From the Guidelines
Naltrexone is not recommended for the acute management of alcohol withdrawal syndrome, and instead, benzodiazepines like diazepam or lorazepam are the first-line treatments for alcohol withdrawal. According to the most recent and highest quality study 1, benzodiazepines are considered the 'gold standard' treatment for AWS, given their efficacy to reduce both withdrawal symptoms and the risk of seizures and/or delirium tremens.
Key Points to Consider
- Naltrexone is used after detoxification is complete to help maintain abstinence from alcohol by reducing cravings and the rewarding effects of alcohol 1.
- The standard dose of naltrexone is 50mg once daily orally, or 380mg as a monthly intramuscular injection (Vivitrol) 1.
- Naltrexone works by blocking opioid receptors, which reduces the pleasurable effects associated with alcohol consumption 1.
- It should only be started after the patient is completely detoxified (typically 3-7 days after the last drink) to avoid precipitating or worsening withdrawal symptoms 1.
- Patients should be informed that naltrexone does not reduce withdrawal symptoms and that they should not take opioid medications while on naltrexone, as it will block their effects and could lead to overdose if the patient attempts to overcome this blockade 1.
Treatment of Alcohol Withdrawal Syndrome
- Benzodiazepines are the treatment of choice for patients with acute withdrawal syndrome and ALD 1.
- Long-acting benzodiazepines (e.g. diazepam, chlordiazepoxide) provide more protection against seizures and delirium, but short and intermediate-acting benzodiazepines (e.g. lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction 1.
Important Considerations
- Naltrexone cannot be recommended in patients with advanced ALD because of the potential side-effects 1.
- In patients with advanced ALD, recent studies suggest that baclofen is safe and effective to prevent alcohol relapse 1.
From the FDA Drug Label
In subjects physically dependent on opioids, naltrexone hydrochloride will precipitate withdrawal symptomatology. The FDA drug label does not answer the question about alcohol withdrawal and naltrexone.
From the Research
Alcohol Withdrawal Treatment
- The treatment of alcohol withdrawal typically involves the use of benzodiazepines, which have been shown to ameliorate or prevent the symptoms and complications of moderate to severe alcohol withdrawal 2.
- Benzodiazepines such as lorazepam, chlordiazepoxide, oxazepam, and diazepam are commonly used for this purpose, with diazepam being suggested as the preferred benzodiazepine for the treatment of patients experiencing moderate to severe alcohol withdrawal under most circumstances 2.
- A study comparing lorazepam and diazepam for the management of alcohol withdrawal found that patients receiving lorazepam had an admission rate similar to that of those receiving diazepam, with no significant difference in outcomes 3.
Naltrexone in Alcohol Withdrawal
- There is no direct evidence in the provided studies regarding the use of naltrexone in alcohol withdrawal.
- However, the studies suggest that benzodiazepines are the first-line treatment for alcohol withdrawal, with other medications such as carbamazepine and gabapentin being used as adjunctive or alternative therapies 4, 5.
Management of Alcohol Withdrawal
- The management of alcohol withdrawal involves a thorough assessment of the patient, recognition of the risk for alcohol withdrawal, and initiation of appropriate treatment to prevent progression to more serious symptoms and complications 6.
- Outpatient management of alcohol withdrawal syndrome is possible for patients with mild to moderate withdrawal symptoms without additional risk factors for developing severe or complicated withdrawal, and should include supportive care and pharmacotherapy as appropriate 4.