A severe dry eye patient who came to see me for the first time a few weeks ago “swears by Naltrexone” 2mg every day given at night. She says this with autologous serum used 8x per day has given back her life.
She would not recommend going above 2mg otherwise it will feel “like a truck hit you.”
At 2mg she has no symptoms.
There are more and more studies showing the benefit of Naltrexone in Dry Eye patients.
Please let me know if you are using Naltrexone. We need more studies on the effect on humans as opposed to animals.
Sandra Lora Cremers, MD, FACS
More information below.
The closely related medication, methylnaltrexone
, is used to treat opioid-induced constipation but does not treat addiction as it does not cross the blood brain barrier
is similar to naltrexone and is used for the same purposes as naltrexone. Naltrexone should not be confused with naloxone
, which is used in emergency cases of opioid overdose
Naltrexone is marketed under the trade name Revia
. In the United States as of 2016, naltrexone tablets cost about US$0.91 per day
The extended-release injections cost about $1,248.50 per month ($41.62 per day).
Naltrexone is also used in formulation with bupropion
) to treat obesity
in the United States.
The main use of naltrexone is for the treatment of alcoholism
. Naltrexone has been shown to decrease the amount and frequency of drinking.
It does not appear to change the percentage of people drinking.
Its overall benefit has been described as “modest”.
may work better than naltrexone for eliminating drinking, while naltrexone may decrease the desire for alcohol to a greater extent.
The Sinclair method is a method of using opiate antagonists such as naltrexone to treat alcoholism. The patient takes the medication about an hour (and only then) before drinking to avoid side effects that arise from chronic use.
The opioid antagonist blocks the positive reinforcement effects of alcohol and allows the person to stop or reduce drinking.
Naltrexone helps patients overcome opioid addiction
by blocking the effects of opioid drugs. It has little effect on opioid cravings.
Naltrexone has in general been better studied for alcoholism than for opioids. It is more frequently used for alcoholism, despite its original approval by the FDA
in 1984 for opioid addiction.
A 2011 review of studies suggested that naltrexone, when taken by mouth, was not superior to placebo or to no medication, nor was it superior to benzodiazepine
. Because of the poor quality of the reviewed studies, the authors found insufficient evidence to support naltrexone therapy when taken by mouth for an opioid use disorder.
While some patients do well with the oral formulation, it must be taken daily, and a patient whose cravings become overwhelming can obtain opioid intoxication simply by skipping a dose. Due to this issue, the usefulness of oral naltrexone in opioid use disorders is limited by the low retention in treatment. Oral naltrexone remains an ideal treatment only for a small part of the opioid-addicted population, usually those with a stable social situation and motivation. With additional contingency management
support, naltrexone is effective in a broader population.
Extended-release depot injections
of naltrexone, administered once per month, have proven somewhat effective in treating opioid abuse, an approach that avoids the compliance
issue that arises with oral formulations.
It is not useful for quitting smoking.
The most common side effects reported with naltrexone are gastrointestinal
complaints such as diarrhea
and abdominal cramping. These adverse effects are analogous to the symptoms of opioid withdrawal
, as the mu receptor blockade will increase GI motility.
Naltrexone has been reported to cause liver damage (when given at doses higher than recommended). It carries an FDA boxed warning for this rare side effect. Due to these reports, some physicians may check liver function tests prior to starting naltrexone, and periodically thereafter. Concerns for liver toxicity initially arose from a study of non-addicted obese patients receiving 300 mg of naltrexone.
Subsequent studies have suggested limited toxicity in other patient populations.
Naltrexone should not be started until several (typically 7-10) days of abstinence from opioids has been achieved. This is due to the risk of acute opioid withdrawal if naltrexone is taken, as naltrexone will displace most opioids from their receptors. The time of abstinence may be shorter than 7 days, depending on the half-life of the specific opioid taken. Some physicians use a naloxone challenge to determine whether an individual has any opioids remaining. The challenge involves giving a test dose of naloxone and monitoring for opioid withdrawal. If withdrawal occurs, naltrexone should not be started.
Naltrexone should not be used by persons with acute hepatitis or liver failure, or those with recent opioid use (typically 7–10 days).
A naltrexone treatment study by Anton et al., released by the National Institutes of Health
in February 2008 and published in the Archives of General Psychiatry,
has shown that alcoholics having a certain variant of the opioid receptor gene (G polymorphism of SNP
Rs1799971 in the gene OPRM1
), known as Asp40, demonstrated strong response to naltrexone and were far more likely to experience success at cutting back or discontinuing their alcohol intake altogether, while for those lacking the gene variant, naltrexone appeared to be no different from placebo.
The G allele of OPRM1 is most common in individuals of Asian descent, with 60% to 70% of people of Chinese, Japanese, and Indian ancestry having at least one copy, as opposed to 30% of Europeans and few Africans.
Because of the characteristics of the patient group in the US, the first study was done on white patients and the next without regard for ethnicity. Anton et al. found that patients of African descent did not have much success with naltrexone in treatment for alcohol dependence because of lacking the relevant gene.
As white patients with the gene had a five times greater rate of success in reducing drinking when given naltrexone than did patients without the gene, when used in a protocol of Medical Management
(MM), Anton et al. concluded,
Studies have found naltrexone to be more efficacious among certain white subjects, because of the genetic basis, than among black subjects, who generally do not carry the relevant gene variant.
A 2009 study of naltrexone as an alcohol dependence treatment among African Americans failed to find any statistically significant differences between naltrexone and a placebo.
Studies have suggested that carriers of the G allele may experience higher levels of craving and stronger “high” upon alcohol consumption, compared to carriers of the dominant allele, and naltrexone somewhat blunts these responses, leading to a reduction in alcohol use in some studies.
