Can naltrexone (opioid receptor antagonist) be restarted in an inpatient with a history of alcohol intoxication?

Restarting Naltrexone After Alcohol Intoxication in Psychiatric Inpatient

Yes, you can restart naltrexone in this psychiatric inpatient after alcohol intoxication, provided the patient has been fully detoxified from alcohol and opioids, liver function tests are acceptable (transaminases less than 3-5 times upper limit of normal), and the patient is not currently requiring opioid analgesics. 1, 2

Critical Pre-Restart Requirements

Before restarting naltrexone, you must verify:

• Complete alcohol detoxification: The patient must be past acute withdrawal symptoms, as naltrexone is used for relapse prevention, not acute detoxification 1, 2
• Opioid-free status: Confirm the patient has not used opioids for at least 7-10 days to avoid precipitating acute opioid withdrawal 1
• Liver function assessment: Check baseline transaminases (AST/ALT); naltrexone causes hepatotoxicity concerns and is contraindicated in patients with alcoholic liver disease 1, 2, 3
• No current opioid requirements: Naltrexone will block all opioid analgesic effects, making pain management impossible with opioid agonists 2

Hepatotoxicity Considerations

The most critical safety concern is liver toxicity, particularly in patients with alcohol-associated liver disease:

• The American Association for the Study of Liver Diseases explicitly states naltrexone has not been studied in patients with alcoholic hepatitis or cirrhosis and carries hepatotoxicity concerns 1
• Naltrexone is metabolized hepatically and can cause hepatocellular injury, especially at higher doses 2, 3
• If this patient has any evidence of alcohol-associated liver disease (elevated transaminases, clinical signs of cirrhosis, history of alcoholic hepatitis), naltrexone should NOT be restarted 1, 2
• Consider baclofen (30-60 mg/day) or acamprosate (666 mg three times daily) as safer alternatives in patients with liver disease, as these have better safety profiles 1, 2

Dosing and Monitoring Protocol

If the patient meets criteria for restart:

• Standard dose: 50 mg orally once daily 1, 4, 5
• Baseline monitoring: Obtain liver function tests before restart 2
• Ongoing monitoring: Repeat liver function tests every 3-6 months during treatment 2
• Combination therapy: Naltrexone should always be combined with psychosocial interventions (cognitive behavioral therapy, motivational enhancement therapy, or 12-step facilitation) for maximum efficacy 1, 5

Clinical Effectiveness in This Setting

Hospital initiation of naltrexone for alcohol use disorder has demonstrated benefit:

• A 2018 study showed that counseling hospitalized patients about naltrexone during alcohol withdrawal admissions resulted in 28.1% receiving prescriptions at discharge, with significantly lower 30-day ED revisits (adjusted OR 0.47) compared to pre-intervention controls 6
• Naltrexone reduces alcohol craving and prevents relapse, with only 23% of naltrexone-treated patients relapsing versus 54.3% on placebo in controlled trials 4
• The medication is particularly effective in preventing full relapse after a patient samples alcohol—50% of naltrexone patients relapsed after drinking versus 95% on placebo 4

Important Caveats

• False-positive drug screens: Naltrexone metabolizes to noroxymorphone, which can cause false-positive oxycodone urine drug screens; use confirmatory testing if this occurs 7
• Side effects: Monitor for nausea (most common), which occurred in some patients but rarely required discontinuation 4
• Abstinence goal: The patient must understand that strict abstinence is the goal; there is no safe amount of alcohol consumption, particularly if any liver disease is present 2
• Alternative if liver disease present: Baclofen is the only alcohol use disorder medication studied in patients with cirrhosis and showed improved abstinence rates with acceptable safety (10 mg three times daily), though it should be avoided in patients with hepatic encephalopathy 1