Can a patient on naltrexone (opioid receptor antagonist) drink alcohol?

Naltrexone and Alcohol Consumption

Patients on naltrexone should avoid alcohol consumption, as continued alcohol use while on naltrexone can lead to disease progression in those with alcohol-induced liver disease and may reduce the medication's effectiveness in treating alcohol dependence. 1

Mechanism and Indications

• Naltrexone is a pure opioid antagonist approved in 1995 for the treatment of alcoholism that works by controlling cravings for alcohol 1
• It decreases dopamine concentration in the brain and dampens activation of the reward pathway by alcohol, thereby decreasing excessive drinking and recurrence rates 1
• Naltrexone has been shown to lower the risk of relapse in short-term treatment according to Cochrane systematic reviews 1

Effects on Alcohol Consumption

• Naltrexone significantly reduces the subjective "high" produced by alcohol - 58% of naltrexone-treated patients reported a diminished alcohol high compared to only 12% of placebo-treated patients 2
• When patients on naltrexone do consume alcohol, they typically drink less during drinking episodes 2
• In clinical trials, only 23% of naltrexone-treated subjects met criteria for relapse compared to 54.3% of placebo-treated subjects over a 12-week period 3
• The most significant effect occurs in patients who sample alcohol while on naltrexone - 50% of these patients avoid full relapse compared to only 5% in the placebo group 3

Safety Concerns and Contraindications

• Naltrexone has been shown to cause hepatocellular injury, particularly at higher doses 1, 4
• FDA labeling indicates that naltrexone at doses up to 300 mg per day (higher than the recommended 50 mg daily dose) can cause hepatocellular injury in a substantial proportion of patients 4
• Liver function tests should be monitored at baseline and every three to six months during treatment 1
• Naltrexone is not recommended in patients with alcoholic liver disease (ALD) due to the risk of toxic liver injury 1

Side Effects

• Common side effects include nausea (10%), headache (7%), dizziness (4%), nervousness (4%), fatigue (4%), insomnia (3%), and vomiting (3%) 4
• Some patients may experience an opioid withdrawal-like symptom complex including tearfulness, mild nausea, abdominal cramps, restlessness, bone or joint pain, myalgia, and nasal symptoms 4
• Discontinuation due to adverse events occurs in approximately 14.1% of patients on the 380 mg long-acting injectable form and 6.7% on the 190 mg form 5

Treatment Recommendations

• For patients with evidence of alcohol-induced liver disease, strict abstinence must be recommended as continued alcohol use is associated with disease progression 1
• Baclofen may be a better alternative for patients with liver cirrhosis who need medication to maintain abstinence 1
• Acamprosate may be considered as an alternative to naltrexone, particularly for patients with liver concerns, as it helps reduce withdrawal symptoms and maintain abstinence 1
• Combination therapy with counseling is recommended to maximize effectiveness in maintaining abstinence 1

Clinical Approach

• For patients with alcohol dependence without liver disease, naltrexone (50 mg daily) combined with counseling can be effective in reducing alcohol consumption 1
• For patients with any degree of alcoholic liver disease, strict abstinence should be recommended and naltrexone should be avoided due to hepatotoxicity risk 1
• Long-acting injectable naltrexone (380 mg monthly) may improve adherence and resulted in a 25% decrease in heavy drinking days compared to placebo in clinical trials 5

Important Caveats

• There is no safe amount of alcohol consumption that can be recommended after an episode of alcoholic hepatitis, as it can persist or redevelop 1
• Patients who attempt to cut back but not stop drinking altogether have a significant risk of recidivism 1
• Naltrexone cannot be used in patients requiring opioids for pain control, as it will block pain relief from opioid agonists 1
• Monitoring for depression and suicidal ideation is important, as these have been reported in patients on naltrexone, though no causal relationship has been established 4