Naltrexone opioid withdrawal

Administer a naloxone challenge test (see below). If signs of opioid withdrawal are still observed following challenge, do not treat with naltrexone. The naloxone challenge can be repeated in 24 hours. 

Patients receiving opioid analgesics opioid-dependent patients patients in acute opioid withdrawal failed naloxone challenge positive urine screen for opioids history of sensitivity to naltrexone acute hepatitis or liver failure. 

Severe opioid withdrawal syndromes Severe opioid withdrawal syndromes precipitated by accidental naltrexone ingestion have occurred in opioid-dependent individuals. Withdrawal symptoms usually appear within 5 minutes or less of ingestion and may last up to 48 hours. 

Contraindications Acute hepatitis, acute opioid withdrawal, failed naloxone challenge test, hepatic failure, history of hypersensitivity to naltrexone, opioid dependence, positive urine screen for opioids... 

Brewer, C., Rezae, H., and Bailey, C. (1988) Opioid Withdrawal and naltrexone induction in 48-72 hours with minimal drop-out, using a modification of the Naltrexone-clonidine technique , British Journal of Psychiatry, 153 340-3. 

Naltrexone 50 mg/day has been used to relieve pruritus in cholestatic liver disease in five patients (7). Pruritus scores fell, but two patients developed severe nausea, vomiting, light-headedness, or tremor, requiring withdrawal of treatment. The reviewers commented that these reactions may or may not have been related to opioid withdrawal and that the trial had had several design limitations. They pointed out that one concern relating to the chronic use of high-dose naltrexone is an asymptomatic rise in serum transaminases, although the doses used in this study have not been reported to produce liver function abnormalities. 

A woman with chronic cholestasis and disabling pruritus had severe but transient opioid withdrawal-like reactions after oral naltrexone 12.5 mg and 2 mg (18). This observation suggests the hypothesis that increased central opioidergic tone is a component of the pathophysiology of cholestasis. 

Six cases of complications loosely related to the use of naltrexone pellet implantation during the highly controversial rapid and ultra-rapid opioid detoxification procedures have been reported (22). These included pulmonary edema, prolonged opioid withdrawal states, drug toxicity, withdrawal from cross-dependence to alcohol and benzodiazepines, aspiration pneumonia, and death. The risk of these controversial procedures and of naltrexone in this novel delivery system are high a robust scientifically validated program of research is needed to justify such treatment packages. 

Jones EA, Dekker LR. Florid opioid withdrawal-like reaction precipitated by naltrexone in a patient with chronic cholestasis. Gastroenterology 2000 118(2) 431-2. 

Bristow K, Meek R, Qark N. Acute opioid withdrawal in the emergency department inadvertent naltrexone abuse Emerg Med (Fremantle) 2001 13(3) 359-63. 

Drug withdrawal Stress (takotsubo) cardiomyopathy occurred in a 44-year-old man in whom severe opioid withdrawal was precipitated 2 hours after administration of naltrexone for alcohol consumption [117 ]. He had a history of heroin use and was taking methadone 120mg/day. Stress cardiomyopathy was beheved to be the result of a marked increase in catecholamine plasma concentrations following abrupt opioid withdrawal. 

Drug fonnniations Naltrexone hydrochloride precipitated severe opioid withdrawal in a 39-year-old woman with a history of chronic pain who instead of methadone 160 mg/day was given Embeda, a new product combining morphine sulfate 30 mg extended release with naltrexone 1.2 mg, intended to reduce the abuse potential of morphine [215 ]. She chewed the tablet, instead of swallowing it, releasing the naltrexone. 

Jang DH, Rohe JC, Hoffman RS, Nelson LS. Severe opioid withdrawal due to misuse of new combined morphine and naltrexone product (Embeda). Ann Emerg Med 2010 55(3) 303-4. 

The adverse reactions associated with the use of naltrexone in patients with alcohol dependence tend to be mild gastrointestinal reactions (nausea, vomiting, and abdominal pain or discomfort) and they occur early in treatment [204 ]. Hepatotoxicity has been reported with high doses (100-300 mg/ day) and especially in obese individuals. Naltrexone can also precipitate opioid withdrawal and may not be suitable for those requiring future opioids, such as those requiring surgery. 

