Management of relapse in naltrexone maintenance for heroin dependence

Abstract

During naltrexone maintenance for opioid dependence unblocked opioid use calls for immediate intervention, such as detoxification or switching to the partial agonist buprenorphine. Episodes of blocked use warrant increased clinical attention, such as direct observation of naltrexone ingestion, increased dose, or increased intensity of treatment contact. Maintenance on oral naltrexone is a fragile treatment because it is so easily undermined by episodes of opioid use while non-compliant. New long-acting injectable or implantable formulations of naltrexone may address this limitation and should be investigated for treatment of opioid dependence.

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

“…Many patients starting treatment with oral naltrexone have difficulty adhering to a daily regimen,59, 60 a pattern often correlated with poor treatment retention and relapse 61, 62. Poor adherence to daily oral medication spurred the development of extended‐release injectable and implantable formulations that would eliminate the need for daily decisions to take a medication 53, 63, 64, 65, 66, 67…”

“…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.…”

Sustained-Release Naltrexone For Opioid Dependence

“…Taking a behavioural perspective, Abraham Wikler's [12] theory on antagonist pharmacotherapy for opioid addiction proposes that blocked heroin use should be harmless or even therapeutic: repeated administrations followed by the lack of reinforcement provided by the heroin 'high' should lead to extinction and gradually eliminate the user's desire for heroin. However, empirical data from clinical studies of oral naltrexone treatment suggest that blocked heroin use among oral naltrexone patients may be harmful in that it often leads to dropout and relapse to unblocked use [10,13].…”

“…_______________________________ Naltrexone is a competitive opioid antagonist that is known to block the action of heroin and other opioids [1][2][3][4]. However, some opioid use persists [5][6][7][8][9][10], even in patients confirmed as having taken naltrexone [10] and in patients on sustained-release formulations of naltrexone [9,11]. Different models of addiction take different perspectives regarding possible harms associated with opioid use during naltrexone treatment.…”

“…San et al 1991;Nunes et al 2006). Retention can be increased when family, Background supervisors, or parole officers administer the tablets (Krupitsky et al 2004;Washton et al 1984;Cornish et al 1997) or comprehensive approaches like Contingency Management or Behavioral Naltrexone Therapy are used Rothenberg et al 2002;Sullivan et al 2007). However, some are skeptical that these approaches will be able to retain more than 20-40% of patients in clinical settings .…”