Question

Substance abuse disorder: JS is a 27-year-old male patient who you are seeing for the first time. His past medical history is significant for his history of heroin and prescription opioid abuse. His substance use disorder started four years ago with prescription pain pills that were originally prescribed for injuries sustained in an automobile accident. For three years after the accident, he was able to readily obtain prescription opioids, but that changed when his prescribing physician was arrested for running a pill mill. JS then turned to the streets to maintain his supply of opioids. As the prescription medications became harder to come by, he turned to heroin. Two months ago he overdosed on heroin. He was admitted to a treatment facility for detoxification and treatment. During treatment he was started on Vivitrol.

1. Explain what Vivitrol is and how it works?
2. How is Vivitrol dosed?
3. What are the potential adverse effects?
4. What monitoring should be done during therapy with the medication?
5. Vivitrol is expensive. What alternatives exist if this patient’s insurance is not willing to cover the medication and the patient cannot afford it?

Answer 1

Ans)a. Naltrexone, sold under the brand names ReVia and Vivitrol among others, is a medication primarily used to manage alcohol or opioid dependence. An opioid-dependent person should not receive naltrexone before detoxification. It is taken by mouth or by injection into a muscle. Effects begin within 30 minutes.

VITIROL WORKS as:

VIVITROL contains naltrexone, an opioid antagonist or blocking medication with highest affinity for the mu opioid receptor.

Occupation of opioid receptors by naltrexone may block the effects of endogenous opioid peptides. It markedly attenuates or completely blocks, reversibly, the subjective effects of exogenous opioids.

Although the mechanism of action in alcohol dependence is not fully understood, this blockade is thought to prevent the increased dopamine release responsible for the pleasurable reinforcing effects of alcohol.

b.

The dose of this medicine will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of this medicine. If your dose is different, do not change it unless your doctor tells you to do so.

The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.

• For oral dosage form (tablets):
  • For alcoholism:
    • Adults—50 milligrams (mg) once a day.
    • Children—Use and dose must be determined by your doctor.
  • For narcotic addiction:
    • Adults—At first, 25 milligrams (mg) (one-half tablet) for the first dose, then another 25 mg 1 hour later. After that, the dose is 350 mg per week. Your doctor will direct you to divide up this weekly dose and take naltrexone according to one of the following schedules:
      • 50 mg (one tablet) every day; or
      • 50 mg a day during the week and 100 mg (two tablets) on Saturday; or
      • 100 mg every other day; or
      • 150 mg every 3 days.
    • Children—Use and dose must be determined by your doctor.

Missed Dose

If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.

c. Common adverse effects of Vivitrol include:

- streptococcal pharyngitis, syncope, anxiety, arthralgia, arthritis, dizziness, drowsiness, fatigue, frequent headaches, headache, joint stiffness, nasopharyngitis, nausea, nervousness, obsessive compulsive disorder, panic attack, pharyngitis, posttraumatic stress disorder.

d.Alcohol and opioid-dependent patients taking VIVITROL should be monitored for depression or suicidal thoughts.

- Alert families and caregivers to monitor and report the emergence of symptoms of depression or suicidality.

- For VIVITROL patients in emergency situations, suggestions for pain management include regional analgesia or use of non-opioid analgesics.

- If opioid therapy is required to reverse the VIVITROL blockade, patients should be closely monitored by trained personnel in a setting staffed and equipped for CPR.