Substance Use Disorder Treatment

Introduction to Naltrexone

Naltrexone is an opioid receptor antagonist that decreases the likelihood of relapse when combined with counseling, as supported by the American Association for the Study of Liver Diseases 1, 2
Naltrexone is recommended as a first-line pharmacotherapy for alcohol use disorder, decreasing the likelihood of relapse when combined with counseling, as supported by the American Association for the Study of Liver Diseases 1, 2

Naltrexone is contraindicated in cases with hepatic insufficiency, according to its Summary of Product Characteristics, although the absolute nature of this contraindication is not supported by solid data in the literature 3
Naltrexone undergoes hepatic metabolism, which raises hepatotoxicity concerns, particularly in patients with liver disease, with low strength of evidence 1
The use of naltrexone has not been extensively studied in patients with alcoholic liver disease, highlighting the need for caution, according to the American Association for the Study of Liver Diseases 1

For patients with liver disease, use of naltrexone should be assessed on a case-by-case basis according to risks, expected benefits, and other treatment options 3
The initial dose of naltrexone should be 25 mg for the first 1-3 days to assess tolerability, then increased to a standard maintenance dose of 50 mg once daily, as recommended by the American Association for the Study of Liver Diseases and the Clinical and Molecular Hepatology society 4
An injectable extended-release formulation of 380 mg monthly is an alternative to daily oral dosing, with the dosage and administration schedule varying depending on the patient's response and medical history, as recommended by the Clinical and Molecular Hepatology society and the American Academy of Family Physicians 1, 5

Acamprosate may be considered as an alternative to naltrexone for patients with liver disease, as it does not have changed indications or conditions of use in liver disease 3
Baclofen may also be considered as an alternative to naltrexone for patients with liver disease, as it is generally not affected by liver disease at doses up to 80 mg/day 3
Buprenorphine/naloxone is a first-line treatment for opioid use disorder, with advantages including office-based treatment, lower overdose risk, and treatment of both opioid withdrawal and cravings, as recommended by the American Psychiatric Association and the American College of Physicians 6, 7, 8

Cognitive Behavioral Therapy (CBT) is a first-line behavioral approach for treating substance use disorders, and combined CBT plus pharmacotherapy shows significantly better outcomes than pharmacotherapy alone, according to the American Psychological Association 9
Contingency Management is highly effective for stimulant use disorders and can be combined with CBT for polysubstance use, as recommended by the National Institute on Drug Abuse 10
Motivational interviewing is a technique used in conjunction with naltrexone, as part of behavioral therapies, with moderate strength of evidence 1

The initial phase (weeks 1-2) of treatment involves beginning buprenorphine/naloxone induction, titrating to effective dose, starting weekly CBT sessions, and continuing current psychiatric medications, as outlined by the Substance Abuse and Mental Health Services Administration and the American Society of Addiction Medicine 6, 8
The stabilization phase (weeks 3-12) involves maintaining effective buprenorphine dose, continuing CBT, and considering adding contingency management for cocaine use, as recommended by the American Society of Addiction Medicine 9
The maintenance phase (months 4-12) involves continuing effective MAT for at least 6-12 months, gradually reducing frequency of CBT sessions, and continuing monitoring psychiatric symptoms and adjusting medications as needed, according to the Centers for Disease Control and Prevention and the American Academy of Family Physicians 6, 5, 11

Regular assessment of mental health symptoms, evaluation for side effects, and urine drug screens at each visit are crucial for effective treatment, as recommended by the National Institute of Mental Health and the American Academy of Family Physicians 9, 5
Liver function tests at baseline and every 3-6 months are necessary for monitoring potential medication interactions, according to the American Association for the Study of Liver Diseases and the Gastroenterology society guidelines 2, 12
Treatment response should be assessed at 12 weeks, and if no significant reduction in drinking is observed, consideration should be given to discontinuing treatment, according to the Clinical and Molecular Hepatology society guidelines and the American Academy of Family Physicians 4, 5

Calorie-dense, high-protein supplements should be considered, as suggested by the National Comprehensive Cancer Network 13
Thiamine supplementation should be 100-300 mg daily for 3-4 days, then 10 mg daily for maintenance, according to the American Society for Parenteral and Enteral Nutrition 14
Daily caloric intake target should be 35-40 kcal/kg body weight, with protein intake of 1.2-1.5 g/kg body weight, as recommended by the European Association for the Study of the Liver 15

Common side effects of naltrexone include nausea and vomiting, headache, dizziness, and arthralgia, although these are generally mild and self-limiting, as recommended by the Clinical and Molecular Hepatology society and the American Academy of Family Physicians 4, 5