Technical Naltrexone questions

[mariedc]

I have a 21 year old who relapsed on heroin after three months of nonuse and asked for my help.  She has used sporadically for two years and was drug free for six months earlier last year.  Her use in the past was sporadic and light enough that she had not undergone withdrawal.  But this last time she did 19 injections in 11 days and knew she would withdraw.  I quickly got her an appointment at an outpatient facility, where she is starting therapy.  She refused medical detox, but eight days ago took 2 mg of suboxone.  Six days ago, she gave in and shot up again.  She has not used any heroin or suboxone since.  

She will see the facilitiy's psychiatrist on Tuesday, three days from now.  This facility does not do suboxone (she got her previous bit of suboxone illegally), but rather naltrexone.  They do not do implants, just pills and Vivtrol.  My first question is whether she will be able to take the naltrexone immediately--it will have been 11 days since she took the Suboxone, the only time she has taken it.  I hear one is supposed to wait 14 days, but as it was just once and a low dose, I am wondering whether an 11 day waiting time is sufficient.

My second question is whether she can take the shot or not.  We have not scheduled it yet, but she is due for nasal surgery soon to reduce her turbinates and fix her deviated septum as she hasnot  been able to breather through her nose for some years.  Would this type of surgery be contraindicated if she has a Vivitrol shot or would she be able to go through the surgery comfortably on Vivtrol? If it is contraindicated, I suppose we are left with the option of naltrexone pills.

Thanks for any advice.

[mariedc]

Thank you for your helpful response!

[Julia M Aharonov, DO]

Vivitrol shots are a terrific idea for someone who is prone to relapsing. However it may be tricky to do surgery while she is on depo-Naltrexone. You might need to time it exactly to the end of the thirty days, do the surgery, tell the anesthesiologist and the ENT to use very short acting opiates such as Vicodins for only a few days, and ibuprophen for control of the rest of post-surgical pain. Than keep a really close eye on her and give her another shot after a week clean. You will have to time it very carefully.
I am not a big believer in oral therapy, because unless you are the one giving her the daily dose every single morning and making sure she actually swallows the pill, it is a difficult re-commitment she will have to make every day. That is a very hard choice to make for any addict. A monthly shot is out of their control and they can better focus on their recovery.
As to the 11 days, Suboxone is funny and can linger in tissues for a while. Keep a close eye on her, or tell her that you will do it on day 14 and if she is not clean, it will be so obvious to everyone, especially to her, as she will be quite miserable. That should be enough incentive for her to stay clean the extra few days. Good luck to you.