Wednesday, January 25, 2017

Low-Dose Naltrexone May Mitigate Severity of Opioid Withdrawal During Detox

An extended-release injectable form of naltrexone (XR-naltrexone) was approved years ago to reduce the risk of relapse in patients with opioid use disorder, but the recommendation that patients abstain from opioids for up to 10 days before receiving the opioid antagonist can be a significant barrier to its use. A study published in AJP in Advance now suggests a low-dose naltrexone treatment regimen may increase the likelihood that opioid-dependent patients receive XR-naltrexone treatment.

“By circumventing the need for a protracted period of abstinence and mitigating the severity of withdrawal symptoms experienced during detoxification, this strategy has the potential to considerably increase patient acceptability of, and access to, antagonist therapy,” Maria Sullivan, M.D., Ph.D., of the New York State Psychiatric Institute and Columbia University College of Physicians and Surgeons and colleagues, wrote.

The researchers randomly assigned 150 patients seeking treatment for heroin or prescription opioid dependence to one of two outpatient detoxification regimens: naltrexone-assisted detoxification or buprenorphine-assisted detoxification.

As described in AJP, “Naltrexone-assisted detoxification lasted seven days and included a single day of buprenorphine followed by ascending doses of oral naltrexone along with clonidine and other adjunctive medications” to alleviate residual withdrawal symptoms. In contrast, “[b]uprenorphine-assisted detoxification included a seven-day buprenorphine taper followed by a week-long delay before administration of XR-naltrexone, consistent with official prescribing information for XR-naltrexone.” Patients in both groups received behavioral therapy focused on medication adherence and a second dose of XR-naltrexone at week 5.

Compared with those in the buprenorphine-assisted detoxification group, participants assigned to naltrexone-assisted detoxification were significantly more likely to receive XR-naltrexone (56.1% compared with 32.7%) and receive the second injection at week 5 (50.0% compared with 26.9%). No overdoses occurred among study participants. A secondary analysis found that prescription opioid users were significantly more likely to receive first and second injections of XR-naltrexone than patients using heroin.

“Our findings support the conclusion that a seven-day opioid detoxification with gradually ascending doses of oral naltrexone is a well-tolerated outpatient procedure, with a success rate comparable to inpatient induction,” the authors wrote. “For heroin-using individuals with greater severity of opioid dependence, further work is needed to make rapid induction more feasible. This outpatient induction strategy may be improved by permitting more flexible oral naltrexone dosing and more rapid transition to XR-naltrexone, thus minimizing the risk of dropout.”

For related information, see the Psychiatric News article “HHS Takes Actions to Expand Treatment, Research in Opioid Crisis.”

(Image: iStock/tuncaycetin)

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