Injectable Naltrexone (Vivitrol) is a long-acting formulation of naltrexone used to manage opioid and alcohol dependence. This guide provides healthcare professionals with a comprehensive, step-by-step approach to administering Vivitrol, ensuring both patient safety and optimal treatment outcomes. Proper administration is essential, as incorrect technique or preparation can lead to complications, reduced efficacy, or adverse reactions. Below, we cover everything from patient readiness evaluation to post-injection care, along with strategies to manage missed doses.


Table of Contents


Evaluating Patient Readiness for Vivitrol Injection

Before administering Vivitrol, it's crucial to assess whether the patient is ready to receive the medication. This evaluation ensures that the patient can safely benefit from the injection without risking complications such as opioid withdrawal or adverse reactions.

  • Opioid-Free Requirement: Vivitrol is only suitable for patients who have been opioid-free for at least 7-10 days. Administering Vivitrol to a patient currently dependent on opioids can cause precipitated withdrawal, a severe and uncomfortable reaction. To confirm opioid-free status, healthcare providers can use urine drug tests, patient interviews, and withdrawal symptom evaluations.
  • Medical History Assessment: A thorough review of the patient's medical history is necessary. Naltrexone is contraindicated in patients with liver failure or acute hepatitis, so liver function tests (LFTs) should be checked. Additionally, be cautious with patients who have renal impairment or other serious health conditions that might complicate treatment.
  • Alcohol Use Evaluation: For patients receiving Vivitrol for alcohol dependence, the provider should review the patient's recent alcohol use and confirm sobriety at the time of injection. Ensure the patient understands that Vivitrol is not a cure but an aid in preventing relapse.
  • Allergy and Medication Review: Ensure the patient has no known allergies to naltrexone or any other component of the Vivitrol suspension. Review all current medications to avoid potential drug interactions.
  • Patient Education and Consent: Before proceeding, inform the patient about the potential side effects, including injection site reactions, nausea, fatigue, and depression. Discuss the importance of staying opioid-free and the commitment to monthly injections. Obtain informed consent, documenting the discussion in the patient’s records.

Preparing the Gluteal Injection Site

Proper preparation of the injection site is essential to reduce the risk of complications such as infection or discomfort and to ensure correct delivery of the medication.

  • Selecting the Injection Site: Vivitrol should be administered into the gluteal muscle, alternating between the right and left side with each dose. This rotation helps prevent irritation and scarring at the injection site.
  • Patient Positioning: The patient should lie on their stomach or stand while leaning slightly forward. This position helps fully expose the gluteal muscle, ensuring proper access for the injection.
  • Cleaning the Area: Clean the injection site with an alcohol swab, starting from the center and moving outward in a circular motion. Allow the skin to dry completely before proceeding with the injection to avoid discomfort and infection.
  • Avoiding Problematic Areas: Avoid injecting into any area that shows signs of irritation, swelling, infection, or scarring. If the skin looks compromised, choose an alternative site on the other gluteal muscle.

Reconstituting the Vivitrol Suspension

Vivitrol comes as a microsphere powder that must be reconstituted before administration. The correct preparation of the suspension is critical for delivering the proper dose of medication.

  1. Gather the Vivitrol Kit: The kit includes the powder vial, a vial of diluent, a 20-gauge needle for reconstitution, and a second needle for injection.
  2. Inspect the Vials: Before starting, visually inspect both the powder vial and diluent to ensure there are no particles or signs of contamination.
  3. Attach the Mixing Needle: Secure the 20-gauge needle to the syringe and draw up 3.4 mL of diluent from the vial.
  4. Reconstitute the Suspension: Inject the diluent into the vial containing the Vivitrol powder. Gently swirl the vial to mix the contents—do not shake, as this could affect the suspension’s consistency.
  5. Check for Uniformity: The suspension should appear cloudy but smooth. If any clumps remain, continue swirling gently until the suspension is fully mixed.
  6. Draw the Suspension: Use the same needle to draw the entire suspension back into the syringe, ensuring there are no air bubbles by gently tapping the syringe.
  7. Prepare for Injection: Replace the reconstitution needle with a fresh 1.5-inch 20-gauge needle for injection.

