Naltrexone vs. Suboxone: What Is the Difference?

Naltrexone vs. Suboxone: What Is the Difference?

Naltrexone and Suboxone are both FDA-approved medications for opioid use disorder. They work in opposite ways. They have different induction requirements, different candidate profiles, and different costs.

If you are in Virginia weighing your medication-assisted treatment options, this guide explains the practical differences. The mechanism, the candidate fit, the side effects, the cost, and how to have the conversation with your provider.

How Both Medications Work to Reduce Opioid Cravings

The two medications target the same opioid receptors in fundamentally different ways.

Suboxone (buprenorphine and naloxone) is a partial opioid agonist. Buprenorphine binds to the same receptors as heroin, oxycodone, and fentanyl, but only partially activates them. This eliminates withdrawal, reduces cravings, and blocks other opioids from binding. The naloxone in Suboxone is there to deter injection misuse and is not active when taken sublingually as prescribed.

Naltrexone (Vivitrol injection or ReVia oral) is an opioid antagonist. It binds to opioid receptors and blocks them entirely. Other opioids cannot attach. There is no euphoria, no high, no cravings reinforced. It also reduces alcohol cravings through a related mechanism.

Both medications work. The research is consistent. People on either medication have significantly better outcomes than people in abstinence-only recovery.

Key Differences in How They Are Prescribed and Dispensed

The induction process is where the two medications differ most:

Naltrexone induction. Requires 7 to 14 days completely opioid-free before the first dose. Starting too early causes severe precipitated withdrawal. The monthly Vivitrol injection is administered at a provider's office.

Suboxone induction. Started in mild-to-moderate withdrawal, typically 12 to 24 hours after the last short-acting opioid. The COWS scale confirms readiness. Daily sublingual film or tablet, or monthly Sublocade injection after stabilization.

Suboxone is a Schedule III controlled substance and is dispensed by prescription. Naltrexone is not controlled. The DEA X-waiver requirement for Suboxone was eliminated in 2023, so any DEA-registered prescriber can now prescribe.

Who Is a Better Candidate for Naltrexone vs Suboxone

Several factors influence which medication is the better fit.

Naltrexone may be the better choice when:

• The patient has completed detox or can complete a 7-to-14-day washout period
• Avoiding a controlled substance is important (professional licensure, employer drug testing concerns)
• There is co-occurring alcohol use disorder
• The patient prefers a monthly injection over daily dosing
• Adherence to daily medication is uncertain

Suboxone may be the better choice when:

• The patient needs immediate stabilization without a washout period
• There is significant fentanyl exposure and detox is difficult
• Daily dosing or monthly Sublocade injection both work for the patient
• Cravings management is the primary concern
• The patient has tried naltrexone without success

Neither medication is universally better. The right choice depends on individual circumstances and provider judgment.

Side Effects and Risks of Each Medication

Naltrexone side effects include nausea (especially early), headache, fatigue, injection-site reactions (for Vivitrol), and elevated liver enzymes. The most important risk is post-treatment overdose if the medication is stopped and the patient relapses, because tolerance drops while on naltrexone.

Suboxone side effects include constipation, headache, sweating, insomnia, and dental issues from the sublingual film over time. The most important safety warning is the fatal respiratory depression risk when combined with alcohol, benzodiazepines, or other sedatives.

Both medications require periodic medical monitoring.

Cost and Insurance Coverage Differences in Virginia

Both medications are covered by Virginia Medicaid (Cardinal Care), Tricare, Anthem, UnitedHealthcare, Aetna, and most major insurers under Virginia Code § 38.2-3412.1 and the federal Mental Health Parity Act.

Vivitrol monthly injection retail cost is approximately 1,500 dollars per dose without insurance. The Alkermes Co-Pay Program can reduce out-of-pocket cost to as little as 5 dollars per dose for commercially insured patients meeting eligibility criteria. Medicaid covers Vivitrol with no out-of-pocket cost.

Suboxone daily film retail cost is approximately 200 to 400 dollars per month. Generic buprenorphine/naloxone is significantly less expensive. Sublocade monthly injection is comparable to Vivitrol in cost. Most insurance covers daily Suboxone with low copays.

How to Discuss Options With Your Treatment Provider

Bring these questions to the consultation:

• Which medication do you think is the better fit for my situation and why?
• How long can I expect to be on this medication?
• What is the cost with my insurance?
• If this medication does not work for me, can we switch?
• What support comes with the medication (counseling, group, peer support)?

The right MAT provider welcomes these questions. The conversation matters as much as the medication.

Your Next Step

If you are considering MAT for opioid use disorder, call a licensed Virginia MAT provider for a free assessment. Both naltrexone and Suboxone save lives. Your provider can help you decide which is the better fit for your situation.

‍