Extended-Release Naltrexone Injection Procedure Note

Date/Time: [Date and time of visit]

Location: [Clinic/site]

Clinician: [Name, credentials]

Procedure: Extended-release naltrexone injection (XR-NTX) administration

Visit Type: [Induction (first dose) / Maintenance (subsequent dose) / Re-initiation (restart after discontinuation) / Planned but not administered]

Indication & Treatment Context

Indication: [OUD relapse prevention after detoxification / AUD / Both OUD and AUD]

Last XR-NTX injection: [Date] (Include only for Maintenance or Re-initiation visits)

Recovery plan context: [Brief statement that XR-NTX is provided as part of broader recovery plan with relevant supports noted]

Interval History

(Include only for Maintenance or Re-initiation visits; omit entirely for Induction.)

• Opioid use since last injection: [Yes/No/Not assessed] (If yes: last use date/time, substance, route, amount)
• Overdose events or naloxone administration: [Yes/No/Not assessed] (If yes, describe)
• Hospitalizations or ED visits: [Yes/No/Not assessed] (If yes, describe)
• Pain episodes requiring or anticipating opioid analgesia: [Yes/No/Not assessed] (If yes, describe context and plan)
• Injection adherence: [On schedule / Delayed] (If delayed, explain)
• Adverse effects since last injection: [Site reactions and/or systemic symptoms, or none]
• Engagement with recovery supports: [Counseling attendance, mutual support participation, or not assessed]

Pre-Procedure Assessment

Opioid-Free Verification

• Patient-reported last opioid use: [Date/time, opioid type, route, amount] (Include methadone/buprenorphine/tramadol if relevant; note certainty of recall)
• Calculated opioid-free interval: [Number] days
• Current withdrawal symptoms: [None / Mild / Moderate / Severe] (Describe key symptoms if present)
• COWS score: [Score] (Include only if performed)

Verification methods used:

• Patient interview and collateral: [Summary of sources and findings]
• Medication list review: [Findings regarding opioid-containing medications]
• Urine drug testing: Specimen: [Urine / Oral fluid]; Collection time: [Time]; Panels: [List including methadone/buprenorphine]; Result: [Negative / Positive / Pending / Not obtained] (If positive, list detected analytes)
• Naloxone challenge: [Route, dose, observed response, monitoring duration] (Include only if performed)
• PDMP review: [Findings] (Include only if reviewed)
• Detox completion documentation: [Date, source, summary] (Include only if available)

Clinical rationale regarding opioid dependence status: [Narrative explaining why the clinical team is satisfied the patient is not currently opioid-dependent] (Acknowledge any uncertainties or mixed evidence; document risk discussion and shared decision-making. If UDT is pending or evidence is incomplete, do not conclude "opioid-free verified"—describe risk/benefit assessment and plan. If last use date is uncertain, document uncertainty and treat as higher risk.)

Contraindications Screen

• Current opioid use or physiologic dependence suspected: [Yes / No] (If Yes, explain)
• Acute opioid withdrawal present: [Yes / No] (If Yes, explain and include COWS if available)
• Current or anticipated need for opioid analgesics: [Yes / No] (If Yes, describe context and plan)
• Opioid toxicology positive: [Yes / No / Not tested / Pending] (If Yes, explain)
• Naloxone challenge failed or equivocal: [Yes / No / Not performed] (If Yes, explain)
• Hypersensitivity to naltrexone or injection components: [Yes / No] (If Yes, explain)
• Hepatic disease risk or acute hepatitis symptoms: [Yes / No] (If Yes, describe findings or monitoring plan)
• Bleeding risk for IM injection: [Yes / No / Unknown] (If Yes, explain)
• Pregnancy status (for pregnancy-capable patients): [LMP date / Contraception in use / Pregnancy test result and date / Unknown] (If unknown, document next steps)

Focused Exam

• Vitals: BP [Value], HR [Value] [Additional vitals if obtained]
• General appearance and mental status: [Concise functional assessment]
• Prior injection site inspection: [Appearance: induration, tenderness, erythema, or complications] (Include for Maintenance visits)

Informed Consent

Risks and benefits discussed: [Indication and expected benefits; precipitated withdrawal risk if opioids present; overdose vulnerability after lapse/missed dose/discontinuation; danger of attempting to override blockade; injection site reactions including severe events; liver injury symptoms; mood/depression monitoring; analgesia implications including opioid ineffectiveness and emergency planning]

Alternatives discussed: [Buprenorphine / Methadone / Non-medication pathways / Deferring treatment]

Patient questions: [Summary of questions and responses]

Patient agreement: [Patient verbalized understanding and agreed to proceed] (Include direct patient quote if it supports comprehension, such as confirming last opioid use date. Never infer consent from procedure completion.)

