A preliminary report on possible naltrexone and nonsteroidal analgesic interactions

Treatment of Acute Pain in Patients on Naltrexone: A Narrative Review

PURPOSE OF REVIEW

The tissue damage and trauma associated with surgery almost always result in acute postoperative pain. The intensity of postoperative pain can range from mild to severe. Naltrexone is suitable for patients who do not wish to be on an agonist treatment such as methadone or buprenorphine. However, naltrexone has been shown to complicate postoperative pain management.

RECENT FINDINGS

Multiple studies have found that the use of naltrexone can increase the opioid requirement for postoperative pain control. Other modalities exist that can help outside of opioids such as ketamine, lidocaine/bupivacaine, duloxetine, and non-pharmacological management can help manage pain. Multimodal pain regiments should also be employed in patients. In addition to traditional methods for postoperative pain management, other methods of acute pain control exist that can help mitigate opioid dependence and help control pain in patients who use naltrexone for their substance use disorders.

High-Dose Naltrexone Treatment and Gender in Alcohol Dependence

OBJECTIVES

Little is known about whether safety and effectiveness of high-dose naltrexone (150 mg/d) are different in alcohol-dependent women and men. This study investigated sex differences in safety and treatment outcomes in alcohol-dependent women and men on high-dose naltrexone (150 mg/d).

METHODS

In this exploratory study, safety and effectiveness of high-dose naltrexone (150 mg/d) were examined in men and women with alcohol dependence (n = 24; 11 men and 13 women) treated in an 8-week outpatient setting.

RESULTS

Women and men had similar dropout rates, adverse effects, tolerability, and hepatic function during high-dose naltrexone treatment (150 mg/d). Drinking outcomes were significantly improved in both women and men, but no sex differences were found.

CONCLUSIONS

High-dose naltrexone seems to be well tolerated, safe, and effective in both men and women with alcohol dependence in this small study. Given the small sample size of the current study, our results cannot be considered definitive, and larger trials with longer durations are needed to confirm these findings.

Naltrexone: A Pan-Addiction Treatment?

Addiction is a major public health problem with few efficacious and safe treatments. The goal of this review is to provide an evidence-based assessment of the therapeutic role of the opioid antagonist naltrexone across the addiction spectrum-substance-based and behavioral. The PubMed database was searched for randomized, placebo-controlled clinical trials that investigated the oral or intramuscular long-acting formulation of naltrexone in substance use disorders or behavioral addictions such as pathological gambling, kleptomania, and trichotillomania. Thirty-nine efficacy studies were retrieved, covering alcohol use disorder (n = 22), opioid use disorder (n = 6), nicotine use disorder (n = 5), stimulant use disorder (n = 2), gambling disorder (n = 2), trichotillomania (n = 1), and kleptomania (n = 1). Despite the very different presentations within and between both addiction categories, the data, as a whole, show consistency in favor of naltrexone's relative efficacy and safety. Given the potential benefit and good tolerability revealed in the studies, the high morbidity associated with addiction, and the dearth of alternate treatments, naltrexone would seem like an underutilized treatment option. Further, naltrexone's seemingly broad anti-addiction efficacy supports a shared role for brain opioid pathways in the pathophysiology of addiction, broadly defined. More studies investigating the efficacy and tolerability of naltrexone and other opioid modulators are warranted. Studies should also further examine the effect of combining psychotherapy with naltrexone, as well as the potential role of naltrexone in treating comorbid addictions.

