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Template:Drugbox Naltrexone is an opioid receptor antagonist used primarily in the management of alcohol dependence and opioid dependence. It is marketed in generic form as its hydrochloride salt, naltrexone hydrochloride, and marketed under the trade names Revia and Depade. In some countries including the United States, an extended-release formulation is marketed under the trade name Vivitrol. Also in the US, Methylnaltrexone Bromide, a closely related drug, is marketed as Relistor, for the treatment of opioid induced constipation.

Naltrxone should not be confused with naloxone (which is used in emergency cases of overdose rather than for longer-term dependence control) nor nalorphine. Both nalorphine and naloxone are full antagonists and will treat an opioid overdose, but naltrexone is longer-acting than naloxone (although neither is an irreversible antagonist like naloxazone), making naloxone a better emergency antidote.

Chemical structure

Naltrexone can be described as a substituted oxymorphone – here the tertiary amine methyl-substituent is replaced with methylcyclopropane.

Naltrexone is the N-cyclopropylmethyl derivative of oxymorphone.

Pharmacology

Naltrexone and its active metabolite 6-β-naltrexol are competitive antagonists at μ- and κ-opioid receptors, and to a lesser extent at δ-opioid receptors.[1] The plasma halflife of naltrexone is about 4 h, for 6-β-naltrexol 13 h. The blockade of opioid receptors is the basis behind its action in the management of opioid dependence—it reversibly blocks or attenuates the effects of opioids.

Its use in alcohol (ethanol) dependence has been studied and has been shown to be effective [2]. Its mechanism of action in this indication is not fully understood, but as an opioid-receptor antagonist it's likely to be due[citation needed] to the modulation of the dopaminergic mesolimbic pathway which is hypothesised to be a major center of the reward associated with addiction (being one of the primary centers for risk-reward analysis in the brain, and a tertiary "pleasure center") that all major drugs of abuse are believed to activate.

Naltrexone is metabolised 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 metabolised by conjugation with glucuronide.

Rapid detoxification

Naltrexone is sometimes used for rapid detoxification ("rapid detox") regimens for opioid dependence. The principle of rapid detoxification is to induce opioid-receptor blockage while the patient is in a state of impaired consciousness, so as to attenuate the withdrawal symptoms experienced by the patient. Rapid detoxification under general anaesthesia involves an unconscious patient and requires intubation and external ventilation. Rapid detoxification is also possible under sedation. The rapid detoxification procedure is followed by oral naltrexone daily for up to 12 months for opioid dependence management. There are a number of practitioners who will use a naltrexone implant, usually placed in the lower abdomen, to replace the oral naltrexone. This implant procedure has not been shown scientifically to be successful in "curing" subjects of their addiction, though it does provide a better solution than oral naltrexone for medication compliance reasons. Naltrexone implants are made by at least three companies, though none have been approved by the U.S. Food and Drug Administration (FDA) or the Australian Therapeutic Goods Administration.[2] There is currently scientific disagreement as to whether this procedure should be performed under local or general anesthesia, due to the rapid, and sometimes severe, withdrawal that occurs from the naltrexone displacing the opiates from the receptor sites.

Rapid detoxification has been criticised by some for its questionable efficacy in long-term opioid dependence management.[3] Rapid detoxification has often been misrepresented as a one-off "cure" for opioid dependence, when it is only intended as the initial step in an overall drug rehabilitation regimen. Rapid detoxification is effective for short-term opioid detoxification, but is approximately 10 times more expensive than conventional detoxification procedures. Aftercare can also be an issue,[3] since at least one well-known center in the United States reported that they will remove an implant from any patient arriving in their facility before admission.[citation needed][who?]

The usefulness of naltrexone in opioid dependence is very limited by the low retention in treatment. Like disulfiram in alcohol dependence, it temporarily blocks substance intake and does not affect craving. Sustained-release preparations of naltrexone have shown rather promising results, it remains a treatment only for a small part of the opioid-dependent population, usually the ones with an unusually stable social situation and motivation (e.g., dependent health care professionals). It is given orally by physicians to help reduce the side effects of opiate dependence. Naltrexone implants have been used successfully in Australia for a number of years as part of a long-term protocol for treating opiate addiction. Naltrexone treats the physical dependence on opioids, but further psychosocial interventions are often required to enable people to maintain abstinence.[4]

Alcohol dependence

The main use of naltrexone is for the treatment of alcohol dependence. After publication of the first two randomized, controlled trials in 1992, a number of studies have confirmed its efficacy in reducing frequency and severity of relapse to drinking.[5] The multi-center COMBINE study has recently proven the usefulness of naltrexone in an ordinary, primary care setting, without adjunct psychotherapy.[6]. Mechanism of action may be antagonism to endogenous opiates such as tetrahydropapaveroline, whose production is augmented in the presence of alcohol.[7]

The standard regimen is one 50 mg tablet per day. Initial problems of nausea usually disappear after a few days, and other side effects (e.g., heightened liver enzymes) are rare. Drug interactions are not significant, besides the obvious antagonism of opioid analgesics. Naltrexone has two effects on alcohol consumption.[8] The first is to reduce craving while naltrexone is being taken. The second, referred to as the Sinclair Method, occurs when naltrexone is taken in conjunction with normal drinking, and this reduces craving over time. The first effect persists only while the naltrexone is being taken, but the second persists as long as the alcoholic does not drink without first taking naltrexone.

