• VIVITROL is a prescription injectable medicine used to:
-Treat alcohol dependence. I should stop drinking before starting VIVITROL and
-Prevent relapse to opioid dependence, after opioid
detoxification.
• Alcohol Dependence: I agree, I must stop drinking alcohol or alcohol containing products before starting Vivitrol.
• Opioid Dependence: I agree to must stop opioids 7-10 days before starting Vivitrol.
• I agree, VIVITROL is not right for everyone. There are significant risks from VIVITROL treatment, including risk of opioid overdose, severe reaction at the injection site, sudden opioid withdrawal, liver damage, or hepatitis.
• I agree and understand, it is my responsibility If I am being treated for alcohol dependence but also use or addicted to opioid-containing medicines or opioid street drugs, it is important that I tell my healthcare provider before starting VIVITROL to avoid having sudden opioid withdrawal symptoms when I start VIVITROL treatment.
• I agree and understand, VIVITROL blocks the effects of opioids, such as heroin or opioid pain medicines. I will not try to overcome this blocking effect by
taking large amounts of opioids—this can lead to serious injury, coma, or death.
• I agree and understand to call 911 or get emergency medical help right away in
all cases of known or suspected opioid overdose, even if naloxone is administered.
• I agree to tell my family and the people closest to me of this increased sensitivity to opioids and the risk of overdose.
• I agree and understand that severe reactions at the site of injection can occur. Some people on VIVITROL have had severe injection site reactions, including tissue death.
Some of these reactions have required surgery. VIVITROL must be injected by a healthcare provider every 4 weeks. I will call healthcare provider right away if I notice any of the following at injection sites.
• I agree and understand that Naltrexone, the active ingredient in VIVITROL, can cause liver damage or hepatitis. I will communicate with my healthcare provider if I have any of these symptoms during treatment with VIVITROL.
• I agree and understand that a reaction at the site of Vivitrol may occur and symptoms includes pain, tenderness, induration, redness, soreness, bruising and itching. These symptoms usually subside in a week. If symptoms persist more than a week then I will call the office. I can call anytime or on as needed basis.
• I agree and understand, the risks associated with pregnancy. It is my responsibility to update my pregnancy or breast-feeding status to my medical professional. I will also update my medical provider if I am planning to get pregnant.
• I agree and understand that I will continue behavioral therapy and counseling. I will update the clinic with medical updates and changes including any new onset or worsening of current mental health issues.
• I understand that vivitrol may cause an allergic pneumonia or severe nausea. I will notify my provider if I experience shortness of breath, cough, wheezing, fever, severe nausea, or vomiting.
• I will carry the card of vivitrol and will update my other medical providers.
• I agree to inform my medical provider before starting any new medications including
over the counter medications or supplements due to possible contraindications.
• I agree not to drive or operate machinery or do dangerous activities until it is known how this medication will affect me.
• I agree and understand that I will not drink alcohol or take any other illicit drugs while on Vivitrol.
• I agree to return to clinic in one month for next injection.
• I agree, it is my responsibility to update my phone number and address for communication purposes.
• I have read all the information about Vivitrol. All my questions are answered. Side effects, dosage, risks, benefits, and adverse effects discussed in detail. I agree and understand that I am responsible to abide by these instructions. I have no further questions currently. I acknowledged and repeated back the risks and benefits to
medical provider. I would like to start my treatment of Vivitrol with WellCare Medical Clinic.