Off Label May Keep Your MAT Patients On Track

As we work with more facilities seeking to treat patients with opioid use disorder, a specific challenge has emerged with injectable extended-release naltrexone (XR-NTX). Let me set the scene for you.

At intake, George reports that he is on medication-assisted treatment for opioids, specifically on XR-NTX. Dr. Jones cannot prescribe it to George because the drug is not available in her facility due to the cost, lack of familiarity, or some other factor. Dr. Jones knows that stopping treatment is unethical and clinically unsound. What can she do?

A recent issue brief published by Health Management Associates provides medically sound options that are greatly preferred over discontinuing treatment. In fact, they point out “Termination of naltrexone treatment for OUD deviates from the standard of care and places the facility at risk of legal action for failure to treat. It also places the detainee at serious risk of relapse, overdose, and death both if opioids are accessed in the facility and/or if a precipitous release occurs.”

The brief points out that oral substitution, while not ideal, may be an option in a correctional setting. It requires thoughtful patient selection and the right environment where patients can be carefully monitored to support compliance. Note that oral naltrexone is not a substitute for XR-NTX and is not a first-line treatment. While there is limited literature on the topic of switching, there is potential for use in certain situations.

As physicians, we have great latitude to use our professional judgment on behalf of our patients. This is what we are trained and licensed to do. This issue brief touches on one such area, the off-label use of medications. Whether we think about it or not, off-label medication use is extremely common and does not imply that a clinician is experimenting or being careless with their patients. Common examples are everywhere. If you have ever taken more than two over-the-counter ibuprofen tablets within four hours to treat pain, you have participated in off-label medication use.

The issue brief is very sound and I’m happy to recommend it to you. Opioid use disorder is one of the largest challenges facing our society, and of course, correctional leaders and institutions. Providing the field with resources is one of NCCHC’s top priorities. We expect to expand our assistance with the recent award of a grant to the NCCHC Foundation from the Bureau of Justice Assistance Comprehensive Opioid, Stimulant, and Substance Abuse Program to work on clinical guidelines for withdrawal management in jails.

Let’s talk about your options, ideas, and challenges with patient care and MAT. Contact me at [email protected].

By Brent Gibson, MD, MPH, CCHP-P
Managing Director, NCCHC Resources