Dr. William Jacobs1. After you evaluate a heroin addict, what are the next steps for stabilization and detoxification in a residential setting? How would you do this safely in an outpatient setting? 

Next steps after a good addiction history, including any previously prescribed or unprescribed exposure to buprenorphine, would be to do drug testing which now includes screening for fentanyl as we are seeing that in nearly all “heroin” addicts. Afterward, a detailed medical and psychiatric assessment is performed. If the decision is made to transition to depo-naltrexone for withdrawal management in a residential setting, we use maximum tolerated doses of clonidine and look forward to using lofexidine as a potentially better tolerated alternative. If the patient is unable to tolerate sufficient doses of clonidine to adequately manage withdrawal symptoms despite use of prn medications for GI upset, body aches and other symptoms of opioid withdrawal, we use small 2-4 mg doses of sublingual buprenorphine but we try to minimize those to reduce the buprenorphine delaying depo-naltrexone administration. We usually start low dose oral naltrexone (12.5-25 mg) within 5-7 days after last assuming the patient has not been taking methadone and the urine drug screens are negative for methadone. Usually by day 2 of oral naltrexone we can increase dose to a full 50mg. During the naltrexone induction, we continue PO or transdermal clonidine and prn medications. If the patient is tolerating oral naltrexone at 50 mg, we inject depo-naltrexone 380 mg monthly and usually continue it for at least 12 months to provide support while the patient is building and strengthening their recovery program.

In an outpatient setting, clinical trials have shown that straight forward opioid detoxification and induction to depo-naltrexone can be accomplished in 7-8 days, so long as the patient has not been using methadone or buprenorphine. ASAM criteria should be used to determine which patients are potential candidates for an outpatient setting with special attention being paid to dimensions 4, 5 and 6. The patient would return to the outpatient office daily for assessment until depo-naltrexone has been administered.

Intravenous or Intramuscular naloxone challenge can be used in any setting to provide the healthcare provider assurance that the depo-naltrexone injection will not precipitate withdrawal.

2. Insurance companies and other factors may be a factor but what is an ideal detox period if you were using Vivitrol? Would you have a typical schedule you might be able to share? 

In the residential setting, we usually start clonidine 0.1mg PO q 4h x 24h, then q 6h x 24h, then q 8h x 24h, then qhs x 3 nights checking orthostatic vital signs but if blood pressure allows, nurses may also give additional clonidine prn for significant opioid withdrawal symptoms.

In the outpatient setting, the clonidine is usually dosed 0.1mg tid but transdermal patches can also be used.

3. Would you use something to help alongside Vivitrol like clonidine or lofexidine to reduce irritability and sleep problems?

In the residential setting, we use prn medications for nausea (ondansetron), for abdominal cramping (bentyl), for diarrhea (loperamide), for pain and body aches (NSAIDs, acetaminophen and muscle relaxants including methocarbamol, baclofen or tizanidine), for sleep we usually start with phenobarbital but after the first few days, if still needed, we will transition to gabapentin or trazadone on a temporary basis.

In the clinical trials for outpatient depo-naltrexone induction, clonazepam was used as a prn “comfort” medication during the day and at night for sleep.

4. We have mandated use in anesthesiologists and similar addicts, but which other patients are more logical for Vivitrol vs Suboxone?

Many patients have had experience with buprenorphine and if they have been prescribed the medication and have used it appropriately but still relapsed, they could be good candidates for depo-naltrexone. I have treated a number of patients who entered treatment abusing buprenorphine as their “drug of choice” and I have encouraged those patients to consider depo-naltrexone. If a patient has had good success with buprenorphine in the past but relapsed after discontinuing it, we tend to encourage them to restabilize on buprenorphine.

A number of my colleagues across the country and I have seen patients relapse on the current formulation after three weeks post injection of the current Vivitrol formulation. Researchers may develop a longer lasting option, such as an 8 week formulation but I would be concerned that some healthcare providers would then not follow the patients closely especially early in recovery when most need frequent monitoring with drug testing and accountability.

5. How long have you been able to keep patients on Vivitrol? Why would they stop if they are immune to relapse?

I have had patients continue monthly depo-naltrexone injections for more than three years in some cases but usually we encourage patients to remain on it until they have demonstrated >12 months of not just abstinence but have developed a solid 12-step based recovery at which time we ask the patients, their sponsors and support systems, including their healthcare providers, to carefully evaluate their recovery maintenance program for any weakness that could be addressed prior to discontinuing the monthly injections. We also ask them to try to look ahead for the next few months, and if they identify any major stressors or potential relapse triggers, we encourage them to remain on depo-naltrexone until those have been resolved.

Depo-naltrexone does not confer “immunity” from relapse. I consider it and other medications to assist recovery as supports to help the patient remain abstinent until they have developed a maintenance recovery program that is strong enough to support them without the medications.

It is vitally important for treating healthcare providers to continue to monitor patients’ recovery including drug testing and to provide assistance in developing strong maintenance recovery programs.

In closing, it is also critical that patients be educated that it is still possible to overdose and die if they use opioids, especially the potent synthetic fentanyl analogues while on depo-naltrexone, and their continuing care should include initial and regular monitoring of liver function, as naltrexone does carry a black box warning regarding potential for hepatotoxicity. We regularly inject depo-naltrexone in patients with liver function tests up to three times normal as long as we have seen a downward trend in the results, but we do follow those patients more closely for evidence of worsening hepatic function.  We also provide prescriptions for rescue naloxone to patients and their families in the event they do relapse and overdose.