How to manage a 22-year-old patient with opioid addiction who is taking Naltrexone (naltrexone) and experiencing emotional numbing, while also considering alternative treatments and counseling for underlying mental health issues?

Management of Naltrexone-Associated Emotional Numbing in a 22-Year-Old with Opioid Use Disorder

This patient requires immediate transition from naltrexone to buprenorphine-based medication-assisted treatment, given the dangerous pattern of unprescribed opioid use (Suboxone, Xanax) while on naltrexone, combined with concerning emotional numbing that is undermining treatment adherence.

Critical Safety Concerns

The patient's recent behavior reveals multiple high-risk issues that demand urgent intervention:

• Unprescribed Suboxone use while on naltrexone creates risk of precipitated withdrawal and respiratory depression, which the patient already experienced 1
• Concurrent propranolol and Suboxone use increases respiratory depression risk 2
• Unprescribed benzodiazepine (Xanax) use combined with opioid exposure dramatically increases overdose mortality risk 2
• Testing naltrexone's blockade with alcohol and smoking demonstrates impulsive substance-seeking behavior that naltrexone alone cannot address 2
• Emotional numbing is undermining the patient's adherence and driving relapse behavior 1

Recommended Treatment Algorithm

Step 1: Discontinue Naltrexone and Transition to Buprenorphine

Buprenorphine is the superior choice for this patient based on multiple factors 2:

• The patient is already obtaining and using unprescribed Suboxone (buprenorphine), indicating physiologic compatibility and preference 2
• Buprenorphine reduces mortality, opioid use, and increases treatment retention more effectively than naltrexone 3
• Naltrexone has demonstrated limited success in non-highly-motivated populations, and this patient's impulsive behavior pattern suggests suboptimal candidacy 2
• The emotional numbing reported is a recognized adverse effect of naltrexone that can undermine treatment success 1

Transition protocol:

• Naltrexone must be discontinued and the patient must wait 7-10 days before buprenorphine initiation to avoid precipitated withdrawal 1
• During this waiting period, the patient is at extremely high risk for opioid overdose due to decreased tolerance from naltrexone treatment 2
• Provide naloxone rescue kit and overdose education immediately 2
• Consider brief hospitalization or intensive outpatient monitoring during this vulnerable transition period 2

Step 2: Buprenorphine Induction and Maintenance

Initiate buprenorphine when patient demonstrates objective opioid withdrawal (Clinical Opiate Withdrawal Scale >8) 2:

• Start with buprenorphine 4-8 mg sublingual based on withdrawal severity 2
• Target maintenance dose of 16 mg daily for most patients 2
• Prescribe buprenorphine/naloxone combination (not buprenorphine alone) to reduce diversion risk 2
• This requires DATA 2000 waiver certification for prescribing physicians 2

Step 3: Address Underlying Mental Health Comorbidities

The patient's complex trauma history and anxiety require concurrent psychiatric treatment 2:

• Restart SSRI therapy: The patient previously responded well to Prozac (fluoxetine) for anxiety/panic attacks before self-discontinuation 2
• Trauma-focused therapy: Multiple significant losses (mother at age 11, witnessed fiancé's suicide at 17-18, best friend's death, grandfather's death) require evidence-based trauma therapy 2
• Avoid benzodiazepines: Despite patient's preference for Xanax, benzodiazepines are contraindicated with opioid use disorder due to respiratory depression and overdose risk 2
• Propranolol can continue for autonomic anxiety symptoms at appropriate dosing (up to 3 times daily as patient requested is reasonable) 2

Step 4: Intensive Behavioral Therapy Integration

Medication-assisted treatment must be combined with behavioral interventions 2, 3:

• Cognitive behavioral therapy (CBT) is evidence-based for both opioid use disorder and anxiety 2
• Motivational interviewing to address ambivalence about recovery 2
• Mutual support groups (Narcotics Anonymous, SMART Recovery) at any stage of readiness 2
• Address the patient's "dead set mindset" pattern that drives impulsive substance use 2

Step 5: Ongoing Monitoring and Risk Mitigation

Close monitoring is essential given this patient's high-risk profile 2:

• Weekly visits initially, then every 3 months minimum once stabilized 2
• Prescription drug monitoring program (PDMP) checks at each visit 2
• Urine drug testing to monitor for unprescribed substances 2
• Liver function tests every 3-6 months (naltrexone baseline concern, though now discontinuing) 2
• Screen for depression and suicidal ideation at every visit given trauma history 2, 1
• Naloxone prescription for home rescue 2

Critical Pitfalls to Avoid

Do not continue naltrexone in this clinical scenario. The combination of emotional numbing, impulsive unprescribed opioid use, and testing the medication's blockade indicates treatment failure 2, 1. Naltrexone works best in highly motivated populations (e.g., healthcare professionals) with stable support systems 2, 4, 5, which does not describe this patient's current presentation.

Do not prescribe benzodiazepines despite the patient's stated preference, as concurrent benzodiazepine and opioid use dramatically increases overdose mortality 2. The patient's history of unprescribed Xanax use indicates risk for benzodiazepine use disorder 2.

Do not dismiss the patient from your practice due to substance use behaviors, as this represents patient abandonment and increases mortality risk 2. Instead, intensify treatment and support.

Do not underestimate overdose risk during the naltrexone-to-buprenorphine transition period. Patients discontinuing naltrexone have decreased opioid tolerance and face increased overdose and death risk 2. This 7-10 day window requires intensive monitoring and harm reduction strategies 1.

Why Buprenorphine Over Continuing Naltrexone

The evidence strongly favors buprenorphine for this patient 2, 3:

• Mortality reduction: Buprenorphine reduces all-cause mortality in opioid use disorder 3
• Treatment retention: Buprenorphine has superior retention rates compared to naltrexone 3, 5
• Patient behavior: The patient is already seeking and using buprenorphine (Suboxone) unprescribed, indicating preference and need 2
• Emotional symptoms: Buprenorphine does not cause the emotional numbing reported with naltrexone 1
• Relapse pattern: Naltrexone's high attrition rates (38-77% dropout by 3-4 weeks in some studies) make it unsuitable for patients with impulsive patterns 4, 5

The patient's statement that "I've been the most sober I've been in my entire life" on naltrexone is undermined by concurrent unprescribed Suboxone, Xanax, alcohol, and marijuana use, indicating that naltrexone is providing a false sense of treatment success while dangerous polysubstance use continues.