Opioid Detoxification and Naltrexone Induction Strategies: Recommendations for Clinical Practice
Last Update: 04/15/14 (Dr. Maria Sullivan, MD, PhD and Danielle M. Simpson, MS I)
For patients transitioning from opioid use to naltrexone therapy, initial low doses of buprenorphine combined with clonidine and other medications should be followed by progressively increasing doses of oral naltrexone over 3 to 5 days, until the target dose of naltrexone is reached.
Opioid dependence is associated with a high risk of relapse, and patients benefit from continued treatment with medication by remaining abstinent and in staying in treatment. While continued use of opioid agonists (with opioid-like effects) like methadone and buprenorphine works well for some patients, naltrexone therapy (an opiate blocker) may offer a useful alternative following detoxification. However, the transition from either illicit opioid use (e.g. heroin) or buprenorphine (or methadone) to naltrexone treatment may cause the rapid onset of withdrawal symptoms if not carefully supervised and dosed. Using certain non-opiate medications (i.e. for muscle cramping, nausea, and insomnia) can reduce withdrawal symptoms and make it easier for patients to begin naltrexone treatment. Some patients may need a higher level of support (i.e. inpatient transition to naltrexone) if they have a more severe pattern of opioid use or the presence of complicating factors (e.g. medical or psychiatric illness). But using comfort medications to alleviate withdrawal can allow most opioid-dependent patients to convert to naltrexone treatment, either on an outpatient or inpatient basis. Patients taking naltrexone have lost their tolerance to opioids and will be at risk of accidental overdose if they drop out of treatment and no longer experience an opioid blockade. Since 2010, injectable sustained-release naltrexone has been FDA-approved for the treatment of opioid use disorder, and this formulation (compared to the earlier tablet form) has helped many patients to stay in treatment longer and to remain free of opioids.
Sigmon SC, Bisaga A, Nunes EV, O’Connor PG, Kosten T, Woody G. (2012). Opioid detoxification and naltrexone induction strategies: recommendations for clinical practice. American Journal of Drug and Alcohol Abuse, 38(3):187-199.