Management of precipitated opiate withdrawal syndrome induced by nalmefene mistakenly prescribed in opiate-dependent patients: a review for clinicians

ABSTRACT

Introduction: Nalmefene, a long-acting µ-opioid antagonist approved to treat alcohol use disorder, is occasionally mistakenly prescribed to opiate-dependent or opioid-treated patients. We review recent literature on drug-drug interactions between nalmefene and opioids that lead to precipitated opioid withdrawal, and focus on its management and planning for care at discharge.

Areas covered: This article provides a brief and comprehensive review of management of precipitated opioid withdrawal syndrome when nalmefene is associated with an opioid, whether misused or legally prescribed.

Expert opinion: When treating an opiate-dependent patient with co-occurring alcohol use disorder, both conditions need to be a focus of clinical attention. New drugs for alcohol use disorder have been approved, but must be given cautiously and with a full understanding of their potential drug-drug interactions with opioid medications. Opiate-dependent patients should be intensively monitored for risk factors of alcohol use disorder and should be continuously motivated for treatment maintenance. When nalmefene is administered to opiate-dependent patients, acute opioid withdrawal syndrome may occur. Management of precipitated acute opioid withdrawal may include short or long-acting µ-opioid agonists during hospitalization, in addition to supportive treatment. The best management of polydrug abusers is based on a multidisciplinary approach, which should be pursued and improved through continuing medical education.

KEYWORDS:

• Addiction medicine
• nalmefene
• opioid maintenance therapy
• precipitated opioid withdrawal

Article highlights

• Nalmefene is an opioid system modulator which possesses antagonistic properties at the μ- and δ-receptors and partial agonistic properties at the κ-receptor.

• Nalmefene has been indicated to reverse opioid overdose in view of its similar chemical structure to naloxone. Since 2013, the European Medicines Agency has approved nalmefene in alcohol-dependent patients who have a high drinking risk level without physical withdrawal symptoms and who do not require immediate detoxification.

• Opiate-dependent patients often suffer from alcohol use disorder. This has largely been associated with increased prescription of drugs known to be beneficial for treatment of alcohol disorder.

• Physicians considering prescribing nalmefene for alcohol use disorder should carefully evaluate patients for possible current opioid misuse or dependency.

• During hospitalization, management of precipitated acute opioid withdrawal should include the use of titrated doses of opioids depending on the opiate misused or taken before admission, in addition to supportive treatment.

• Physicians should facilitate patient discharge and create a linkage with the primary care provider.

This box summarizes key points contained in the article.

Declaration of interest

N Franchitto received sponsorship to attend scientific meetings from Lundbeck in 2014. B Rolland declares competing interests with Lundbeck, Indivior, Ethypharm, and Bouchara-Recordati. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

No funding was received for the preparation of this manuscript.