Naltrexone

Executive Home Detox encourages the use of anti-craving medications, such as Naltrexone. The number of relapses in clients with Alcohol Use Disorder is high across the continuum of care. EHD likes to use any resource at our disposal to effect change in the client’s alcohol use. Naltrexone has been highly successful with a percentage of clients post detox.  Unfortunately, Naltrexone has also had it’s share of failures.  

Naltrexone is a medication approved for treatment of Alcohol Use Disorders. SAMHSA publishes a guide to assist clinicians in prescribing medications approved for alcohol disorders. Here are a number of excerpts from the chapter on oral Naltrexone. I will comment throughout this blog.

What is Oral Naltrexone?

Naltrexone hydrochloride is a relatively pure and long-lasting opioid antagonist. It has been used to treat opioid dependence for many years and has been approved to treat alcohol use disorders (AUDs) since 1994. It reduces both the rewarding effects of alcohol and craving for it. (Tip 49)

I have witnessed this medication decrease or eliminate the craving for alcohol. I have not witnessed this medication reduce the rewarding effects of alcohol.  This is important as many doctors tell patients if they drink they won’t get the pleasure of alcohol, again, I have witnessed clients obtain the desired effects when they drink alcohol on Naltrexone.

Why use this medication?

Naltrexone appears to be effective for attenuating craving in people who are alcohol dependent (Monti et al., 1999, 2001). By blocking craving, naltrexone may enhance the ability of patients to abstain from drinking. By blocking the pleasure from alcohol, naltrexone also may reduce the amount of heavy drinking in those who do drink. (Tip 49)

The research is pretty clear. Clients or patients have less drinking days while on this medication than when they are on a placebo.

The excerpt below is a more technical, but informative description.

Controlled clinical trials have demonstrated this can be an effective medication for the treatment of patients who are alcohol dependent. Clinicians indicate that some patients report that naltrexone helps, and some report no difference with its use. These anecdotal reports provide intriguing suggestions that particular patient types or subgroups may be more likely than other groups to respond. A recent finding has suggested that a variant in a gene encoding for the mu opiate receptor (OPRM1) in the opiate neurotransmitter system may predict response to naltrexone treatment in people dependent on alcohol (Anton et al., 2008). When treated with naltrexone and a medical management intervention, 87.1 percent of persons carrying the less prevalent Asp40 variant had a good clinical outcome, compared with only 54.8 percent of individuals with the more common Asn40/Asn40 genotype (odds ratio, 5.75; confidence interval, 1.88–17.54); no difference between groups was observed in placebo treatment outcomes. This finding suggests that OPRM1 genotyping may be a useful procedure for improving identification of those patients most likely to benefit from naltrexone treatment for alcohol dependence. It also suggests that clinicians should not become discouraged if the first patients they prescribe naltrexone for do not find it beneficial. It’s efficacy is modest, but it is significantly better than placebo in most studies, and some patients benefit from this therapy.

Although attention is frequently drawn to the risks of hepatotoxicity with naltrexone, this rarely occurs, is typically reversible, and is more likely with very high doses used over a sustained period. It is unfortunate that such effects have become so closely associated with naltrexone, but the clinician would be prudent to monitor liver function.

Naltrexone—and all the medications described in this TIP—does not “cure” AUDs the way an antibiotic cures bacterial pneumonia. However, as a part of comprehensive treatment, it may increase the likelihood of sustained remission from problem alcohol use.

A very important consideration prior to consideration of starting this medication. Do not take this medication if you are taking an opiate, have been on opiates the past six days, or plan on taking an opiate for pain medication in the near future.

As an opioid antagonist, naltrexone competitively displaces opioid medications from their binding sites, precipitating withdrawal. Healthcare providers must ensure that patients have been fully withdrawn from all opioids before considering therapy with naltrexone.

As a side note, there is additional research that Naltrexone, combined with Campral and Antabuse has been demonstrated to be much more effective than using Naltrexone (Revia) alone.

Reference

1. Incorporating Alcohol Pharmacotherapies into Medical Practice. A Treatment Improvement Protocol. Tip 49. Chapter Four; Oral Naltrexone.  U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment.   http://www.ncbi.nlm.nih.gov/books/NBK64042/