assuming the only reason they are asking for it is not because it will get them out of jail quicker as often happens). It sounds like the patient had already relapsed and sensibly declined Vivitrol prior to his death. In psychiatry, we take it a lot more personally when our patients die in a way that other physicians do not. We have been conditioned to think that any deaths are unacceptable and are due to personal failings. As you know, opioid use disorder is one of the most fatal psychiatric disorders. It sounds like you gave this patient good care and he had treatment available, but ultimately succumbed to his illness. That sometimes happens. And it sucks. But that doesn't mean it is your fault. And while I'm cautious about Vivitrol and potential for sensitizing patient's opioid receptors, that is less relevant if the patient is non-adherent. This was a very high risk patient.

 

[Bartelby]

I agree with splik, this was a high-risk patient and this serves as a reminder that psychiatric disorders are at times fatal (and often at a relatively young age). I know from personal experience how much you question your care after an event like this, but try to keep in perspective that even our best efforts cannot save every patient.

I don't think prescribing Vivitrol was an error in this case at all. Personally I think withholding naltrexone when an OUD patient asks for it (and has a goal of sobriety) would be the error. Keep in mind that the typical course for OUD without MAT is relapse, and fatality rates are pretty high. The best evidence says you did the right thing by prescribing.

Hope you can take some time to care for yourself, and process with your program colleagues. I think talking with other professionals who worked on the case (psychologist, SW, etc) has helped me work through outcomes like this.

 

[dl2dp2]

I do Vivitrol all the time. Echo above, from what you wrote I don't see anything you've done wrong, and it probably has nothing to do with Vivitrol. This happens unfortunately, and likely would've happened sooner without MAT.

 

[whopper]

Not enough to judge but agree with the above comments that in such cases you can't take it personally, though in doing so it's cause you're a human, and if someone didn't take it personally at least to some degree I'd question their ability to empathize.

There is a type of patient that doesn't want to go clean, or after some success with being clean think they can re-use in a safe manner. Some patients have to mess up a few times before they realize they can't ever touch the substance again. Most of the time during their process of relapsing, they realize they screwed up, and tend to be more committed to being clean and sober.

Buprenorphine and Naltrexone success rates are about the same after the the patient's been on both for at least weeks. Buprenorphine shows superiority during the first few weeks of treatment likely because it greatly calms the patients desire for an opioid by giving them a weaker version of one but he was apparently past that phase.

 

[NickNaylor]

I would just second what other folks have said, which is that in OUD relapse is the rule rather than the exception. Even with ORT relapse rates approach 50% at one year.

It's unfortunate, but there are going to be bad outcomes no matter what. It sounds like you appropriately managed the patient from your end of things. That isn't necessarily sufficient, though, and people ultimately have the ability to make bad - and even fatal - decisions. Just because they have the ability to do that - and sometimes do - doesn't subsequently mean that you failed to manage the patient correctly. It's not like you were prescribing the patient a bunch of opiates for "chronic back pain" - you were actively trying to manage the patient, you followed evidence-based treatment, and from your report it sounds like the patient was doing quite well until he suddenly was not.

We use naltrexone less frequently in our OUD patients that buprenorphine, but that doesn't make naltrexone a bad treatment.