Opioid Detoxification and Naltrexone Induction Strategies: Recommendations for Clinical Practice

Abstract

Background Opioid dependence is a significant public health problem associated with high risk for relapse if treatment is not ongoing. While maintenance on opioid agonists (i.e., methadone, buprenorphine) often produces favorable outcomes, detoxification followed by treatment with the μ-opioid receptor antagonist naltrexone may offer a potentially useful alternative to agonist maintenance for some patients. Method Treatment approaches for making this transition are described here based on a literature review and solicitation of opinions from several expert clinicians and scientists regarding patient selection, level of care, and detoxification strategies. Conclusion Among the current detoxification regimens, the available clinical and scientific data suggest that the best approach may be using an initial 2–4 mg dose of buprenorphine combined with clonidine, other ancillary medications, and progressively increasing doses of oral naltrexone over 3–5 days up to the target dose of naltrexone. However, more research is needed to empirically validate the best approach for making this transition.

Baseline characteristics of patients predicting suitability for rapid naltrexone induction

“…However, evidence suggests that anesthesiabased detoxification is no more effective at reducing withdrawal symptoms than more gradual detoxification-naltrexone induction methods, and is potentially dangerous in that serious medical complications have been observed. 18,19 Older age has been associated with better retention in treatment for other substance problems and treatment settings. 35,36 This might reflect the "aging out" phenomenon, or greater maturity or motivation for treatment.…”

Antagonists in the medical management of opioid use disorders: Historical and existing treatment strategies

“…First, buprenorphine can be given for 1 day, as it replaces the full agonist at the receptor, while providing partial agonist activity to prevent significant withdrawal. Buprenorphine is then followed by 1–2 days of washout and a gradual ascending titration of oral naltrexone over the subsequent 3–5 days, beginning with a low dose of 1–3 mg 82. Throughout this procedure, patients receive standing doses of adjunctive medications, usually clonidine and clonazepam (Table 1).…”

“…Throughout this procedure, patients receive standing doses of adjunctive medications, usually clonidine and clonazepam (Table 1). 58, 82 The second procedure employs buprenorphine taper in combination with very low doses of oral naltrexone (≤1 mg/day) over the first 2–3 days, followed by a gradual up‐titration of naltrexone to full blocking doses (≥25 mg/day), usually accomplished within 7 days83 (Table 2). These procedures have allowed 50–70% of outpatients to successfully initiate treatment with XR‐NTX58, 83 with favorable tolerability and no serious adverse events due to precipitated withdrawal 52, 55, 56, 83…”

“…Up to one third of patients who receive XR‐NTX use illicit opioids at some point during treatment, commonly as single episodes to “test” the blocking effect of the medication 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 62. A recent study of patients using opioids during XR‐NTX blockade found that most did not feel euphoria and used lower doses than before receiving XR‐NTX.…”

Treatment of Opioid-Use Disorders

“…T h e ne w e ngl a nd jou r na l o f m e dicine Tr e atment of Opioid -W ithdr awa l S y ndromes Treatment of acute withdrawal syndromes (i.e., medically supervised withdrawal or detoxification) 17 can improve the patient's health and facilitate his or her participation in a rehabilitation program. This treatment also may help patients better consider abstinence from opioids because they can think more clearly once the acute withdrawal phase has passed.…”