How many days before and after Vivatrol (naltrexone) administration should patients be opioid-free?

Opioid-Free Period Required Before and After Vivitrol Administration

Patients must be completely opioid-free for a minimum of 7-10 days before starting Vivitrol (naltrexone) to avoid precipitating severe withdrawal, and after discontinuation, oral naltrexone requires 2-3 days clearance while extended-release Vivitrol requires 24-30 days before opioids can be safely used. 1, 2

Before Starting Vivitrol: Required Opioid-Free Period

Standard Short-Acting Opioids

• Minimum 7-10 days opioid-free is required for patients previously dependent on short-acting opioids (such as oxycodone, hydrocodone, heroin) before initiating naltrexone 1
• This waiting period prevents precipitated withdrawal, which can be severe enough to require hospitalization 1, 2

Extended Considerations for Long-Acting Opioids

• Patients transitioning from buprenorphine or methadone may be vulnerable to precipitated withdrawal for as long as 2 weeks after their last dose 1
• Healthcare providers should be prepared to manage withdrawal symptomatically with non-opioid medications during this extended period 1

Clinical Verification Methods

• Do not initiate Vivitrol in patients showing clinical signs or symptoms of opioid withdrawal 1
• Do not start treatment if urine contains opioids 1
• A naloxone challenge test may be helpful if there is any question of occult opioid dependence, but should not be performed in patients with clinical withdrawal signs or positive urine opioids 1

After Vivitrol: Required Clearance Before Opioid Use

Oral Naltrexone Clearance

• Hold oral naltrexone for 2-3 days (or 3-4 days) before opioids are needed for procedures or pain management 2, 3, 4
• This shorter clearance time is due to naltrexone's plasma half-life of 4 hours and its active metabolite's half-life of 13 hours, with antagonist effects persisting 2-3 days 2, 3

Extended-Release Vivitrol Clearance

• Extended-release Vivitrol must be held 24-30 days after the last injection before elective procedures requiring opioids 2, 3, 4
• This prolonged clearance period reflects the sustained-release formulation that provides therapeutic levels for approximately one month 5

Critical Safety Warnings

Risk of Precipitated Withdrawal

• Administering naltrexone to patients with opioid dependence or recent opioid exposure can precipitate severe, potentially life-threatening withdrawal requiring hospitalization 2, 1
• Withdrawal precipitated by naltrexone is different from spontaneous withdrawal and can be more severe 1
• Patients must understand they should not take naltrexone if they have any symptoms of opioid withdrawal 1

Risk of Overdose After Discontinuation

• Patients who discontinue naltrexone treatment have increased risk of opioid overdose and death due to decreased opioid tolerance 3, 4, 1
• If patients return to previous opioid use after naltrexone discontinuation, they may be more sensitive to lower doses of opioids and at risk of accidental overdose 1
• Provide opioid overdose education and consider offering naloxone to patients undergoing naltrexone discontinuation 3

Common Pitfalls to Avoid

• Never assume all opioids clear at the same rate: Short-acting opioids require 7-10 days, but buprenorphine and methadone may require up to 2 weeks 1
• Do not confuse oral and injectable formulation clearance times: Oral naltrexone clears in 2-3 days, but Vivitrol requires 24-30 days 2, 3, 4
• Avoid starting naltrexone based solely on patient report: Verify opioid-free status with urine testing and clinical assessment for withdrawal signs 1
• Do not attempt to overcome naltrexone blockade with large opioid doses: This may lead to serious injury, coma, or death 1