From the Guidelines
Naltrexone should be held 3-4 days before surgery for oral formulations and 24-30 days for intramuscular injections, as recommended by the Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement 1. This allows for effective opioid pain management during the post-operative period.
Key Considerations
- For patients on oral naltrexone, stopping the medication 3-4 days before surgery enables opioid pain medications to work effectively during the immediate post-operative period 1.
- For those on extended-release injectable naltrexone, holding the medication 24-30 days before surgery is recommended 1.
- Resuming naltrexone too early can precipitate withdrawal in patients still requiring opioid pain control and block necessary pain relief.
Perioperative Management
- Patients with opioid use disorder require careful monitoring and multimodal pain management strategies, including non-opioid medications like NSAIDs, acetaminophen, gabapentinoids, and regional anesthesia techniques when appropriate 1.
- The anesthesia and surgical teams should be informed about the patient's naltrexone use to properly plan pain management strategies.
Post-Operative Care
- Before restarting naltrexone, patients should be opioid-free for at least 7-10 days for short-acting opioids and longer for long-acting formulations.
- Close monitoring and individualized care are crucial to ensure a smooth recovery and minimize the risk of complications.
From the Research
Naltrexone Use Post-Op
- Naltrexone is an opioid antagonist that can complicate postoperative pain management, as it may increase the opioid requirement for postoperative pain control 2.
- Patients receiving extended-release naltrexone who are having surgery present unique challenges to anesthesia providers, including an altered response to the effects of opioid agonists and potential hypersensitivity to dangerous side effects 3.
- Redosing extended-release naltrexone soon after opioid use may precipitate opioid withdrawal, making it essential to carefully plan intraoperative and postoperative anesthetic and analgesic management 3.
- Multimodal pain regimens, including non-opioid modalities such as ketamine, lidocaine/bupivacaine, duloxetine, and non-pharmacological management, can help manage pain in patients on naltrexone 2.
- Perioperative considerations for patients with opioid use disorder on naltrexone maintenance therapy require an in-depth understanding of how to manage these medications to provide optimal pain control and minimize the risk of relapse and overdose 4.
Postoperative Pain Management
- The use of naltrexone can increase the complexity of postoperative pain management, and alternative strategies, such as multimodal pain regimens, may be necessary to effectively manage pain 2.
- Naltrexone is suitable for patients who do not wish to be on an agonist treatment, but its use requires careful consideration of postoperative pain management options 2.
- Other methods of acute pain control, such as non-pharmacological management, can help mitigate opioid dependence and control pain in patients who use naltrexone for their substance use disorders 2.
Naltrexone and Opioid Use Disorder
- Naltrexone is one of the medications demonstrated to be effective for opioid use disorder (OUD), acting by blocking the effects of opioid agonists 5.
- New depot and implant formulations of naltrexone have been developed to address issues of safety and problems of poor treatment adherence 5.
- Naltrexone can be used to precipitate acute opioid withdrawal, allowing for rapid transition from methadone to buprenorphine in some cases 6.