Roy Eskapa, who wrote a book advocating the Sinclair Method, argues that Naltrexone does not work in conjunction with abstinence.[9] Eskapa cites as evidence a Finnish clinical trial in which "Naltrexone tended to be worse than those for placebo,"[10] and two studies that produced "almost identical graphs": an alcoholism clinical trial at Yale[11] and a Naltrexone for cocaine addiction trial at the University of Texas.[12]

Depot injectable naltrexone (Vivitrol, formerly Vivitrex, but changed after a request by the FDA) was approved by the FDA on April 13, 2006 for the treatment of alcoholism. This version is made by Alkermes, and will be jointly marketed by Cephalon, Inc. The medication is administered by intra-muscular injection and lasts for up to 30 days. Clinical trials for this medication were done with a focus on alcohol, presumably due to the larger number of alcoholics that it could be used to treat; however, Alkermes was asked to run a safety study for the off-label use of the injection for opiate addicts. This was found to be a successful use of the medication in patients who were single drug abusers, though multi-drug abusers would generally decrease their opiate use and increase their use of other drugs (i.e. cocaine) while on the injection. Other studies, however, provide preliminary evidence that naltrexone with the right protocol can be effective in treating cocaine addiction.[13]

Another study released by the National Institute of Health in February 2008 and published in the Archives of General Psychiatry has shown that alcoholics having a certain gene variant of the opioid receptor were far more likely to experience success at cutting back or discontinuing their alcohol intake altogether.[14]

Safety

In alcohol dependence, naltrexone is considered a safe medication. Control of liver values prior to initiation of treatment is recommended. There has been some controversy regarding the use of opioid-receptor antagonists, such as naltrexone, in the long-term management of opioid dependence due to the effect of these agents in sensitising the opioid receptors. That is, after therapy, the opioid receptors continue to have increased sensitivity for a period during which the patient is at increased risk of opioid overdose. This effect reinforces the necessity of monitoring of therapy and provision of patient support measures by medical practitioners.

Other uses

Low dose naltrexone (LDN)

Low dose naltrexone (LDN), where the drug is used in doses approximately one-tenth those used for drug/alcohol rehabilitation purposes, is being used by some as an "off-label" experimental treatment for certain immunologically-related disorders,[15] including HIV/AIDS,[16] multiple sclerosis[17] (in particular, the primary progressive variant,[18]) Parkinson's disease,[citation needed] cancer,[19] fibromyalgia,[20] autoimmune diseases such as[citation needed] rheumatoid arthritis, ankylosing spondylitis, transverse myelitis, Crohn's disease, ulcerative colitis, Hashimoto's thyroiditis, and central nervous system disorders.[citation needed] Certain medications will work against the naltrexone such as Hydrocodone, Oxycodone, Oxymorphone and other opiate/opioid narcotics.[citation needed] These medications should not be taken while on Naltrexone, as nausea, vomiting, cold sweats, chills, and sometimes numbness in the limbs may occur.[citation needed] Naltrexone may also interfere or counteract both low and high doses of over-the-counter NSAID medications.[citation needed]

Sexual dysfunction

Naltrexone can induce early morning erections in patients who suffer from psychogenic erectile dysfunction. The exact pathway of this effect is unknown. Priapism has been reported in two individuals receiving Vivitrol.

Naltrexone has been shown to be effective in the reversal of sexual satiety and exhaustion in male rats.[21]

Tobacco study

The Chicago Stop Smoking Research Project at the University of Chicago studied whether naltrexone could be used as an aid to quit smoking. The researchers discovered that Naltrexone improved smoking cessation rates in women by fifty percent, but showed no improvement for men.[22]

Use for Crohn's disease

In a clinical trial conducted by Pennsylvania State University, it was concluded that low dose naltrexone helped people with Crohn's disease, putting the disease into remission in many cases, though it was stated that further study would be required.[23]

Self-injurious behaviors

Some studies suggest that self-injurious behaviors present in developmentally disabled and autistic people can sometimes be remedied with naltrexone.[24] 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.[25] By removing the "rush" generated by self-injury, the behavior may stop.