Naltrexone may produce withdrawal symptoms in those physically dependent on narcotics. The patient must not have taken any opiate for the last 7 to 10 days. Concurrent use of naltrexone with tiiioridazine may cause increased drowsiness and lethargy. Naltrexone may prevent the action of opioid antidiarrheals, antitus-sives, and analgesics. 

Carroll KM, Ball SA, Nich C, et al Targeting behavioral therapies to enhance naltrexone treatment of opioid dependence. Arch Gen Psychiatry 38 755-761, 2001 Centers for Disease Control and Prevention Recommendation for prevention and control of hepatitis (virus (HCV) infection and HCV-related chronic disease. MMWR Recommendations and Reports 47(RR19) l-39, 1998 Charney DS, Steinberg DE, Kleber HD, et al The clinical use of clonidine in abrupt withdrawal from methadone. Arch Gen Psychiatry 38 1273-1277, 1981 Charney D S, Heninger OR, Kleber H D The combined use of clonidine and naltrexone as a rapid, safe, and effective treatment of abrupt withdrawal from methadone. Am J Psychiatry 143 831-837, 1986... 

Kleber HD, Weissman MM, Rounsaville BJ, et al Imipramine as treatment for depression in addicts. Arch Gen Psychiatry 40 649-633, 1983 Kleber HD, Riordan CE, Rounsaville BJ, et al Clonidine in outpatient detoxification from methadone maintenance. Arch Gen Psychiatry 42 391-394, 1983 Kleber HD, Topazian M, Gaspari J, et al Clonidine and naltrexone in the outpatient treatment of heroin withdrawal. Am J Drug Alcohol Abuse 13 1-17, 1987 Kornetsky C. Brain stimulation reward, morphine-induced stereotypy, and sensitization implications for abuse. Neurosci Biobehav Rev 27 777-786, 2004 Kosten TR, Kleber HD Buprenorphine detoxification from opioid dependence a pilot study. Life Sci 42 633-641, 1988... 

Similarly opioid peptides are important in nicotine addiction and may have a role in causing nicotine withdrawal symptoms in some smokers [35]. Opioid antagonists such as naltrexone are licensed treatments for dependence syndromes arising from other addictive drugs and could also be of use in some smokers to aid nicotine withdrawal [59] although there is no definitive evidence overall that they are beneficial [60]. 

Naloxone (Narcan). Naloxone, like naltrexone, is a potent opioid receptor blocker. Its primary use has been to reverse opiate toxicity after an overdose. However, some physicians have found it is also useful for a process known as rapid opiate detoxification. Although opiate withdrawal is not life threatening, it can be extremely unpleasant. Most opiate addicts are fearful of the withdrawal symptoms therefore, it usually requires a slow, deliberate detoxification to keep the withdrawal symptoms in check. Rapid opiate detoxification is an alternative approach that keeps the taper and detoxification as brief as possible. In this approach, naloxone is used in conjunction with general anesthesia or a nonopiate sedative such as the benzodiazepine mid-... 

Morphine antagonists and partial agonists. The effects of opioids can be abolished by the antagonists naloxone or naltrexone (A), irrespective of the receptor type involved. Given by itself, neither has any effect in normal subjects however, in opioid-dependent subjects, both precipitate acute withdrawal signs. Because of its rapid presystemic elimination, naloxone is only suitable for parenteral use. Naltrexone is metabolically more stable and is given orally. Naloxone is effective as antidote in the treatment of opioid-induced respiratory paralysis. Since it is more rapidly eliminated than most opioids, repeated doses may be needed. Naltrexone may be used as an adjunct in withdrawal therapy. 

Pharmacology Nalmefene, an opioid antagonist, is a 6-methylene analog of naltrexone. Nalmefene prevents or reverses the effects of opioids, including respiratory depression, sedation, and hypotension. Nalmefene has no opioid agonist activity it does not produce respiratory depression, psychotomimetic effects or pupillary constriction, and no pharmacological activity was observed when it was administered in the absence of opioid agonists. Nalmefene can produce acute withdrawal symptoms in individuals who are opioid-dependent. 

Before initiating treatment, careful attention should be paid to the use of any opioid analgesics, since naltrexone may provoke acute withdrawal symptoms. The main contraindications are (1) treatment with opioid analgesics, (2) opioid dependence, (3) acute opioid... 

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