Naltrexone (known by the brand name Vivitrol) is an opiate blocker, which means that it completely blocks the euphoric or feel-good effects of opioids like heroin and prescription pain pills. It is given in pill form or as a shot. A person must be opioid-free for 7-14 days prior to getting the first shot to prevent withdrawal. Many providers will initially offer the pill form as a precautionary measure to make sure the person has no adverse reaction to the medication.
While most people will get the shot monthly, some may metabolize the medication more quickly and need the shot every three weeks. If insurance won’t cover more frequent administration, the pill form of naltrexone can be used, taken on a daily basis until the next shot.
It’s important to complete the course of treatment as prescribed by the treatment team. If a person prematurely stops taking naltrexone, they may be more at risk for an overdose due to lower tolerance.
Naltrexone can be expensive, especially if there is limited or no insurance coverage. The manufacturer, Alkermes, offers a co-pay card on their website that can help reduce the overall expense. Families may also consider appealing to their insurance company under healthcare parity laws for coverage, similar to medications needed for any other chronic illness.
Because naltrexone is a complete opioid blocker, an alternative pain medication plan will be needed for injuries and surgeries. Your child may not feel the therapeutic effects of opioid medications for pain, cough and colds. Therefore, carrying a patient wallet card or bracelet is important as a safety measure not only for naltrexone, but for all forms of MOUD.
In rare cases, a person may try to “override” the medication, taking an excessive amount of opioids in order to feel the drug’s effects, which can lead to dangerous consequences including death. Abruptly stopping the medication also poses an overdose risk due to lower tolerance of heroin and opioids, so it’s best to make this decision with the prescribing doctor.
Buprenorphine (known by the brand names Suboxone, Zubsolv, Sublocade, Subutex and Brixadi), is taken daily as an oral pill, as a film placed under the tongue or as a monthly injection. It is used to manage withdrawal symptoms when a person is detoxing, and can be used as part of an ongoing maintenance plan to manage cravings. It can be prescribed by any doctor who has completed specialized training and obtained a waiver, or a doctor with a DEA registration number. It is administered in the privacy of an office setting or outpatient clinic.
Typically the medication is taken once a day or every other day once a stable dosage is achieved. Sublocade, a monthly injection, may be recommended for people who have been stable on buprenorphine for some time and don’t want the hassle of daily dosing. Brixadi is also in the form of an injection, but offers both weekly and monthly doses.
Some people still experience cravings while taking buprenorphine, in which case the prescribed dose may be too low and needs to be increased. It is important to discuss this with the provider to see if the dosage is adequate.
Some people don’t like the taste of the Suboxone film, finding Subutex or Zubsolv more palatable. A provider can help address this issue.
Buprenorphine will result in a degree of dependence on the medication, similar to other medications like those for acid reflux, insulin, etc. If a person abruptly stops taking the medication, withdrawal symptoms can be experienced. The best course of action is to stay on the medication as prescribed and use a very slow taper with guidance by the provider over several months or longer. This likely means that treatment will run the course of a year or more, and must be tailored to the patient’s needs.
A person who has never used buprenorphine before will likely experience a sense of euphoria on the medication, but for a loved one who has been using opiates, it does not create this experience — rather, it creates a sense of normalcy, reducing cravings.
Suboxone and Zubsolv contain naloxone, which is used to prevent the misuse of the medication by IV injection. (Note that this is the same naloxone that is used to reverse overdoses; however, in this case, it is used to prevent opioid misuse, and will not reverse an overdose.) This precaution is not part of the formulation for Subutex, and, as a result, some providers will not prescribe Subutex unless it’s for a pregnant woman.
Overdosing on buprenorphine is usually not a result of the medication itself but in combination with other substances like benzodiazepines (i.e. Xanax, Klonopin, Valium) and alcohol.
Methadone is given in a pill, wafer or liquid form to be taken daily, usually at a clinic — although some states allow clients to take the medication home after a period of time. Many doctors will recommend methadone for patients who have been unsuccessful using buprenorphine.
Methadone lasts fairly long in the system, usually for 24 to 36 hours, preventing the frequent highs and lows associated with drug-seeking behaviors. Clinic staff will check toxicity levels as the medication builds up in the body, and adjust dosage levels accordingly.
While methadone has been around for decades and many people do very well on this medication, it needs to be obtained at an authorized clinic. Daily trips to a clinic can be helpful to receive counseling and support, but it may be a big commitment from a time standpoint, especially if the clinic is a significant distance from your home.
There is no specified duration of treatment; however, 12 months is considered a minimum for methadone maintenance. Some people may be on this medication for a lifetime.
There is a risk of overdosing on methadone, though the oversight provided in the clinic setting is a protective factor. Most of the people who overdose on methadone are using it for pain management purposes, not as MAT.
While MOUD has been widely endorsed by experts in the field of substance use disorders as part of comprehensive treatment plans, parents may find that their loved ones are confronted by situations where it would be helpful to have MOUD, but it isn’t allowed or offered. This is true of some treatment facilities, sober living homes and jails. Unfortunately, there is no easy answer for this other than to try and find programs that will support your son or daughter’s treatment plan.
Your voice, as part of a chorus of advocacy efforts, is needed to make these scientifically proven treatment options more universally available.
These medications are designed to address heroin and other opioids (although Vivitrol can be used to address alcohol), but will not prevent the use of other substances, like alcohol, marijuana, benzodiazepines and stimulants.
While these considerations are important in understanding how MOUD works, your support and encouragement are an essential part of your loved one’s recovery and will greatly contribute to their well-being. The longer they use MOUD, the greater the opportunities for success.