Naltrexone for Compulsive Shopping
Naltrexone is not recommended for compulsive shopping disorder based on current evidence, as placebo-controlled trials have failed to demonstrate efficacy, and no clinical guidelines support its use for this indication.
Evidence Base for Naltrexone in Compulsive Shopping
The available evidence for naltrexone in compulsive shopping is limited to case reports and lacks robust support:
Two placebo-controlled trials of fluvoxamine (an SSRI) showed no superiority over placebo for compulsive buying disorder, and these remain the only controlled trials in this condition 1, 2.
Naltrexone has only been reported as effective in individual case reports for compulsive buying, which represents the lowest level of clinical evidence 1, 2.
A comprehensive 2016 systematic review concluded that no treatment recommendations can be made for compulsive buying disorder due to insufficient evidence for any pharmacologic agent 1.
Mechanism and Theoretical Rationale
While naltrexone has theoretical appeal based on its mechanism, this has not translated to clinical efficacy:
Naltrexone functions as an opioid receptor antagonist that may theoretically reduce urge-related symptoms in impulse control disorders 3.
The drug is FDA-approved only for opioid dependence and alcohol use disorder, not for any impulse control disorders including compulsive shopping 4, 5.
In impulse control disorders generally, naltrexone appears to require doses higher than 50 mg/day (often 100-150 mg/day), but even at these doses, evidence remains limited to case series 3.
Alternative Evidence-Based Approaches
Given the lack of efficacy data for naltrexone, other interventions should be prioritized:
Cognitive behavioral therapy represents the evidence-based first-line approach for impulse control and compulsive behaviors without medication side effects 6.
SSRIs have more established evidence than naltrexone, with open-label trials of citalopram showing clinical improvement, though controlled trials of fluvoxamine were negative 1, 2.
If pharmacotherapy is pursued, escitalopram showed effectiveness in open-label trials, though it failed to maintain efficacy in double-blind phases 1.
Safety Considerations if Naltrexone is Considered Off-Label
Should naltrexone be considered despite limited evidence, important safety monitoring is required:
Baseline and ongoing liver function tests every 3-6 months are mandatory due to hepatotoxicity risk at therapeutic and supratherapeutic doses 5, 4.
Common adverse effects include nausea (4.6-9.6%), headache, dizziness, and gastrointestinal symptoms, with 25% of patients discontinuing due to adverse effects in obesity trials 4.
Naltrexone cannot be used in patients requiring opioid analgesics, as it blocks opioid receptors and can precipitate withdrawal in opioid-dependent individuals 4, 5.
The medication should be discontinued before any surgical procedures requiring opioid analgesia, with oral naltrexone held 2-3 days prior to elective procedures 5.
Clinical Bottom Line
The absence of positive placebo-controlled trials, combined with only anecdotal case report evidence, makes naltrexone an inappropriate choice for compulsive shopping disorder. Cognitive behavioral therapy should be the primary intervention, with SSRIs considered as second-line pharmacotherapy if needed 6, 1.