Pharmacological enhancement of naltrexone treatment for opioid dependence: a review

PURPOSE: Opioid dependence (OD) is a serious and growing clinical condition with increasing social costs that requires expanding treatment beyond opioid agonist substitution. The opioid antagonist naltrexone has displayed a remarkable association of theoretical effectiveness and poor clinical utility in treating OD due to noncompliant behavior and low acceptability among patients, only partly modified by psychosocial interventions. We reviewed pharmacological studies, including naltrexone depot formulations and combination treatments. METHOD: We searched PubMed for clinical studies on the use of naltrexone implants and slow-release injections in OD, and investigations using adjunct medications to improve naltrexone maintenance therapy of OD. We discussed the results in view of their application to the clinical practice. RESULTS: Significant reduction in opioid use and improved retention in treatment have been found in several studies using depot naltrexone formulations, some of which are controlled clinical trials. Pilot investigations have gathered initial positive results on the use of naltrexone in combination with serotonin reuptake inhibitors, α-2 adrenergic, opioid, and γ-aminobutyric acid agonist medications. CONCLUSION: Current evidence suggests that more research on effectiveness and safety is needed in support of depot naltrexone treatment for OD. Further research comparing slow-release with oral naltrexone and opioid agonist medications will help characterize the role of opioid antagonist-mediated treatment of OD. Preliminary investigations on naltrexone combination treatments suggest the opportunity to continue study of new mixed receptor activities for the treatment of OD and other drug addictions.

Safety, tolerability, and feasibility of high-dose naltrexone in alcohol dependence: an open-label study

OBJECTIVE

Prior trials testing standard-dose naltrexone (50 mg/day) have generated mixed results in the treatment of alcohol dependence. The purpose of this study was to evaluate the short-term safety, tolerability, and feasibility of high-dose naltrexone (150 mg/day) for treating alcohol-dependent patients with prominent alcohol craving.

METHODS

Twenty-four alcohol-dependent outpatients received high-dose naltrexone at a dose of 150 mg/day in an 8-week open-label pilot study. All patients had current alcohol dependence and alcohol craving symptoms. Safety and tolerability were assessed weekly. Liver function tests were obtained at weeks 0, 3, 5, 7, and 9. The main outcome measures were percentage of drinking days and number of drinks per drinking day.

RESULTS

High-dose naltrexone was safe and well tolerated using the procedure described. No serious adverse effects were reported. The mean of γ-glutamyl transferase showed an improvement trend (p = 0.06), and other hepatic transaminase profiles were stable during the trial. High-dose naltrexone significantly reduced alcohol consumption (percentage of drinking days (p < 0.0001); and number of drinks per drinking day (p < 0.0001)).

CONCLUSIONS

High-dose naltrexone may serve as a viable treatment option for alcohol-dependent patients with prominent alcohol craving. Further controlled studies are needed to confirm our findings.

Hepatic safety of once-monthly injectable extended-release naltrexone administered to actively drinking alcoholics

BACKGROUND

Hepatoxicity has been reported with oral naltrexone. Hepatic safety data were examined from a 6-month study evaluating the efficacy and safety of a now available extended-release formulation of naltrexone (XR-NTX) in patients with alcohol dependence.

METHODS

In all, 624 patients (68% male; median age of 44 years) were randomly assigned to XR-NTX 380 mg (n = 205), XR-NTX 190 mg (n = 210), or placebo (n = 209).

RESULTS

There were no significant differences in alanine aminotransferase, aspartate aminotransferase, or bilirubin levels between the study groups at study initiation or at subsequent assessments. Gamma-glutamyltransferase in the XR-NTX 380 mg group was lower compared with placebo at weeks 4, 8, 12, and 20. Both high (>3 times the upper limit of normal) liver chemistry tests (LCTs) and hepatic-related adverse events were infrequent in all study groups. In patients who were drinking heavily throughout the study, obese subjects, or those taking nonsteroidal anti-inflammatory drugs, there was no increase in frequency of high LCTs or hepatic-related adverse events in patients receiving XR-NTX (either dose) compared with placebo.

CONCLUSION

Extended-release formulation of naltrexone does not appear to be hepatotoxic when taken at the recommended clinical doses in actively drinking alcohol-dependent patients.

