Naltrexone


Article Author:
Dharminder Singh


Article Editor:
Abdolreza Saadabadi


Editors In Chief:
Dustin Constant
Donald Kushner


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Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
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Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
10/9/2019 3:21:39 PM

Indications

Naltrexone is an opioid antagonist used to treat alcohol use disorder and opioid dependence. It was developed in 1963 and patented in 1967. In 1984, naltrexone was approved for medical use in the United States. While experimenting with rats at the University of Pennsylvania, Dr. Joseph Volpicelli first recognized naltrexone's potential to treat alcoholism. The World Health Organization (WHO) estimates that over 75 million people had alcohol abuse or dependence worldwide. Naltrexone is a mu-opioid antagonist. It is FDA-approved for alcohol abuse and opioid dependence treatment.[1] Off-label use includes treatment of cholestatic pruritus in adults. Researchers are studying its use in patients with stimulant addiction, particularly for patients with polydrug dependence on opioids, heroin, and amphetamine.

Another clinical use for naltrexone is for opiate toxicity/addiction. Exogenous opioids include the commonly prescribed pain relievers such as hydrocodone, oxycodone, among others[2] and drugs of abuse such as heroin. Heroin induces euphoria at much higher doses than those prescribed by medical providers to relieve pain. Heroin leads to addiction via the euphoria it induces in its abusers. Opioid overdose can lead to coma and respiratory compromise.  Opioids act mainly via the mu receptor although they have effects on mu, delta, and kappa-opioid receptors. Synthetic opioid antagonists can modify the action of opioids on these receptors.[3] Naltrexone competes as an antagonist at opioid receptors and can be used to treat alcohol and opioid addiction.

Mechanism of Action

Medications used to treat alcohol and opioid addiction focus on altering their reinforcing effects on inducing euphoria.[4] Naltrexone is pharmacologically effective against alcohol and opioids by blocking the mu-opioid receptor. Endogenous opioids are involved in modulating alcohol and opioids by reinforcing their effects.[5] Naltrexone blocks the effect of opioids and prevents opioid intoxication and physiologic dependence on opioid users. Naltrexone also modifies the hypothalamic-pituitary-adrenal axis to suppress ethanol consumption.

Administration

Naltrexone is available as an oral tablet (50 mg), and the usual dose for alcohol treatment is 50 to 100 mg.  Naltrexone formulation is also available for depot injection (380 mg). Naltrexone absorption is almost complete after oral administration but has an extensive first-pass effect. Naltrexone excretion is primarily through urine. After oral administration, the half-life is 4 hours and following an intramuscular injection, (IM) the half-life is 5 to 10 days.

Patient must first be detoxified from opioid dependence before starting naltrexone. If there is a possibility of opiate or alcohol withdrawal, a naltrexone challenge test is recommended. One should start 25 mg orally, and if there are no withdrawal symptoms observed, then repeat the test in 1 hour and continue 50 mg, orally, every day. Naltrexone can be given 3 times a week at doses of 100 to 150 mg or as a depot form for monthly administration.  Naltrexone is typically combined with alpha-2 agonist which minimizes patient discomfort during the withdrawal stage to shorten the duration of opioid withdrawal. Another benefit of rapid opiate detoxification is the reduced time between opioid use and the commencement of sustained naltrexone treatment to prevent relapse. Rapid opiate detoxification completion rates using naltrexone and clonidine range from 75% to 81% compared to 40% for methadone and clonidine alone.

Studies have suggested that carriers of the G-allele may experience a higher level of craving and a stronger euphoria following alcohol use.  Naltrexone, 50 to 150 mg per day orally, appears to shorten subsequent relapses, whether used in the oral form or as once per month 380-mg injection, especially in individuals with the G-allele of the AII8G polymorphism of the mu-opioid receptor.

Naltrexone can be given orally with or without food. Administration with food or after meals may minimize adverse gastrointestinal (GI) effects. Advise patients not to self-administer opioids while receiving naltrexone therapy. The IM form must be injected using provided needles for administration into the upper outer quadrant of the gluteal area; clinicians should avoid injection into the blood vessel.[6] Do not administer intravenously (IV), subcutaneously, or into fatty tissue.  Because many patients with a substance-abuse disorder are non-compliant with the oral formula, the IM injection is recommended.[7]  Data indicate that outcomes for patients with alcohol dependence who take naltrexone may be more favorable when using the IM formula.

Naltrexone maintenance combined with psychosocial therapy is effective in reducing heroin use, but medication adherence is low. Depot injection formulation lasting up to 4 weeks improves adherence, retention, and drug use markedly. Subcutaneous naltrexone implants in Russia, China, and Australia have doubled treatment retention and reduced relapse to half that of oral naltrexone.

Adverse Effects

Naltrexone may cause gastrointestinal irritation such as diarrhea, abdominal cramps, and in some studies, it shows clinically insignificant increases in blood pressure. Naltrexone can precipitate a withdrawal syndrome in opioid-dependent patient characterized by dysphoria, irritability, and having signs of autonomic hyperactivity such as tachycardia, tremor, and sweating. Piloerection is often associated with opioid withdrawal, especially when the drug is stopped suddenly. Clonidine, an alpha2-adrenergic agonist, can aid in detoxification by reducing the signs of autonomic hyperactivity.

Contraindications

Contraindications to naltrexone use are hypersensitivity reactions including urticaria, angioedema, and anaphylaxis. Opioid dependence or current use of opioid analgesics, including partial agonists, acute opioid withdrawal, and failure to pass a naloxone challenge or positive urine screen for opioids are also contraindications to the use of naltrexone.

