From the Guidelines
Vivitrol (naltrexone) does not cause physical withdrawal symptoms when discontinued because it is an opioid antagonist, not an opioid itself. When stopping Vivitrol, patients will not experience the typical withdrawal symptoms associated with opioid medications, such as cravings, abdominal cramping, nausea, vomiting, diarrhea, agitation, anxiety, and myalgias, as described in the context of opioid withdrawal 1. However, some individuals may notice psychological effects like increased cravings for alcohol or opioids since the medication was blocking these substances' rewarding effects.
After discontinuation, patients should be aware that their tolerance to opioids may have decreased significantly, making them more vulnerable to overdose if they return to previous opioid use. This reduced tolerance is particularly dangerous in the first two weeks after stopping Vivitrol. The treatment of opioid withdrawal, as outlined in a clinical policy for adult patients presenting to the emergency department 1, may involve symptomatic treatment with α2-adrenergic agonists, antiemetics, atypical antipsychotics, and other medications, but this is not directly applicable to Vivitrol withdrawal since it does not cause opioid-like withdrawal symptoms.
Key considerations for discontinuing Vivitrol include:
- Monitoring for increased cravings for alcohol or opioids
- Awareness of decreased opioid tolerance and the risk of overdose
- Development of a comprehensive relapse prevention plan
- Possible transition to another medication-assisted treatment option
- Close consultation with a healthcare provider to manage the transition period and prevent complications, as the primary goal is to minimize morbidity, mortality, and improve quality of life.
From the Research
Vivitrol Withdrawal
- Vivitrol, also known as extended-release naltrexone, is a medication used to prevent relapse to opioid dependence in detoxified patients 2.
- The risk of severe precipitated opioid withdrawal (POW) is amplified when precipitated by a long-acting opioid antagonist like Vivitrol 3.
- Management of POW from Vivitrol is a challenge to emergency providers, and recommended therapies include intravenous fluids, anti-emetics, clonidine, or benzodiazepines 3.
- To minimize the risk of POW, it is essential for providers instituting Vivitrol to adhere to the manufacturer's warnings and clinic protocols, including a naloxone challenge and ensuring an adequate opioid-free period prior to administration of Vivitrol 3.
Comparison with Other Medications
- Vivitrol has been compared to other medications, such as buprenorphine and methadone, in the treatment of opioid dependence 4, 5.
- A systematic review and meta-analysis found that methadone was associated with better treatment retention than buprenorphine, but there was no evidence suggesting that adherence to treatment differed between the two medications 4.
- A randomized comparative-effectiveness trial found that patients' demographic and clinical characteristics, such as homelessness and parole status, may be important in guiding the choice of treatment between buprenorphine and extended-release naltrexone 5.
Side Effects and Efficacy
- Vivitrol has been shown to be effective in preventing relapse to opioid dependence, with a significant reduction in opioid craving and a longer treatment retention period compared to placebo 2.
- The most common side effects of Vivitrol include hepatic enzyme abnormalities, nasopharyngitis, insomnia, hypertension, influenza, and injection-site pain 2.
- Vivitrol has also been shown to be effective in reducing alcohol consumption and heavy drinking episodes among persons with alcohol use disorders 6.