Long-acting injectable naltrexone for the treatment of alcohol dependence

Combining pharmacotherapy with psychosocial and behavioral interventions has helped improve the treatment of alcohol dependence. However, the clinical use of effective medications, such as naltrexone, is limited by poor adherence to a daily oral regimen. Recently, a once monthly extended-release injectable formulation of naltrexone (Vivitrol, Alkermes, Inc.) became the first FDA-approved long-acting formulation of naltrexone for alcohol dependence. Compared with the oral preparation, extended-release naltrexone shows reduced peaks and minimal fluctuations in plasma levels that may possibly lead to a more benign adverse-event profile. The administration of long-acting naltrexone in conjunction with psychosocial support has been associated with significant improvement in drinking outcome measures, especially among patients who are abstinent entering treatment. Additional studies are warranted to increase the knowledge on the clinical applications of long-acting naltrexone in other addictive disorders and to compare extended-release naltrexone with other long-acting formulations that are in development. The clinical availability of extended-release naltrexone has the potential to enhance treatment outcomes for alcohol and other drug dependence disorders.

Treatment of Compulsive Sexual Behaviour with Clomipramine and Valproic Acid

The concepts of compulsive sexual behaviour or sexual addiction and treatment of the disorder have been argued over by many investigators. From a scientific point of view, both concepts are still not well established in psychiatric nomenclature. On the other hand, authors point out that compulsive sexual behaviour, obsessive-compulsive disorder and substance addiction show similarities in symptomatology and response to treatment. In this article, the case of a 21-year-old female exhibiting compulsive sexual behaviour since childhood who was treated with a combination of clomipramine and valproic acid is presented and discussed in the light of the relevant literature.

Safety of high-dose naltrexone treatment: hepatic transaminase profiles among outpatients

OBJECTIVES

This study was carried out to test the hypothesis that the hepatic safety profile of prolonged high-dose oral naltrexone (150 mg/d) is acceptable if over-the-counter analgesic use is restricted.

METHODS

Data from 41 consecutive outpatients with impulse-control disorder receiving naltrexone therapy were analyzed.

RESULTS

The mean treatment duration was 328 days and the mean naltrexone dose was 142 mg/d. Pretherapy/posttherapy mean aspartate transaminase and alanine transaminase levels in the naltrexone-alone group were 21.79/22.54 and 21.74/21.49 U, respectively (all within reference range).

CONCLUSIONS

Although limited in scope, these findings support the hypothesis that long-term use of high-dose oral naltrexone is safe in otherwise healthy patients with impulse-control disorders who restrict their intake of acetaminophen, aspirin, or nonaspirin nonsteroidal anti-inflammatory drugs (NSAID). However, confirming studies are needed.

Outcome study of kleptomania patients treated with naltrexone: a chart review

PURPOSE

This study examines the response to treatment in 17 patients with kleptomania who were treated with naltrexone as monotherapy for up to 3 years.

METHODS

Patients were treated with naltrexone (range, 50-200 mg/day) and were assessed at each clinic visit for stealing behavior, urges to steal, and for overall symptom severity. Liver function tests were examined regularly during treatment.

RESULTS

Comparison of baseline symptoms with the most recent follow-up visit showed that 13 patients (76.5%) reported reduction in their urges to steal, and 7 (41.1%) reported no stealing behavior. In addition, 9 (52.9%) were rated as being either "not ill at all" or having "very mild" kleptomania symptoms at the most recent clinic visit. The mean effective dose of naltrexone was 135.3 +/- 38.6 mg/day. Monthly liver function tests revealed no elevations or abnormalities.

CONCLUSION

These findings from a clinical setting suggest that a substantial percentage of patients report clinically significant improvement in kleptomania symptoms when treated with naltrexone.

The role of medication in the treatment of pathological gambling: Bridging the gap between research and practice

After reviewing the literature on the pharmacotherapy of pathological gambling, the author discusses treatment strategies and areas for future research. The clearest indication for medicating the pathological gambler is for the treatment of comorbid disorders, primarily depression, bipolar disorder, and attention deficit hyperactivity disorder. However, there are difficulties in diagnosing the dually disordered gambler. Other current pharmacological approaches involve the use of medication to treat specific symptoms, traits, or symptom clusters; to make negative affects more tolerable; and to reduce cravings. Future approaches will be directed at subgroups of gamblers. This may include genetic profiling, paired with recognition of neurotransmitter deficits, and the identification of clinical syndromes and subtypes. The author also discusses the kindling hypothesis as it may pertain to pathological gambling. The presence of kindling would make a strong case for earlier and more aggressive use of medication and for long-term maintenance to prevent relapse.