Pregnancy Implications

Naltrexone is classified as category C for use during pregnancy, which means that the risk of adverse effects on the fetus cannot be ruled out.  There is limited research available related to use of naltrexone during pregnancy. Animal reproduction studies have shown adverse effects. Practice guidelines recommend that if a female being treated with naltrexone to treat opioid use disorder becomes pregnant, naltrexone should be discontinued if the mother and the physician agree that the risk of relapse is low. Naltrexone should not be given for treatment of alcohol use disorder in pregnant women unless needed for the treatment of acute alcohol withdrawal. Other agents are recommended for acute alcohol withdrawal. Naltrexone is also present in breast milk, and considering the importance of treatment of the mother, a decision should be made whether to discontinue breastfeeding or discontinue the drug.

Monitoring

Baseline and periodic liver function tests should be obtained. Clinicians must monitor for opioid withdrawal. Also one has to check injection sites for reactions following IM administration. Further, the patient has to be screened for depression and/or suicidal thinking. When taken chronically for years, it is safe and associated with few side effects such as headache, nausea, and abdominal pain. Patients infected with hepatitis B or C can take naltrexone without worsening of the liver function. However, most providers refrain from prescribing the medication, if liver function tests are 3 to 5 times above normal levels.

Precautions

Monitor patients presenting with dyspnea and hypoxia as there have been a few cases of eosinophilic pneumonia reported in the literature.  Discontinue therapy if signs and symptoms of acute hepatitis develop.  In patients undergoing surgery while on the treatment of opioid addiction, discontinue oral naltrexone for at least 72 hours before the scheduled surgery. The IM naltrexone should be discontinued for at least 30 days before surgery.

Toxicity

Hepatotoxicity

Cases of hepatitis and liver dysfunction have been observed; transient asymptomatic hepatic transaminase elevations may also occur.

Depression/Suicidality

Depression, suicidal ideation, and suicidal attempts have been reported.  Monitor the patient for symptoms of depression or suicidality.

Enhancing Healthcare Team Outcomes

Naltrexone is primarily used to manage alcohol and opioid dependence. The drug is best prescribed by healthcare professionals with experience in the field of drug abuse, psychiatry, and addiction. With many nurses working in outpatient psychiatry, they must need to be aware of how this drug should be used and what precautions are needed. Most of the patients with alcohol and opiate addiction managed with naltrexone need close monitoring but can be managed as outpatients. Data suggest that naltrexone can help reduce alcohol intake, but its benefits are not seen in everyone. When it comes to opiate addiction, naltrexone has been shown to lower the frequency of negative drug tests but relapse rates are high if no adjunct behavior therapy is offered.[8][9][10]


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Naltrexone - Questions

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A patient with a long-standing alcohol use disorder presents for treatment. Recently she was involved in a motor vehicle accident and started to take opiates. Now she feels she has become addicted to these medications and would like a treatment for both of his problems. Which of the following agents may help her with her alcohol and opiate dependence?



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Naltrexone - References

References

Slawson DC, Injectable Extended-Release Naltrexone Effective for Opioid Use Disorder. American family physician. 2018 Jun 15     [PubMed]
Broglio K,Matzo M, CE: Acute Pain Management for People with Opioid Use Disorder. The American journal of nursing. 2018 Sep 11     [PubMed]
Hadland SE,Bagley SM,Rodean J,Silverstein M,Levy S,Larochelle MR,Samet JH,Zima BT, Receipt of Timely Addiction Treatment and Association of Early Medication Treatment With Retention in Care Among Youths With Opioid Use Disorder. JAMA pediatrics. 2018 Sep 10     [PubMed]
Shen WW, Anticraving therapy for alcohol use disorder: A clinical review. Neuropsychopharmacology reports. 2018 Sep     [PubMed]
Kranzler HR,Soyka M, Diagnosis and Pharmacotherapy of Alcohol Use Disorder: A Review. JAMA. 2018 Aug 28     [PubMed]
DeMartini KS,Foster DW,Corbin WR,Fucito LM,Romano D,Leeman RF,Kranzler HR,O'Malley SS, Drinking goals and attainment in a naltrexone trial of young adult heavy drinkers. Journal of consulting and clinical psychology. 2018 Sep     [PubMed]
Dermody SS,Wardell JD,Stoner SA,Hendershot CS, Predictors of Daily Adherence to Naltrexone for Alcohol Use Disorder Treatment During a Mobile Health Intervention. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine. 2018 Aug 16     [PubMed]
Ahmed R,Kotapati VP,Khan AM,Hussain N,Hussain M,Dar S,Kumar J,Begum GA,Esang M,Brainch N,Ahmed S, Adding Psychotherapy to the Naltrexone Treatment of Alcohol Use Disorder: Meta-analytic Review. Cureus. 2018 Aug 6     [PubMed]
Sullivan MA,Bisaga A,Pavlicova M,Carpenter KM,Choi CJ,Mishlen K,Levin FR,Mariani JJ,Nunes EV, A Randomized Trial Comparing Extended-Release Injectable Suspension and Oral Naltrexone, Both Combined With Behavioral Therapy, for the Treatment of Opioid Use Disorder. The American journal of psychiatry. 2018 Oct 19     [PubMed]
Ward S,Smith N,Bowden-Jones H, The use of naltrexone in pathological and problem gambling: A UK case series. Journal of behavioral addictions. 2018 Sep 1     [PubMed]

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