The blockade of opioid receptors
is the basis behind naltrexone’s action in the management of opioid dependence—it reversibly blocks or attenuates the effects of opioids. Its mechanism of action in alcohol dependence is not fully understood, but as an opioid receptor antagonist is likely to be due to the modulation of the dopaminergic mesolimbic pathway
(one of the primary centers for risk-reward analysis in the brain, and a tertiary “pleasure center”) which is hypothesized to be a major center of the reward associated with addiction that all major drugs of abuse are believed to activate. Mechanism of action may be antagonism to endogenous opioids such as tetrahydropapaveroline
, whose production is augmented in the presence of alcohol.
Naltrexone is metabolized mainly to 6β-naltrexol
by the liver enzyme dihydrodiol dehydrogenase
. Other metabolites include 2-hydroxy-3-methoxy-6β-naltrexol and 2-hydroxy-3-methoxy-naltrexone. These are then further metabolized by conjugation with glucuronide.
The plasma half-life
of naltrexone and its metabolite 6β-naltrexol are about 4 hours and 13 hours, respectively.
Vivitrol, a naltrexone formulation for depot injection
, was approved by the FDA on April 13, 2006, for the treatment of alcohol dependence.
Additionally, naltrexone implants that are surgically implanted are available,
although they are authorized for export only (i.e. not for use within Australia).
By 2009, naltrexone implants showed encouraging results.
The FDA authorized use of injectable naltrexone (Vivitrol) for opioid addiction using a single study
that was led by Evgeny Krupitsky MD at Bekhterev Research Psychoneurological Institute, St Petersburg State Pavlov Medical University, St Petersburg, Russia,
a country where opioid agonists such as methadone and buprenorphine are not available. Krupitsky et al. undertook a “double-blind, placebo-controlled, randomised”, 24-week trial running “from July 3, 2008 through October 5, 2009” with “250 patients with opioid dependence disorder” at “13 clinical sites in Russia” on the use of injectable naltrexone (XR-NTX) for opioid dependence. The study was funded by the Boston-based biotech Alkermes
firm which produces and markets naltrexone in the United States. An 2011 article reported that this single trial of naltrexone was performed not by comparing it to the best available, evidence-based treatment (methadone or buprenorphine) but by comparing it with a placebo.
In addition, the study failed to follow up on participants to document post-treatment overdose – a key measure for opioid substitution therapies.
Furthermore, by 2011, Vivitrol cost about $1,100 a month, compared to $11 a month for generic naltrexone. A second 2011 article argued that these factors led to criticism of the study’s design and ethics, and, by extension, of the FDA’s approval of injectable naltrexone for opioid addiction based on this study.
In May 2017, United States Secretary of Health and Human Services Tom Price
, praised [vivitrol] as the future of opioid addiction treatment after visiting the company’s plant in Ohio.
His remarks set off sharp criticism with almost 700 experts in the field of substance abuse submitting a letter to Price cautioning him about Vivitrol’s “marketing tactics” and warning him that his comment “ignore widely accepted science”.
The experts pointed out that Vivitrol’s competitors, buprenorphine
, are “less expensive”, “more widely used” and have been “rigorously studied”.
Price had claimed that buprenorphine and methadone were “simply substitute”s for “illicit drugs”
whereas according to the letter, “the substantial body of research evidence supporting these treatments is summarized in guidance from within your own agency, including the Substance Abuse and Mental Health Services Administration, the US Surgeon General, the National Institute on Drug Abuse, and the Centers for Disease Control and Prevention. To briefly summarize, buprenorphine and methadone have been demonstrated to be highly effective in managing the core symptoms of opioid use disorder, reducing the risk of relapse and fatal overdose, and encouraging long-term recovery.”
According to a June 11, 2017 The New York Times
“has spent years coaxing, with a deft lobbying strategy that has targeted lawmakers and law enforcement officials. The company has spent millions of dollars on contributions to officials struggling to stem the epidemic of opioid abuse. It has also provided thousands of free doses to encourage the use of Vivitrol in jails and prisons, which have by default become major detox centers”.
Naltrexone is sometimes used in the treatment of dissociative
symptoms such as depersonalization
Some studies suggest it might help.
Other small, preliminary studies have also shown benefit.
It is thought that blockade of the KOR by naltrexone and naloxone is responsible for their effectiveness in ameliorating depersonalization and derealization.
Since these drugs are less efficacious in blocking the KOR relative to the MOR, higher dose than typically used seem to be necessary.
“Low-dose naltrexone” (LDN) describes the “off-label
” use of naltrexone at low doses for diseases not related to chemical dependency or intoxication, such as multiple sclerosis
More research needs to be done before it can be recommended for clinical use.
Although there are scientific studies showing its efficacy in some conditions such as fibromyalgia
other, more dramatic claims for its use in conditions like cancer
have less scientific support.
This treatment has received significant attention on the Internet
, especially through websites run by organizations promoting its use.
Some studies suggest that self-injurious behaviors
present in persons with developmental disabilities (including autism) can sometimes be remedied with naltrexone.
In these cases, it is believed that the self-injury is being done to release beta-endorphin
, which binds to the same receptors as heroin and morphine.
If the “rush” generated by self-injury is removed, the behavior may stop.
There are indications that naltrexone might be beneficial in the treatment of impulse control disorders such as kleptomania
, compulsive gambling, or trichotillomania
(compulsive hair pulling), but there is conflicting evidence of its effectiveness for gambling.
A 2008 case study reported successful use of naltrexone in suppressing and treating an internet pornography addiction
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