Acamprosate and naltrexone treatment for alcohol dependence: an evidence-based risk-benefits assessment

This paper provides an evidence-based risk-benefit assessment of acamprosate and naltrexone in the treatment of alcohol dependence. A risk-benefit assessment is based on the premise that the choice of treatment depends on a number of factors, notably the adverse event profile and efficacy. An evidence-based approach attempts to operationalize how such risk-benefit assessments are made to inform physician choices. This approach involves a systematic assessment of all published double-blind, placebo-controlled trials. Based on this review, we conclude acamprosate and naltrexone are both useful in the treatment of alcohol dependence. However, the two drugs act in different ways in the brain, and their clinical profiles are different. Treatment effects seem to be more reliable for acamprosate, and this drug is better tolerated. The safety of the two drugs in combination has been supported by two independent double-blind studies, and combination treatment may offer an advantage for some patients.

Testing combined pharmacotherapies and behavioral interventions for alcohol dependence (the COMBINE study): a pilot feasibility study

BACKGROUND

Medications (such as naltrexone and acamprosate) as well as behavioral therapies have been previously reported to be effective in the reduction of alcohol intake and to prevent relapse drinking. However, the efficacy of using several medications alone or together in combination with behavioral therapies has not been widely investigated. The purpose of this study was to evaluate the feasibility of this combined therapy approach to apply it to a larger scale multisite clinical trial. Outcome focused on recruitment, retention, adherence to study parameters and medication, physical complaints, and physiologic toxicity.

METHODS

At 11 sites, 108 individuals with alcohol dependence were randomized in a double blind fashion to receive placebo, naltrexone, or acamprosate alone or in combination. In addition, some individuals were randomized to receive Medical Management (MM) provided by a health care practitioner alone or in combination with an enhanced behavioral intervention, Combined Behavioral Intervention (CBI), delivered by a trained therapist. A final group received CBI alone without pills. All participants were treated and assessed for a maximum of 16 weeks.

RESULTS

The attendance at therapy and research visits, and medication adherence and tolerability were good with no statistical differences between the medication or behavioral intervention groups. Over 75% of participants completed the week-16, end of study, assessment and the average medication adherence (percent of total pills taken) was about 65%. The level and types of physical complaints were not unexpected and similar among the medication and placebo groups. There were no group differences in liver or kidney toxicity. Importantly, the combination of naltrexone and acamprosate did not present significantly more physical complaints than either alone.

CONCLUSIONS

Sufficient numbers of alcohol dependent participants can be recruited and retained in a relatively sophisticated outpatient trial combining medications and behavioral interventions. Participant adherence to the trial protocol including medication regimens was at acceptable levels. Physical complaints and organ toxicity were within expected and acceptable levels. Based on these results a larger scale study utilizing these methodologies appears feasible.

Current Pharmacotherapies of Alcoholism: A U.S. Perspective

Advances in the neurobiology of addiction and improved clinical trial methodology have accelerated the evaluation of medication for alcoholism. While psychosocial interventions have been useful to reduce consumption and support abstinence, considerable improvement in treatment is needed. Medication can play a crucial role in the reduction of craving and drinking and the maintenance of abstinence. This article reviews pharmacotherapy for alcoholism with an emphasis on the perspective of the United States. The opiate antagonist naltrexone, the glutamate modulator acamprosate, and serotonergic agents will be highlighted in this review. In general, both naltrexone and acamprosate have been found in a number of studies to be efficacious agents for the treatment of alcohol dependence. Serotonin reuptake inhibitors have not consistently shown to be efficacious but may be useful in certain subgroups of alcoholics. The serotonin type-3 antagonist, ondansetron, has shown promise in early-onset alcoholics but needs more extensive study.

