Naltrexone 50 mg Tapering Schedule
For patients requiring discontinuation of naltrexone 50 mg, a gradual taper of 10% per month or slower is recommended to minimize withdrawal symptoms and improve outcomes.
Understanding Naltrexone Discontinuation
- Abrupt discontinuation of naltrexone should be avoided as it may lead to withdrawal symptoms and mental health crises, particularly in patients on long-term therapy 1
- Before initiating taper, assess for depression, anxiety, and insomnia, which should be addressed to improve taper outcomes 1
- Patient agreement and motivation are key components of successful tapers 1
Recommended Tapering Protocol
For Long-Term Users (≥1 year on naltrexone):
- Implement a gradual taper of 10% per month or slower 1
- Each new dose should be 90% of the previous dose rather than a straight-line taper 1
- Example schedule for 50 mg daily:
- Month 1: 45 mg daily
- Month 2: 40.5 mg daily
- Month 3: 36.5 mg daily
- Month 4: 33 mg daily
- Continue reducing by 10% monthly until discontinuation
For Short-Term Users:
- Consider a more moderate taper of 20-25% reduction per week for patients not presenting with substance use disorder 2
- For patients taking naltrexone less than once daily as rescue doses, a formal taper may not be necessary 2
Alternative Tapering Methods
- Some protocols first reduce the dose to the smallest commonly available unit dosage and then increase the interval between doses 2
- The Department of Veterans Affairs suggests tapering by 20% to 50% of the original dose per week for patients without substance use disorder 2
- For inpatient settings, a 3-week structured taper may be appropriate, as used in the Mayo Clinic Program with reported completion rates above 90% 2
Monitoring and Support During Tapering
- Follow up at least monthly with patients during the tapering process 1
- Monitor for signs of withdrawal, including anxiety, insomnia, abdominal pain, vomiting, diarrhea, diaphoresis, mydriasis, tremor, and tachycardia 1
- Clinically significant withdrawal symptoms indicate the need to further slow the taper rate 1
Managing Withdrawal Symptoms
- α2-adrenergic agonists (e.g., clonidine) are well-supported for managing withdrawal symptoms 2, 1
- Symptomatic treatments for muscle aches and pain, such as nonsteroidal anti-inflammatory drugs or acetaminophen, can be helpful 2
- For patients struggling with the taper, maximize non-pharmacologic treatments and address behavioral distress 1
Psychological Support
- Cognitive behavioral therapy and interdisciplinary approaches can support patients during tapering 2, 1
- Address possible anxiety related to the taper, underlying depression, and deficient pain and stress-coping strategies 1
- The addition of psychosocial care significantly reduces dropouts and rate of opioid use during treatment and at follow-up 1
Special Considerations
- For patients on naltrexone for opioid use disorder, provide opioid overdose education and consider offering naloxone during tapering 1
- Patients who discontinue naltrexone treatment have increased risk of opioid overdose due to decreased opioid tolerance 1
- For surgical patients on naltrexone, oral naltrexone should be held for 2-3 days prior to elective procedures if opioids are expected 1
Common Pitfalls to Avoid
- Avoid setting zero as the mandatory target dose; some patients may benefit from maintenance at a lower dose 1
- Avoid "cold referrals" to clinicians who have not agreed to accept the patient 1
- Do not fail to prepare patients for the increased risk of overdose if they return to previous opioid use after naltrexone discontinuation 1