Naltrexone Treatment for Alcohol Use Disorder in a Patient with ADHD on Methylphenidate
Naltrexone should be offered as part of treatment to reduce relapse in this alcohol-dependent patient, and can be safely combined with methylphenidate (Concerta) for concurrent ADHD management. 1, 2
Primary Indication and Mechanism
Naltrexone is FDA-approved and guideline-recommended for alcohol use disorder, functioning as a competitive opioid receptor antagonist that blocks the reinforcing effects of alcohol consumption and reduces cravings. 2, 3, 4 The medication has demonstrated efficacy in reducing the likelihood of return to drinking by 5% and binge-drinking risk by 10%, with moderate quality evidence supporting its effectiveness in preventing relapse. 5, 2
Safety of Concurrent Use with Methylphenidate
The combination of naltrexone with methylphenidate is well-tolerated and does not interfere with the clinical effectiveness of stimulants for ADHD symptoms. 6 A double-blind, placebo-controlled trial specifically demonstrated that coadministration of naltrexone 50 mg with methylphenidate preserved the clinical benefits of stimulants while not producing an increase in adverse events compared to methylphenidate alone. 6
Treatment Protocol
Pre-Treatment Requirements
The patient must be completely alcohol-free for 3-7 days before initiating naltrexone, and only after withdrawal symptoms have completely resolved. 3, 4 This is critical to avoid precipitating withdrawal syndrome.
Obtain baseline liver function tests before starting treatment, as naltrexone carries hepatotoxicity risk at supratherapeutic doses. 2, 3 Naltrexone is contraindicated in patients with alcoholic liver disease or acute hepatitis. 3, 7
Perform urine drug screening to confirm opioid-free status, as naltrexone cannot be used in patients requiring opioids for pain control. 2, 4
Dosing Regimen
Start with 25 mg daily for days 1-3, then increase to 50 mg daily. 3, 4 This initial lower dose helps assess tolerance.
Alternative supervised dosing: 100 mg on Mondays and Wednesdays, 150 mg on Fridays. 2, 4
Injectable formulation (Vivitrol) 380 mg monthly is available and may improve adherence. 2
Treatment Duration
The recommended duration is 3-6 months, with option to extend up to 12 months based on individual response and clinical need. 7 The placebo-controlled efficacy trials used naltrexone 50 mg once daily for up to 12 weeks. 4
Monitoring Requirements
Repeat liver function tests every 3-6 months throughout treatment due to potential hepatotoxicity. 2, 3, 7
Monitor for adherence and response to both ADHD and alcohol use disorder treatments through frequent follow-up visits.
Continue methylphenidate at current dose without adjustment, as naltrexone does not interfere with stimulant efficacy. 6
Essential Treatment Context
Naltrexone must be combined with psychosocial interventions to be effective. 7, 4 The medication should be part of a comprehensive management plan that includes:
- Counseling and behavioral therapy for alcohol use disorder 4, 5
- Compliance-enhancing techniques for medication adherence 4
- Community-based support groups 4
- Continued ADHD-specific psychotherapy or psychoeducation 8
Critical Safety Warnings
Patients who discontinue naltrexone have increased risk of opioid overdose and death due to decreased opioid tolerance. 2 Provide overdose education if there is any history of opioid use.
If the patient requires surgery, hold oral naltrexone for 2-3 days prior to elective procedures if opioids are expected for pain management. 2
Never initiate naltrexone during active alcohol withdrawal - benzodiazepines remain the gold standard for managing acute withdrawal syndrome. 3
Medication Selection Rationale
The decision to use naltrexone over alternatives (acamprosate or disulfiram) should consider: 1
- Patient preference and motivation - this patient is appropriate for naltrexone given normal liver function (implied by lack of contraindication mentioned)
- Availability - naltrexone is widely available in both oral and injectable forms
- Liver function status - acamprosate would be preferred if alcoholic liver disease were present 3