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.

• opioid dependence
• detoxification
• taper
• naltrexone
• naloxone
• buprenorphine
• methadone

ACKNOWLEDGMENTS

We acknowledge the assistance from Alkermes, Inc., which convened an Advisory Board to review the existing peer-reviewed literature and clinical experience on the topics of detoxification from opioids and maintenance of opioid abstinence, in a manner consistent with the FDA-approved labeling for naltrexone for extended-release injectable suspension. In this context, Alkermes provided payment for Drs. Sigmon, Kosten, and Woody’s participation. David Gastfriend of Alkermes, Inc., provided assistance with concept generation and writing assistance, and Paladin Consulting Group, under contract from Alkermes, provided literature research and writing assistance. Dr. Nunes was supported by NIH grant K24 DA022412.

Declaration of Interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.