Can a patient be prescribed Suboxone (buprenorphine) for opioid addiction and additional naltrexone for alcoholism?

Concurrent Use of Suboxone and Naltrexone for Dual Addiction Treatment

Patients should not be prescribed both Suboxone (buprenorphine/naloxone) for opioid addiction and naltrexone for alcoholism concurrently, as naltrexone will block the therapeutic effects of buprenorphine and can precipitate severe withdrawal in patients on opioid agonist therapy. 1, 2, 3

Pharmacological Incompatibility

Naltrexone and buprenorphine have fundamentally incompatible mechanisms of action:

• Buprenorphine (in Suboxone): Partial opioid agonist that binds to mu-opioid receptors 1
• Naltrexone: Competitive opioid receptor antagonist with high affinity for opioid receptors 2

When administered together:

• Naltrexone will displace buprenorphine from opioid receptors due to its higher binding affinity
• This displacement can precipitate severe opioid withdrawal syndrome 3
• The therapeutic effect of buprenorphine would be completely blocked 2

Evidence of Contraindication

Research clearly demonstrates this incompatibility:

• A 2024 case report documented severe precipitated withdrawal when naltrexone was inadvertently administered to a patient on buprenorphine therapy 3
• The American Academy of Family Physicians guidelines note that naltrexone "cannot be used in patients in whom opioids are required for pain control, because it will block pain relief from opioid agonists" 1
• Naltrexone requires patients to be completely opioid-free for 7-10 days before initiation 2

Alternative Approaches for Dual Addiction

For patients with both opioid and alcohol use disorders, clinicians should consider:

1. Choose one medication-assisted treatment approach:

   • Continue Suboxone for opioid addiction and use non-pharmacological approaches for alcohol use disorder
   • Discontinue Suboxone, observe 7-10 day washout period, then start naltrexone (which treats both conditions)

2. Consider buprenorphine alone:

   • Some evidence suggests buprenorphine may help reduce alcohol cravings in addition to treating opioid dependence 2
   • This approach avoids the pharmacological incompatibility

3. Sequential treatment:

   • Stabilize opioid addiction with Suboxone first
   • Once stable, consider transitioning to naltrexone for both conditions after appropriate washout period

Monitoring and Precautions

If transitioning between medications:

• Ensure complete washout of buprenorphine (7-10 days minimum) before starting naltrexone 2
• Monitor for depression, as naltrexone has been reported to worsen comorbid depression in some patients with dual dependence 4
• Consider liver function testing at baseline and every 3-6 months during naltrexone therapy 1, 2

Clinical Decision Making

When faced with a patient with both opioid and alcohol use disorders:

1. Assess which substance use disorder poses the greater risk to morbidity and mortality
2. Select the medication that addresses the primary disorder
3. Use behavioral interventions for the secondary disorder
4. Consider transitioning to naltrexone only after complete discontinuation of buprenorphine with appropriate washout period

Remember that attempting to use both medications simultaneously is contraindicated and potentially dangerous, as it may precipitate severe withdrawal and undermine treatment efficacy.