What is the indication for naltrexone (opioid receptor antagonist) in an adult patient with a confirmed diagnosis of porn addiction who has failed other treatments such as cognitive-behavioral therapy?

Naltrexone for Pornography Addiction: Off-Label Indication

For pornography addiction, you should document the indication as "compulsive sexual behavior" or "behavioral addiction" since naltrexone is FDA-approved only for opioid and alcohol use disorders, not pornography addiction. 1

Understanding the Off-Label Context

• Naltrexone is FDA-approved exclusively for opioid dependence and alcohol use disorder—there is no FDA approval for pornography addiction or any behavioral addiction. 1
• The mechanism of action involves blocking mu-opioid receptors, which dampens activation of the brain's reward pathway and reduces cravings for addictive behaviors. 2, 3
• This same reward pathway dysfunction underlies both substance addictions and behavioral addictions, providing the theoretical rationale for off-label use. 4

Appropriate Documentation Language

Use one of these specific diagnostic terms for the indication:

• "Compulsive Sexual Behavior (CSB)" - This is the most clinically appropriate term and appears in the psychiatric literature. 5, 6
• "Behavioral addiction with compulsive sexual behavior" - This frames it within the broader addiction medicine context. 5
• "Hypersexual disorder" or "problematic pornography use" - These are alternative terms used in research settings. 7

Evidence Supporting Off-Label Use

• Case reports demonstrate that naltrexone (50 mg daily) reduced symptoms of pornography addiction, with one patient achieving complete remission maintained for over 3 years. 8, 4
• A case series of 19 male patients with compulsive sexual behavior showed 89% reported symptom reduction when naltrexone was added to their treatment regimen. 6
• Nalmefene (a related mu-opioid antagonist) at 18 mg daily showed impressive reduction in addictive symptoms, with symptom recurrence upon discontinuation and improvement upon restarting. 8
• One case demonstrated that naltrexone simultaneously reduced both tobacco use and pornography viewing in a patient with co-occurring addictions. 7

Practical Prescribing Approach

Start with standard dosing:

• Oral naltrexone 50 mg daily is the typical starting dose used in case reports. 5, 4, 6
• Alternative dosing of 100 mg on Mondays/Wednesdays and 150 mg on Fridays can be used. 3
• Extended-release injectable naltrexone (Vivitrol 380 mg monthly) may improve adherence but has not been specifically studied for this indication. 2

Document that the patient has:

• Failed cognitive-behavioral therapy or other non-pharmacologic interventions first. 5, 6
• No current opioid use or need for opioid pain medications (absolute contraindication). 2, 3
• Been screened for liver disease with baseline liver function tests. 2, 3

Critical Safety Considerations

• Patients must be completely opioid-free before starting naltrexone to avoid precipitating severe withdrawal. 2, 3
• Monitor liver function tests at baseline and every 3-6 months due to potential hepatotoxicity. 2, 3
• If the patient requires opioid analgesia for surgery or injury, oral naltrexone must be held 2-3 days prior, or 24-30 days for extended-release formulation. 2, 9
• One case reported anhedonia as an adverse effect at higher doses, which resolved with dose reduction. 7

Insurance and Prior Authorization Strategy

When submitting for prior authorization, include:

• The diagnosis code for "other specified impulse control disorder" or "compulsive sexual behavior" depending on your coding system. 5, 6
• Documentation that this is off-label use with supporting case report literature. 8, 5, 7, 4, 6
• Evidence of failed behavioral interventions (cognitive-behavioral therapy, support groups). 5, 6
• Statement that the patient has significant functional impairment from the condition. 5, 4

Common Pitfalls to Avoid

• Do not use the term "pornography addiction" in official documentation—use "compulsive sexual behavior" instead, as it is more clinically recognized. 5, 6
• Do not prescribe naltrexone as monotherapy—it should be combined with ongoing psychotherapy or behavioral interventions. 5, 6
• Do not fail to screen for co-occurring substance use disorders—many patients have multiple addictions that may respond to naltrexone. 5, 7
• Do not prescribe without baseline liver function tests—hepatotoxicity is a known risk at therapeutic doses. 2, 3