What is the best course of action to prepare a patient taking Vivitrol (naltrexone) 480 mg/5 mL every 4 weeks for pain management during an upcoming hip replacement surgery?

From the Guidelines

The best course of action to prepare JD for pain management during his upcoming hip replacement surgery is to discontinue the naltrexone (Vivitrol®) injection at least 30 days before the scheduled surgery, as recommended by the Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement 1. This approach allows the naltrexone to clear from the body's receptors, enabling opioid pain medications to work effectively post-surgery. The surgical team should be clearly informed about JD's Vivitrol treatment. During this pre-surgical period, non-opioid pain management options should be optimized, including acetaminophen, NSAIDs (if not contraindicated), and possibly gabapentinoids. For the surgery itself, regional anesthesia techniques like spinal or epidural anesthesia and peripheral nerve blocks should be considered as primary pain control methods. Post-operatively, higher doses of opioids may be required initially as some naltrexone effect might persist. The pain management plan should include multimodal approaches with scheduled acetaminophen, NSAIDs, and physical therapy. Vivitrol can be resumed once JD is stable and no longer requires opioid pain management, typically 7-10 days after surgery, as suggested by the consensus statement 1. This approach is necessary because naltrexone blocks opioid receptors, which would otherwise render standard opioid pain medications ineffective and potentially lead to inadequate pain control or dangerous attempts to overcome the blockade with excessive opioid doses. Key considerations include:

• Discontinuing naltrexone 30 days prior to surgery to ensure its effects are minimized during the surgical period 1
• Utilizing non-opioid pain management strategies pre-operatively
• Employing regional anesthesia techniques during surgery
• Implementing a multimodal pain management plan post-operatively
• Resuming Vivitrol once opioid pain management is no longer necessary, typically after 7-10 days 1

From the FDA Drug Label

When Reversal of Naltrexone Hydrochloride Blockade is Required:- for Pain ManagementIn an emergency situation in patients receiving fully blocking doses of naltrexone hydrochloride, a suggested plan of management is regional analgesia, conscious sedation with a benzodiazepine, use of non-opioid analgesics or general anesthesia In a situation requiring opioid analgesia, the amount of opioid required may be greater than usual, and the resulting respiratory depression may be deeper and more prolonged.

The best course of action to prepare a patient taking Vivitrol (naltrexone) for pain management during an upcoming hip replacement surgery is to stop the naltrexone therapy.

• The patient should not receive the injection 4 weeks prior to surgery.
• Oral naltrexone 50 mg once daily can be started, but it should be discontinued 72 hours prior to surgery.
• Naltrexone therapy should not be restarted for at least 7-10 days after the last opioid was taken. This approach allows for alternative pain management strategies, such as regional analgesia or non-opioid analgesics, to be considered, while minimizing the risk of opioid-related complications 2.

From the Research

Preparation for Pain Management During Surgery

To prepare a patient taking Vivitrol (naltrexone) 480 mg/5 mL every 4 weeks for pain management during an upcoming hip replacement surgery, several factors must be considered:

• The patient's current medication regimen and its potential impact on postoperative pain management 3
• The use of non-opioid pain management strategies to reduce opioid consumption 4, 5
• The potential challenges of managing pain in patients taking opioid antagonists 6

Considerations for Naltrexone Therapy

• Naltrexone can complicate postoperative pain management by increasing the opioid requirement for postoperative pain control 3
• Discontinuing naltrexone therapy prior to surgery may be necessary to ensure effective pain management 6
• Alternative pain management strategies, such as multimodal pain regimens and non-pharmacological management, can help mitigate opioid dependence and control pain in patients taking naltrexone 3, 5

Recommendations for Pain Management

• Consider discontinuing naltrexone therapy 4 weeks prior to surgery and starting oral naltrexone 50 mg once daily, then discontinuing oral naltrexone 72 hours prior to surgery 6
• Use non-opioid pain management strategies, such as ibuprofen, to reduce opioid consumption 4
• Employ a multimodal pain management approach, including local periarticular injections and non-pharmacological management, to reduce postoperative pain levels and opioid consumption 5

Potential Risks and Outcomes

• Patients taking opioids prior to total hip arthroplasty may be more likely to suffer from opioid-induced hyperalgesia and have worse clinical outcomes 7
• Efforts should be made to use alternative modes of analgesia or wean patients from opioid use prior to total hip arthroplasty 7