Naltrexone Contraindications and Precautions

Mechanism and Contraindication

Concomitant use of opioid antagonists with opioids should be avoided in the absence of clinically significant respiratory depression as it results in reduced opioid efficacy and can precipitate opioid withdrawal, as recommended by the Mayo Clinic Proceedings 1, 2

Administration of naltrexone to patients using chronic opioids can cause acute and severe withdrawal symptoms, including bone and muscle pain (15.9%) 1
Abrupt reversal of opioid effects in opioid-tolerant patients may result in nausea, vomiting, sweating, tachycardia, increased blood pressure, tremulousness and seizures, pulmonary edema, cardiac arrhythmias, and cardiac arrest (in severe cases), according to the Journal of the National Comprehensive Cancer Network : JNCCN 4

Patients must be completely opioid-free before starting naltrexone to avoid precipitation of withdrawal, as suggested by Praxis Medical Insights: Practical Summaries of Clinical Guidelines 3
For oral naltrexone, the American College of Physicians may recommend that patients should be off all opioids, including opioid-containing medicines, for a minimum of 7 to 10 days before starting treatment, however this is not explicitly stated in the provided references, but the Mayo Clinic Proceedings recommends holding oral naltrexone for 3-4 days prior to elective procedures 1, 2

Oral naltrexone should be held for 3-4 days prior to elective procedures, and intramuscular naltrexone should be held 24-30 days after the last injection before elective procedures, as recommended by the Mayo Clinic Proceedings 1, 2

For patients with chronic pain who also have opioid use disorder, consider alternative non-opioid pain management strategies, as suggested by Praxis Medical Insights: Practical Summaries of Clinical Guidelines 3
Buprenorphine may be an option for some patients as it has both analgesic properties and is effective for opioid use disorder treatment, according to the Mayo Clinic Proceedings 1