Is naltrexone (Naltrexone) contraindicated in a patient with a history of opioid use disorder?

From the Guidelines

Naltrexone is not contraindicated in patients with a history of opioid use disorder; in fact, it is specifically approved for treating this condition, as stated in the 2016 CDC guideline for prescribing opioids for chronic pain 1. When considering naltrexone for patients with a history of opioid use disorder, it is essential to ensure they are completely opioid-free for 7-10 days before starting the medication to avoid precipitating severe withdrawal symptoms. The typical oral dosing is 50 mg daily, while the extended-release injectable form (Vivitrol) is administered as a 380 mg intramuscular injection once monthly, as noted in a study on a primary care approach to substance misuse 1. Before initiating treatment, patients should undergo a naloxone challenge test or urine drug screen to confirm opioid abstinence, as recommended by experts in the field 1. Naltrexone works by blocking opioid receptors, preventing the euphoric and reinforcing effects of opioids if they are used, which helps reduce cravings and supports recovery, as explained in the 2016 CDC guideline 1. The medication has minimal abuse potential and doesn't cause physical dependence, making it a valuable treatment option for patients with opioid use disorder, as stated in the 2016 JAMA article 1. Some key points to consider when prescribing naltrexone include:

• Ensuring patients are opioid-free before starting treatment
• Monitoring liver function tests at baseline and every three to six months, as naltrexone has been associated with hepatic injury at supratherapeutic doses 1
• Warning patients about the risks of attempting to overcome the blockade with high doses of opioids, which could lead to overdose, respiratory depression, or death, as noted in the 2016 CDC guideline 1
• Considering the use of naltrexone in nonpregnant adults, particularly those who are highly motivated, as an alternative to buprenorphine or methadone maintenance therapy, as recommended by the CDC guideline 1.

From the FDA Drug Label

CONTRAINDICATIONS Naltrexone hydrochloride is contraindicated in Patients receiving opioid analgesics. Patients currently dependent on opioids, including those currently maintained on opiate agonists (e.g., methadone ) or partial agonists (e.g., buprenorphine) Patients in acute opioid withdrawal (see WARNINGS). Any individual who has failed the naloxone challenge test or who has a positive urine screen for opioids. Any individual with a history of sensitivity to naltrexone hydrochloride or any other components of this product.

Naltrexone is contraindicated in patients with a history of opioid use disorder who are currently dependent on opioids or have not been opioid-free for an adequate period of time, as it may precipitate opioid withdrawal. However, the label does not explicitly state that a history of opioid use disorder is a contraindication if the patient is no longer dependent on opioids.

• The patient should be opioid-free for a minimum of 7 to 10 days before starting naltrexone hydrochloride to avoid precipitation of opioid withdrawal 2.
• Patients transitioning from buprenorphine or methadone may be vulnerable to precipitation of withdrawal symptoms for as long as two weeks 2.

From the Research

Naltrexone Contraindication in Opioid Use Disorder

• Naltrexone is an opioid antagonist that can precipitate opioid withdrawal if administered too quickly after the use of full or partial opioid agonists for those with either dependence or use disorder 3.
• The use of naltrexone in opioid-dependent patients can cause acute and severe withdrawal symptoms, including agitation, altered level of consciousness, nausea, vomiting, abdominal pain, diarrhea, bone and muscle pain, tachycardia, and dilated pupils 4.
• Naltrexone is a Food and Drug Administration-approved medication for the treatment of opioid use disorder in the United States, but it may not be suitable for all patients, particularly those with a history of opioid use disorder who are not yet ready for antagonist treatment 5.

Transitioning from Buprenorphine to Naltrexone

• Some patients with opioid use disorder may seek to transition from buprenorphine to extended-release naltrexone, with common reasons including seeking to be opioid-free and tired of daily pill taking 6.
• Positive predictors of transition from buprenorphine to naltrexone include a more extensive buprenorphine treatment history and a history of prescription opioid abuse 6.
• Alternative dosing strategies for naltrexone, such as increasing the frequency of intramuscular administration, may be considered in high-risk patients to prevent opioid overdose 7.

Considerations for Naltrexone Use

• Naltrexone can be an effective treatment for opioid use disorder, but it requires careful consideration of the patient's history and treatment goals 3, 4, 5.
• Patients with opioid use disorder who are considering naltrexone treatment should be aware of the potential risks and benefits, including the risk of precipitated withdrawal and the potential for reduced cravings 3, 4, 6, 7.