From the Guidelines
Prescribing low-dose oral hydromorphone for a patient on naltrexone is not recommended as it would be ineffective and potentially dangerous. Naltrexone is an opioid antagonist that blocks opioid receptors, preventing hydromorphone and other opioids from providing pain relief, as noted in the study by 1. This blockade is powerful and competitive, meaning that attempting to overcome it by increasing the opioid dose could lead to respiratory depression and overdose once the naltrexone effect diminishes.
For patients on naltrexone with severe knee pain, non-opioid alternatives should be used, including:
- NSAIDs (if not contraindicated)
- Topical analgesics
- Corticosteroid injections
- Physical therapy
- Interventional procedures like nerve blocks. If the pain is severe and temporary, the provider might consider temporarily discontinuing naltrexone, but this requires careful consideration of the patient's substance use disorder treatment plan and should involve addiction medicine specialists, as suggested by the guidelines in 1. The patient should understand that naltrexone's opioid-blocking effects can persist for days to weeks depending on the formulation used, with oral naltrexone having a shorter duration of action that should be held 3-4 days before attempting opioid therapy, according to 1.
From the Research
Potential Interactions and Effects
- The use of low-dose oral hydromorphone in a patient on naltrexone may be complicated due to the opioid antagonist properties of naltrexone 2, 3.
- Naltrexone can increase the opioid requirement for pain control, which may lead to higher doses of hydromorphone being needed to achieve adequate pain relief 3.
- The combination of opioids and non-opioids for pain management is a well-established strategy, but the use of naltrexone may affect the efficacy of this approach 4.
- Alternative pain management options, such as ketamine, lidocaine/bupivacaine, duloxetine, and non-pharmacological methods, may be considered to mitigate opioid dependence and control pain in patients on naltrexone 3.
Considerations for Pain Management
- Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain, but may not be sufficient for severe pain 5.
- For severe or refractory acute pain, treatment can be briefly escalated with the use of medications that work on opioid and monoamine receptors, but this should be done with caution in patients on naltrexone 5.
- Multimodal pain regimens should be employed in patients on naltrexone to manage pain effectively and minimize the risk of opioid dependence 3.