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Outpatient opioid detoxification with naltrexone more effective than buprenorphine

An outpatient detoxication regimen using naltrexone was more effective for transitioning adults with opioid dependence to extended-release naltrexone than a regimen using buprenorphine.

“An extended-release injectable form of naltrexone has FDA approval for relapse prevention following opioid detoxification. However, a substantial barrier to its effective implementation is the need to detoxify patients from opioids before naltrexone is initiated,” Maria Sullivan, MD, PhD, of College of Physicians and Surgeons of Columbia University, and colleagues wrote. “The official prescribing information recommends that individuals abstain from opioids for 7 to 10 days before receiving an [extended-release naltrexone] injection to avoid precipitated withdrawal. This waiting period, combined with conventional methods of opioid detoxification employing agonist tapers over several days, represents a delay of 2 weeks or more before [extended-release naltrexone] can be administered. This is feasible during an extended residential treatment stay; however, the availability of inpatient detoxification beds is decreasing, and patients are increasingly seeking treatment in outpatient settings.”

To assess efficacy of an approach for transitioning adults with opioid dependence to extended-release injection naltrexone while preventing relapse, researchers conducted a randomized trial among 150 individuals with opioid dependence. Study participants were randomly assigned to receive naltrexone-assisted detoxification or buprenorphine-assisted detoxification followed by an injection of extended-release naltrexone.

Naltrexone-assisted detoxification included 1 day of buprenorphine followed by increasing doses of oral naltrexone, clonidine and other adjunctive medications for 7 days.

Buprenorphine-assisted detoxification included a 7-day buprenorphine taper followed by a 7-day delay before administration of extended-release naltrexone.

Both treatment groups received behavioral therapy for medication adherence and a second dose of extended-release naltrexone.

Participants who received naltrexone-assisted detoxification were significantly more likely to receive extended-release naltrexone (56.1% vs. 32.7%) and receive a second injection at week 5 (50% vs. 26.9%), compared with the buprenorphine-assisted group.

These findings remained consistent when adjusting for primary type of opioid use, route of opioid administration and morphine equivalents at baseline.

“The study results support the feasibility of ascending low doses of oral naltrexone, in combination with an initial dose of buprenorphine and standing nonopioid ancillary medications, as an outpatient regimen for opioid detoxification and [extended-release naltrexone] induction. 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,” the researchers concluded. – by Amanda Oldt

Disclosure: Sullivan reports receiving medication for this NIH-funded study through the Alkermes Investigator-Initiated Trial program while a full-time faculty member at Columbia University; and participating in the design, initiation, and conduct of this study while at Columbia, and in the data analysis and manuscript preparation after becoming an employee of Alkermes. Please see the study for a full list of relevant financial disclosures.