Naltrexone with Ativan (Lorazepam): Precautions and Management
Direct Answer
Naltrexone can be safely combined with lorazepam (Ativan) without direct pharmacological contraindications, but critical precautions exist when managing pain emergencies in patients on naltrexone, where benzodiazepines like lorazepam serve as a preferred alternative to opioid analgesia. 1
Emergency Pain Management: The Primary Clinical Concern
When patients on naltrexone require acute pain management, benzodiazepines including lorazepam are specifically recommended as part of the pain management strategy because naltrexone blocks opioid receptors, rendering standard opioid analgesics ineffective or requiring dangerously high doses. 1
Recommended Approach for Pain in Naltrexone Patients:
- Regional analgesia should be first-line 1
- Conscious sedation with benzodiazepines (including lorazepam) is an FDA-recommended alternative 1
- Non-opioid analgesics should be maximized 1
- General anesthesia may be necessary for severe pain 1
Critical Warning About Opioid Use:
If opioids must be used to overcome naltrexone blockade, the required opioid dose will be substantially higher than usual, resulting in deeper and more prolonged respiratory depression that requires monitoring by trained personnel in a setting equipped for cardiopulmonary resuscitation. 1
Naltrexone-Bupropion Combination Considerations
When naltrexone is prescribed as part of naltrexone-bupropion ER (for obesity/weight management), additional precautions apply that may interact with benzodiazepine use:
Seizure Risk Management:
- Naltrexone-bupropion ER is contraindicated in patients with seizure disorders 2, 3
- Abrupt discontinuation of benzodiazepines (including lorazepam) is an absolute contraindication for bupropion use due to dramatically increased seizure risk 4
- Patients on chronic benzodiazepines who need naltrexone-bupropion require extremely gradual benzodiazepine taper if discontinuation is planned 4
Cardiovascular Monitoring:
- Blood pressure and heart rate must be monitored periodically, especially during the first 12 weeks of naltrexone-bupropion treatment 2, 3
- This monitoring is particularly important if lorazepam is being used for anxiety, as both medications can affect cardiovascular parameters 3
Specific Clinical Scenarios
Scenario 1: Patient on Naltrexone Alone + Lorazepam
No direct drug interaction exists. The combination is safe from a pharmacological standpoint. 1
Key precaution: Ensure the patient carries naltrexone identification and that all healthcare providers know about naltrexone use, particularly if emergency pain management becomes necessary. 1
Scenario 2: Patient on Naltrexone-Bupropion ER + Lorazepam
This combination requires careful management:
- Never abruptly discontinue lorazepam while patient is on bupropion 4
- Monitor for neuropsychiatric effects, especially in patients under 24 years old 3
- Assess for seizure risk factors before initiating or continuing therapy 2, 3
Scenario 3: Transitioning Off Lorazepam in Naltrexone-Bupropion Patients
If benzodiazepine discontinuation is clinically necessary:
- Complete the benzodiazepine taper before starting naltrexone-bupropion 4
- Allow adequate washout period (typically 7-14 days minimum after benzodiazepine discontinuation) 4
- Never initiate bupropion-containing products during active benzodiazepine withdrawal 4
Monitoring Requirements
For All Patients on Naltrexone:
- Liver function tests every 3-6 months for long-term naltrexone treatment 5
- More frequent monitoring (every 2-4 weeks) if using doses >50 mg/day 5
- Essential liver monitoring in patients with chronic hepatitis C or HIV 5
For Patients on Naltrexone-Bupropion ER:
- Blood pressure and heart rate especially first 12 weeks 2, 3
- Serum bicarbonate levels periodically for long-term use 3
- Neuropsychiatric assessment for suicidal ideation, particularly in patients <24 years 3
Contraindications to Be Aware Of
Absolute Contraindications for Naltrexone-Bupropion:
- Current opioid use (naltrexone component) 2, 3
- Uncontrolled hypertension (bupropion component) 3
- Seizure disorders (bupropion component) 2, 3
- Concurrent MAOI use or within 14 days of MAOI discontinuation (bupropion component) 3
Special Populations
Renal Impairment:
- Naltrexone and metabolites are renally excreted; use caution in renal impairment 1
- Reduce naltrexone-bupropion dose by half in moderate to severe renal impairment 4
Hepatic Impairment:
- Naltrexone AUC increases 5-10 fold in compensated and decompensated cirrhosis respectively 1
- Maximum 150 mg daily of bupropion component in moderate to severe hepatic impairment 4
Clinical Pearl: Benzodiazepine as Therapeutic Adjunct
Emerging evidence suggests benzodiazepines may actually enhance naltrexone efficacy in opioid dependence treatment. A study demonstrated that naltrexone plus prazepam (a benzodiazepine) resulted in significantly better abstinence rates (12/14 patients remained opioid-free at 6 months) compared to naltrexone alone (6/14 patients), with the combination also reducing cannabis use. 6 This suggests lorazepam co-administration may provide therapeutic benefit rather than harm in addiction treatment contexts.