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Am J Emerg Med. 2018 Jun;36(6):1128.e1-1128.e2. doi: 10.1016/j.ajem.2018.03.052. Epub 2018 Mar 21.

Severe opioid withdrawal precipitated by Vivitrol®.

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Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Brown Emergency Medicine, Providence, RI, 02903, USA. Electronic address:
Rutgers New Jersey Medical School, Newark, NJ, 07103, USA.
NYU School of Medicine, Department of Population Health, New York, NY, 10016, USA.
Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY, 10016, USA; Institute for Innovations in Medical Education, NYU Langone Health, New York, NY, 10016, USA.


The risk of severe precipitated opioid withdrawal (POW) is amplified when precipitated by a long-acting opioid antagonist. IM extended release naltrexone (XRNTX;Vivitrol®) is an FDA approved therapy to prevent relapse of opioid and alcohol abuse. Two cases of precipitated opioid withdrawal from XRNTX are presented that illustrate different patient reactions to POW. A 56-year-old woman developed a hypertensive emergency and required continuous intravenous vasodilator, clonidine, and intensive care monitoring after re-initiation of XRNTX following opioid relapse. A 25-year-old man developed agitation and altered mental status after receipt of XRNTX at the conclusion of a twelve-day detoxification program during which he continued surreptitious use of heroin. The patient received benzodiazepines and haloperidol without adequate affect, and required intubation with propofol, lorazepam, and dexmedetomidine infusions. Management of POW from XRNTX is a challenge to emergency providers and protocols to guide management do not exist. Recommended therapies include intravenous fluids, anti-emetics, clonidine, or benzodiazepines as well as therapy tailored to the organ system affected. To minimize risk of POW it is important for providers instituting XRNTX to adhere to the manufacturers warnings and clinic protocols including a naloxone challenge and ensure an adequate opioid free period prior to administration of XRNTX.


Addiction medicine; Medication safety; Naltrexone; Opioid withdrawal; Toxicology


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