What is the recommended tapering strategy for naltrexone (opioid receptor antagonist)?

Naltrexone Tapering Strategy

For naltrexone tapering, a slow reduction of 10% of the previous dose per month or slower is recommended to minimize withdrawal symptoms and optimize patient outcomes.

Understanding Naltrexone Discontinuation

• Naltrexone is an opioid receptor antagonist that requires careful discontinuation to avoid withdrawal symptoms 1
• Patients must be monitored closely during tapering as discontinuation of long-term therapy has been associated with adverse events including mental health crises 2
• Abrupt discontinuation should be avoided as it may lead to withdrawal symptoms similar to those seen with other medications 2

Recommended Tapering Protocol

Initial Assessment

• Before initiating taper, assess for depression, anxiety, and insomnia which should be addressed to improve taper outcomes 2
• Evaluate patient's motivation and readiness for tapering, as patient agreement and interest are key components of successful tapers 2
• Screen for opioid use disorder (OUD) as this may affect the tapering approach 2

Tapering Schedule

• For patients who have been on naltrexone long-term (≥1 year), tapers of 10% per month or slower are likely to be better tolerated than more rapid tapers 2
• Each new dose should be 90% of the previous dose rather than a straight-line taper from the starting dose 2
• For oral naltrexone, consider starting with a reduction from 50mg to 25mg for the first step of the taper 3
• Alternative dosing schedules may include 50mg every weekday with 100mg on Saturday, or 100mg every other day during the tapering process 3

Monitoring and Support

• Follow up frequently (at least monthly) with patients during the tapering process 2
• Team members such as nurses, pharmacists, and behavioral health professionals can provide support through telephone contact, telehealth visits, or face-to-face visits 2
• Monitor for signs of withdrawal including anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, and tachycardia 2

Managing Withdrawal Symptoms

• Use of α2-adrenergic agonists (e.g., clonidine) is well-supported for managing withdrawal symptoms 2
• For patients struggling to tolerate the taper, maximize non-pharmacologic treatments and address behavioral distress 2
• Clinically significant withdrawal symptoms signal the need to further slow the taper rate 2
• At times, tapers might need to be paused and restarted when the patient is ready 2

Special Considerations

• Patients who discontinue naltrexone treatment have increased risk of opioid overdose and death due to decreased opioid tolerance 1
• Provide opioid overdose education and consider offering naloxone to patients undergoing naltrexone tapering 2
• For patients with poor response to taper but without OUD, consider: (1) treatment with buprenorphine/naloxone or (2) continuing a very slow opioid dose taper that may take months or years 2
• For surgical patients on naltrexone, oral naltrexone should be held for 2-3 days prior to elective procedures if opioids are expected 1

Psychological Support

• Cognitive behavioral therapy and interdisciplinary approaches can support patients during tapering 2
• Address possible anxiety related to the taper, underlying depression, and deficient pain and stress-coping strategies 2
• The addition of psychosocial care has been found to significantly reduce dropouts and rate of opioid use during treatment and at follow-up 2

Common Pitfalls to Avoid

• Avoid abrupt discontinuation which can precipitate withdrawal symptoms 2
• Avoid "cold referrals" to clinicians who have not agreed to accept the patient 2
• Do not set zero as the mandatory target dose; some patients may benefit from maintenance at a lower dose 2
• Do not fail to prepare patients for the increased risk of overdose if they return to previous opioid use after naltrexone discontinuation 2, 1