Naltrexone Treatment Guidelines

Introduction to Naltrexone

The American Academy of Family Physicians recommends naltrexone for the treatment of alcohol dependence, where it functions by blocking opioid receptors and dampening activation of the reward pathway by alcohol, thereby decreasing excessive drinking and increasing abstinence duration 1, 2
Naltrexone reduces alcohol craving and consumption in alcohol-dependent patients, with moderate quality evidence supporting its effectiveness in reducing relapse to heavy drinking 1

The American Family Physician guidelines suggest that naltrexone is available as 50-mg tablets taken daily, or alternatively 100 mg on Mondays and Wednesdays, and 150 mg on Fridays 2, 1
The extended-release injectable formulation (Vivitrol, 380-mg monthly) provides reliable naltrexone release over 1 month at therapeutic levels, and significantly improves medication compliance compared to daily oral dosing 2, 1

The American Family Physician guidelines indicate that naltrexone has been shown to be most helpful in maintaining abstinence from opioids in highly motivated populations, such as healthcare professionals who cannot or do not wish to take continuous opioid agonist therapy 2, 1
Patients must be completely opioid-free for a minimum of 7-10 days for short-acting opioids before starting naltrexone to avoid precipitating severe, potentially life-threatening withdrawal 1, 3
Naltrexone cannot be used in patients requiring opioids for pain control, as it blocks pain relief from opioid agonists and causes precipitated withdrawal 2, 1

The American Academy of Family Physicians warns that patients who discontinue naltrexone treatment are at increased risk of opioid overdose and death resulting from decreased opioid tolerance 2, 1
Opioid overdose education and naloxone should be offered to patients discontinuing naltrexone 1
Oral naltrexone should be held for 2-3 days prior to elective procedures if opioids are expected to be used perioperatively, and extended-release naltrexone should be held for 24-30 days after the last injection before elective procedures 1, 3

The Cochrane systematic review concluded that short-term naltrexone treatment lowers the risk of relapse in alcoholism 4
Patients with alcohol dependence who describe food cravings or addictive eating behaviors are best candidates for naltrexone craving reduction, as evidenced by studies published in Gastroenterology 5
Naltrexone/bupropion combination addresses multiple cravings, including those for patients with concomitant depression or those trying to quit smoking, as reported in Gastroenterology 5

Most common side effects of naltrexone are nausea, constipation, headache, and gastrointestinal symptoms—generally mild and transient, as noted in Gastroenterology 5