Can naltrexone be given to someone presenting with alcohol withdrawal?

Naltrexone Should NOT Be Given During Active Alcohol Withdrawal

Naltrexone is contraindicated during the acute alcohol withdrawal phase and should only be initiated after withdrawal management is complete and the patient has achieved abstinence. 1

Timing of Naltrexone Initiation

During Withdrawal Management (Days 0-7+)

• Benzodiazepines are the gold standard for managing alcohol withdrawal syndrome, reducing withdrawal symptoms and preventing seizures and delirium tremens 1
• Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide superior protection against seizures and delirium 1
• Short-acting benzodiazepines (lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction 1
• Naltrexone has no role in treating withdrawal symptoms and is not mentioned in any withdrawal management protocols 1

After Withdrawal Resolution (Post-Detoxification)

• Naltrexone should be initiated 3-7 days after the last alcohol consumption and only after withdrawal symptoms have completely resolved 1
• The medication is used for relapse prevention, not acute withdrawal management 1
• Standard dosing: 25 mg on days 1-3, then 50 mg daily for 3-6 months (up to 12 months) 1

Critical Safety Concerns

Hepatotoxicity Risk

• Naltrexone carries risk of toxic liver injury and is NOT recommended in patients with alcoholic liver disease (ALD) 1
• The FDA label warns of hepatotoxicity, particularly at supratherapeutic doses 2
• Patients should be monitored for signs of acute hepatitis (jaundice, dark urine, right upper quadrant pain) 2
• Liver function tests should be obtained at baseline and every 3-6 months 1

Opioid-Related Complications

• Patients must be opioid-free for minimum 7-10 days before starting naltrexone to avoid precipitated withdrawal 2
• Naltrexone blocks all opioid effects, preventing pain relief from opioid analgesics 2
• Attempting to overcome the opioid blockade can lead to life-threatening overdose 2

Alternative Medications for Patients with Liver Disease

Baclofen (Preferred in ALD)

• Baclofen is the only alcohol pharmacotherapy tested and proven safe in cirrhotic patients 1
• Can be used for both withdrawal management and relapse prevention 1
• GABA-B receptor agonist that reduces alcohol craving 1

Acamprosate

• Reduces withdrawal effects and craving for alcohol 1
• Initiated 3-7 days after last alcohol consumption, after withdrawal resolves 1
• Dosing: 1,998 mg/day for patients ≥60 kg 1

Common Pitfalls to Avoid

1. Never start naltrexone during active withdrawal - it provides no benefit for withdrawal symptoms and delays appropriate benzodiazepine therapy 1

2. Do not use naltrexone in patients with elevated liver enzymes (>3× normal) or active alcoholic liver disease 1

3. Screen for occult opioid use before initiating naltrexone, even in alcohol-dependent patients, as precipitated withdrawal has occurred in patients unaware of their opioid co-dependence 2

4. Naltrexone is only effective as part of comprehensive treatment including psychosocial support, counseling, and mutual help groups like Alcoholics Anonymous 1, 3