Should naltrexone (Naltrexone) be continued post-operatively?

From the Guidelines

Naltrexone should be held for 24 to 30 days after the last injection before elective surgical procedures if opioids are expected to be used perioperatively. This is based on the most recent consensus statement from the Society for Perioperative Assessment and Quality Improvement (SPAQI) published in 2021 1. When considering continuing naltrexone post-operatively, it's essential to weigh the benefits of preventing relapse in patients with opioid use disorder against the potential complications with pain management.

Key Considerations

• For patients on extended-release injectable naltrexone, the medication remains active for 28 days, which can complicate pain management if surgery occurs while the injection is active.
• Higher doses of opioids may be needed for pain control, and non-opioid pain management strategies should be emphasized.
• Alternative pain control strategies, including regional anesthesia, NSAIDs, acetaminophen, gabapentinoids, and ketamine, may be necessary.

Post-Operative Management

• Close coordination between the surgeon, anesthesiologist, and addiction medicine specialist is crucial to manage pain effectively and prevent relapse.
• Resuming naltrexone promptly after surgery is important for patients with opioid use disorder to prevent relapse, but the timing should be individualized based on the patient's specific situation and the type of naltrexone formulation used.

Important Factors

• The opioid antagonist effect of naltrexone blocks opioid receptors, which can complicate pain management.
• The decision to continue or discontinue naltrexone post-operatively should be made on a case-by-case basis, considering the patient's medical history, the type of surgery, and the expected pain management needs.

From the FDA Drug Label

When Reversal of Naltrexone Hydrochloride Blockade is Required:- for Pain ManagementIn an emergency situation in patients receiving fully blocking doses of naltrexone hydrochloride, a suggested plan of management is regional analgesia, conscious sedation with a benzodiazepine, use of non-opioid analgesics or general anesthesia

• The decision to continue naltrexone post-operatively should be made on a case-by-case basis, considering the patient's individual needs and medical history.
• If the patient requires pain management, alternative methods such as regional analgesia, conscious sedation, or non-opioid analgesics should be considered to avoid the risks associated with opioid use in patients taking naltrexone 2.
• It is essential to monitor the patient closely and be prepared for potential complications, such as respiratory depression, if opioids are necessary 2.
• Patients should be informed of the risks of opioid use after naltrexone treatment is discontinued or temporarily interrupted, and the importance of carrying identification to alert medical personnel to their naltrexone treatment 2.

From the Research

Continuing Naltrexone Post-Operatively

• The decision to continue naltrexone post-operatively is complex and requires careful consideration of the patient's individual needs and circumstances 3, 4, 5, 6.
• Naltrexone can complicate postoperative pain management, and its use may increase the opioid requirement for postoperative pain control 3.
• Multimodal pain regimens, including non-opioid analgesics and non-pharmacological interventions, can help manage pain in patients taking naltrexone 3, 7.
• The timing of the last naltrexone dose can affect the patient's response to opioid agonists, and redosing naltrexone soon after opioid use may precipitate opioid withdrawal 4.
• There is limited high-quality evidence on the risks and benefits of continuing or stopping naltrexone perioperatively, and future studies and guidelines should address both acute pain management and maintaining recovery 6.
• In patients with risk factors for return to use of opioids or alcohol, the discontinuation of naltrexone should have a strong rationale 6.
• Perioperative management of patients on naltrexone is inconsistent and remains a controversial topic, with mismanagement posing a significant risk to the long-term health of these patients 6.