A Practical Review of Naltrexone 9/26/2019

Medication assisted treatment (MAT) has been increasingly shown in the literature to be helpful component of substance abuse treatment. The range of treatments has grown over the years, and certain treatments bring risks that limit their use in the primary care setting. Both methadone and buprenorphine, effective medications for opioid abuse, can be abused, have some element of risk for respiratory depression, and require specific licenses to prescribe. Other treatments can be challenging for patients to manage, such as disulfiram, which causes alcohol induced nausea, or acamprosate which must be taken multiple times per day. Naltrexone is a practical option for adjunctive treatment of alcohol abuse in the primary care setting. While it has some evidence supporting use for other abuse of other substances, we will focus on its role in the treatment of alcohol abuse.

Naltrexone is an opioid antagonist, not to be confused with naloxone, also an opioid blocker, which is used for opioid overdose reversal. Naltrexone is FDA approved for the treatment of alcoholism in adults. It is fairly easy to use, requires once daily dosing and has real world benefits for patients struggling with alcoholism. It can be helpful for those who are in a stage of abstinence, increasing days of abstinence, decrease cravings and decrease rates of relapse. It can be helpful for those in a stage of action (attempting to cut back but still drinking) by decreasing number of heavy drinking days.

Naltrexone can be used for treatment of opioid abuse, but its application is somewhat more complicated as it is contraindicated in people who are actively using opioids, including as analgesics, or withdrawing.

To start naltrexone, it is important to rule out opioid abuse or use as for analgesia. Patients should be counseled of a risk of liver injury and to notify their doctor of any signs or symptoms of liver inflammation. Use is not recommended in acute hepatitis or hepatic failure.

Baseline and periodic LFTS are recommended, though there is not clear consensus on the periodicity of these labs. Naltrexone can be started at 25 – 50 mg daily. Doses as high as 100 mg can be needed.

All patients with alcoholism should be counseled about the various substance abuse therapies in their community. This can range from AA, 12 step groups, individual therapy, SMART recovery groups, and for more complex cases, residential treatment.


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