Procedure Details

(Include this section only if injection was administered. If not given, omit and complete Deferred Procedure section instead.)

Pre-Procedure Verification

• Correct patient verified using two identifiers: [Yes]
• Correct medication/dose/route/site verified: XR-NTX 380 mg, deep IM, [Right / Left] gluteal
• Allergies reviewed: [Yes]
• Medication expiration date and lot number verified: [Yes]
• Emergency readiness confirmed: [Naloxone available; precipitated withdrawal plan in place]

Medication Details

• Medication: Extended-release naltrexone 380 mg suspension for injection
• Dose/Volume: [Dose] mg / [Volume] mL
• Route: Deep IM
• Site: Upper outer quadrant gluteal, [Right / Left]
• Needle: [Length] / [Gauge] (If non-standard, document selection rationale)
• Lot number: [Lot #]
• Expiration date: [Date]

Administration

[Narrative of procedure: skin prep performed, reconstitution per manufacturer instructions with visual confirmation of milky suspension, deep IM gluteal injection with aspiration performed per product instructions] Aspiration result: [No blood return / Blood aspirated—needle changed and new site used / Needle clogged—needle changed]. Patient tolerance: [Tolerated well / Describe any difficulty]. Immediate complications: [None / Describe with management]. Sharps disposed per protocol.

Deferred Procedure

(Include this section only if injection was planned but not administered.)

• Planned dose and site: [Dose] mg at [Right / Left] gluteal
• Reason not administered: [Positive UDT / Recent opioid use reported / Withdrawal symptoms present / Patient declined / Contraindication identified / Medication unavailable / Other: specify]
• Actions taken: [Symptomatic care provided / Referral to: / Rescheduled for: date / Discussed alternate MOUD / Referral to monitored setting / Other]

Post-Procedure Monitoring

(Include this section only if injection was administered.)

• Observation period: [Duration]
• Post-procedure vitals: [Values] (If obtained)
• Injection site at discharge: [Appearance; dressing applied if used]
• Patient condition on departure: [Stable / Other]

Patient Counseling & Safety Planning

(Required for every XR-NTX visit per prescribing information.)

• Overdose risk: [Discussed increased sensitivity/loss of tolerance after detox, at end of dosing interval, after missed dose, and after stopping; warned against attempting to override blockade]
• Naloxone: [Prescribed / Dispensed / Confirmed patient has kit]; education on use and calling 911 provided
• Precipitated withdrawal: [Signs reviewed and when to seek care]
• Injection site red flags: [Worsening swelling, severe pain, drainage, necrosis signs reviewed]
• Liver injury symptoms: [Abdominal pain, jaundice, dark urine, fatigue reviewed]
• Mood/depression monitoring: [Discussed; crisis resources provided]
• Pain management: [Instructed to inform all clinicians of XR-NTX; emergency pain plan reviewed]
• Medical identification: [Recommended]

Individualized relapse prevention: [Current counseling/therapy and next appointment; mutual support engagement; high-risk triggers and coping strategies identified; contingency plan for lapse including who to contact and harm reduction steps] (If patient declines any counseling, document refusal and what was offered.)

Assessment & Plan

Opioid Use Disorder [Mild / Moderate / Severe / Unspecified]

• [XR-NTX administered today / Reason deferred: specify]
• Next dose due: [Date]
• Monitoring plan: [UDT frequency, follow-up interval, counseling linkage]

Alcohol Use Disorder

(Include if applicable.)

• [XR-NTX role for AUD and plan]
• Next dose due: [Date]
• Monitoring plan: [Follow-up interval, counseling linkage, labs if indicated]

Adverse Effects

(Include only if present.)

• [Injection site reaction: description and management]
• [Systemic effects: description and management]

Harm Reduction

• Naloxone: [Prescribed / Dispensed / On hand / Declined]; education reinforced
• Safer-use counseling: [Key points covered] (If ongoing risk)

Follow-up: [Next appointment date/time/location]; next injection appointment: [Date]. Return precautions reviewed: [Overdose signs, severe withdrawal, severe injection site reaction, allergic reaction]. Care coordination: [Therapist/PCP/specialists notified or coordinated with].

Orders

• XR-NTX administration: [Completed / Deferred]
• Naloxone: [Prescribed / Dispensed / Recommended / Declined]
• UDT: [Completed / Pending / Not obtained] (Collection time: [Time]; panels: [List])
• Pregnancy test: [Completed / Pending / Not indicated] (If applicable)
• Liver function tests: [Ordered / Completed / Pending / Not indicated]
• Referrals: [Counseling/therapy / Case management / Higher level of care / None]

(If a recommended order was not placed, document reason and reconciliation plan.)