Administering the Intramuscular Injection

After preparing the Vivitrol suspension, follow these steps to administer the intramuscular injection correctly:

  1. Confirm the Injection Site: Verify the gluteal muscle site, ensuring the area has been cleaned and is free of irritation.
  2. Change to the Injection Needle: Attach the fresh needle to the syringe, ensuring it's securely in place.
  3. Insert the Needle: Holding the syringe like a dart, insert the needle at a 90-degree angle into the muscle. Make sure the needle is deep enough to reach the gluteal muscle, but not too deep to hit bone or too shallow to stay in the subcutaneous tissue.
  4. Aspirate the Syringe: Gently pull back on the plunger to check for blood. If blood appears in the syringe, this indicates you’ve entered a blood vessel, and you should withdraw the needle, discard the product, and prepare a new dose. If no blood appears, proceed with the injection.
  5. Inject the Suspension: Slowly inject the Vivitrol suspension into the muscle, taking around 30 seconds to deliver the entire dose. This helps ensure that the medication is evenly distributed in the muscle.
  6. Withdraw the Needle: After administering the dose, swiftly withdraw the needle and apply light pressure to the injection site with a gauze pad to prevent bleeding.
  7. Disposal: Immediately discard the needle and syringe in a sharps container.

Patient Care Immediately Following the Injection

Proper post-injection care ensures that patients experience minimal discomfort and reduces the risk of complications:

  • Apply Pressure: After withdrawing the needle, apply pressure to the injection site for a few moments to prevent bleeding. Use a sterile gauze or bandage as needed.
  • Monitor for Immediate Reactions: Observe the patient for 15-20 minutes after the injection to check for any immediate allergic reactions, dizziness, or signs of distress.
  • Advise Rest: Encourage the patient to rest the injection site and avoid strenuous physical activity for the remainder of the day to reduce discomfort.
  • Educate the Patient: Explain that mild soreness, redness, or swelling at the injection site is common and typically resolves within a few days. Over-the-counter pain medications, such as ibuprofen or acetaminophen, can be recommended if necessary.

Preventing and Addressing Injection Site Reactions

Injection site reactions are common but can be managed and minimized with proper care and technique. Here's how to prevent and address these reactions:

  • Rotate Injection Sites: Alternating between the left and right gluteal muscles with each injection helps reduce the risk of irritation and scarring.
  • Manage Mild Reactions: For mild redness, soreness, or swelling, recommend warm compresses or over-the-counter pain relievers. Instruct the patient to monitor the site for improvement over the next few days.
  • Identify Severe Reactions: Severe injection site reactions, including abscesses, necrosis, or infection, require immediate medical attention. Instruct patients to contact their healthcare provider if they notice extreme pain, increased swelling, pus, or fever. Surgical intervention may be necessary for abscesses.

Recording the Administration and Scheduling Follow-Up

Accurate documentation of each Vivitrol administration is crucial for continuity of care:

  • Record the Dose: Document the date, time, dose, and site of injection in the patient's medical record. Include any adverse reactions observed during or after the administration.
  • Schedule Follow-Up: Vivitrol is administered once every four weeks. Schedule the next injection immediately following the current one, ensuring that the patient understands the importance of adhering to the treatment schedule.
  • Patient Reminders: Remind the patient to keep their follow-up appointment. Consider using automated reminders via phone or text to reduce the likelihood of missed doses.

Managing Missed Doses

If a patient misses a scheduled dose of Vivitrol, it's important to manage the situation appropriately to maintain treatment efficacy:

  • Contact the Patient: If a patient misses an appointment, contact them as soon as possible to reschedule. A missed dose can increase the risk of relapse.
  • Evaluate for Relapse: If the patient has missed their injection by more than a few days, reassess their opioid-free status before proceeding with the next dose. Consider using a urine drug screen or withdrawal symptom evaluation.
  • Restart the Opioid-Free Period: If the patient has relapsed on opioids or more than 30 days have passed since the last injection, a 7-10 day opioid-free period may need to be restarted before resuming Vivitrol.
  • Patient Education: Reiterate the importance of maintaining regular injections and staying opioid-free to prevent relapse and withdrawal.

Glossary

Opioid-Free Period
A duration during which an individual abstains from opioid use, often required before starting opioid antagonists like naltrexone to avoid precipitated withdrawal.
Gluteal Muscle
A group of muscles in the buttocks that are often used as an injection site for medications requiring intramuscular administration.
Intramuscular
Relating to or situated within a muscle, often referring to an injection given directly into a muscle.

References

Administration Procedure for Injectable Naltrexone (Vivitrol)

Preparing the Gluteal Injection Site

Reconstituting the Vivitrol Suspension

Administering the Intramuscular Injection

Patient Care Immediately Following the Injection

Preventing and Addressing Injection Site Reactions

Recording the Administration and Scheduling Follow-Up

Managing Missed Doses