Advances in the pharmacological treatment of pathological gambling

In the present paper we discuss the current status of drug treatment for pathological gambling and the scientific rationales underlying the various pharmacological approaches. Specifically, we summarize the treatment study results of serotonin reuptake inhibitors, mood stabilizers, opioid antagonists, and atypical antipsychotics in pathological gambling. We also discuss dosage strategies, the duration of treatment, issues surrounding medication compliance, and approaches to treatment-refractory pathological gambling, such as pharmacological and behavioral augmentation.

Gambling: an addictive behavior with health and primary care implications

Over the past several decades, and particularly during the last 10 to 15 years, there has been a rapid increase in the accessibility of legalized gambling in the United States and other parts of the world. Few studies have systematically explored the relationships between patterns of gambling and health status. Existing data support the notion that some gambling behaviors, particularly problem and pathological gambling, are associated with nongambling health problems. The purpose of this article is to provide a perspective on the relationship between gambling behaviors and substance use disorders, review the data regarding health associations and screening and treatment options for problem and pathological gambling, and suggest a role for generalist physicians in assessing problem and pathological gambling. A rationale for conceptualization of pathological gambling as an addictive disorder and a model proposing stress as a possible mediating factor in the relationship between gambling and health status are presented. More research is needed to investigate directly the biological and health correlates associated with specific types of gambling behaviors and to define the role for generalist physicians in the prevention and treatment of problem and pathological gambling.

Treatment of compulsive sexual behaviour with naltrexone and serotonin reuptake inhibitors: two case studies

Although there is no universally accepted definition of compulsive sexual behaviour (CSB), the term is generally used to indicate excessive sexual behaviour or sexual cognitions that lead to subjective distress, social or occupational impairment, or legal and financial consequences. Similar to impulse control disorders, CSB is characterized by a failure to resist the impulse for sex. Opioid antagonists have been effective in treating urge-driven disorders, such as pathological gambling disorder, alcoholism, borderline personality disorder with self-injurious behaviour, cocaine abuse, mental retardation with self-injurious behaviour and eating disorders. Based upon the efficacy of opioid antagonists in treating disorders associated with urges, we hypothesized that naltrexone would reduce both the urges associated with CSB and therefore reduce the sexual behaviour. We present two case reports of individuals with CSB treated successfully with naltrexone, a novel treatment for CSB. In both cases, symptoms dramatically decreased and psychosocial functioning improved with the use of naltrexone. Although more research is needed to determine the mechanism that leads to the excessive sexual behaviour in individuals with CSB, the present case reports suggest that naltrexone may be effective in treating some cases of CSB.

Double-blind naltrexone and placebo comparison study in the treatment of pathological gambling

BACKGROUND

The authors' goal was to assess the efficacy and tolerability of naltrexone in the treatment of pathologic gambling disorder.

METHODS

Eighty-three subjects who met criteria for DSM-IV pathologic gambling disorder were enrolled in a 1-week single-blind placebo lead-in followed by an 11-week double-blind naltrexone or placebo trial. Naltrexone was started at 25 mg/day and titrated upward until maximum symptom improvement or 250 mg/day was achieved. Gambling symptom change was assessed with the patient-rated Clinical Global Impression (PG-CGI-PT), clinician-rated CGI (PG-CGI-MD), and the Gambling Symptom Rating Scale (G-SAS). Side effects were monitored weekly and liver function tests biweekly.

RESULTS

Data from 45 patients were analyzed. Using random regression analysis, significant improvement was noted in all three gambling symptom measures: patient-rated Clinical Global Impression, p <.001; clinician-rated CGI, p <.001; Gambling Symptom Rating Scale, p <.019. At study end, 75% of subjects taking naltrexone were much or very much improved on both the PE-CEI PT and the PG-CGI-MD, compared with only 24% of those on placebo. Elevated liver enzymes occurred in four subjects who were taking analgesics concurrently. Nausea was common during the first week of treatment.

CONCLUSIONS

Results suggest that naltrexone is effective in reducing the symptoms of pathologic gambling. Until further studies corroborate the present findings, our report should be interpreted cautiously.