Opiate addiction

Naltrexone helps patients overcome urges to abuse opiates by blocking the drugs’ euphoric effects. While some patients do well with the oral formulation, there is a drawback in that it must be taken daily, and a patient whose craving becomes overwhelming can obtain opiate euphoria simply by skipping a dose before resuming abuse. A preferable alternative for those likely to skip doses is the naltrexone implant, which may be surgically inserted under the skin. The implant provides a sustained dose of naltrexone to the patient, thereby preventing the problems which may be associated with skipping doses. It must be replaced every several months. The naltrexone implant appears to be a far more effective means of treating heroin addiction than the oral formulation.[26]

Kleptomania

There are indications that naltrexone might be beneficial in the treatment of impulse control disorders such as kleptomania (compulsive stealing), trichotillomania, or pathological gambling.[27]

Study in overweight and obese patients

Clinical trials are ongoing regarding the use of naltrexone in combination with another drug, bupropion, as a weight loss therapy.[28]

Autism

Dr. Jaak Panksepp of Washington State University has conducted studies using naltrexone to treat patients with autism. He found that half the autistic children treated with the drug become more social.[29]

References

  1. Shader, RI. "Antagonists, Inverse Agonists, and Protagonists." Journal of Clinical Psychopharmacology. 2003 Aug; 23(4):321–322. PMID 12920405
  2. [|Therapeutic Goods Administration]. "Australian Register of Therapeutic Goods Medicines" (Online database of approved medicines). https://www.ebs.tga.gov.au/ebs/ANZTPAR/PublicWeb.nsf/cuMedicines?OpenView. Retrieved 2009-03-22.
  3. 3.0 3.1 Wodak, Dr. Alex (Summer 07/08). "I woke up cured of Naltrexone!" (Online Version of published magazine article). User's News (New South Wales User's and AIDS Association). http://www.nuaa.org.au/index.php?option=com_content&view=article&id=105:i-woke-up-cured-of-naltrexone&catid=7:issue-no-53&Itemid=57. Retrieved 2009-03-22. ""Maybe there was an increased risk of death when people took naltrexone for a while and then started taking heroin? Maybe the success rate of naltrexone, whether started with UROR or ROD, was not as great as some had claimed?""
  4. Hanson, Merideth (2001). "Three". In Alex Gitterman. The Handbook of Social Work practice with vulnerable and resilient populations, 2nd Edition (Second ed.). New York: Columbia University Press.
  5. Latt NC, Jurd S, Houseman J, Wutzke SE (June 2002). "Naltrexone in alcohol dependence: a randomised controlled trial of effectiveness in a standard clinical setting". Med J Aust 176 (11): 530–4. PMID 12064984. http://www.mja.com.au/public/issues/176_11_030602/lat10411_fm.html.
  6. Template:Cite press release
  7. Template:Cite pmid
  8. Sinclair JD (2001). "Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism". Alcohol and Alcoholism 36 (1): 2–10. doi:10.1093/alcalc/36.1.2. PMID 11139409. http://alcalc.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=11139409.
  9. Eskapa, Roy (2008). The Cure for Alcoholism. BenBella Books. pp. 35. ISBN 1933771550. http://www.TheCureForAlcoholism.com.
  10. P. Heinälä et al., "Targeted Use of Naltrexone without Prior Detoxification in the Treatment of Alcohol Dependence: A Factorial Double-Blind Placebo-Controlled Trial," Journal of Clinical Psychopharmacology 21 (2001): 287-292.
  11. S.S. O'Malley, A. Jaffe, G. Chang, G. Witte, R. S. Schottenfeld, and B. J. Rounsaville, "Naltrexone in the Treatment of Alcohol Dependence," in Opioids, Bulimia, and Alcohol Abuse and Alcoholism, ed. L. D. Reid (New York: Springer, 1990), 149-157. S.S. O'Malley, A. J. Jaffe, G. Chang, R. S. Schottenfeld, and B. J. Rounsaville, "Naltrexone and Coping Skills Therapy for Alcohol Dependence," Archives of General Psychiatry 49 (1992): 881-887.
  12. J. M. Schmitz, A. L. Stotts, H. M. Rhoades, and J. Grabowski, "Naltrexone and Relapse Prevention Treatment for Cocaine-Dependent Patients," Addictive Behavior 26 (2001): 167-180.
  13. Schmitz J, Stotts A, Rhoades H, Grabowski J (2001). "Naltrexone and relapse prevention treatment for cocaine-dependent patients". Addict Behav 26 (2): 167–80. doi:10.1016/S0306-4603(00)00098-8. PMID 11316375.
  14. Anton R, Oroszi G, O’Malley S, Couper D, Swift R, Pettinati H, Goldman D (2008). "An Evaluation of Opioid Receptor (OPRM1) as a Predictor of Naltrexone Response in the Treatment of Alcohol Dependence". Archives of General Psychiatry 65 (2): 135–144. doi:10.1001/archpsyc.65.2.135. PMC 2666924. PMID 18250251.
  15. Low Dose Naltrexone as a preferential mu opiate receptor antagonist in the treatment of various autoimmune diseases. Power Point presentation
  16. [1]
  17. LDN for Multiple sclerosis
  18. Gironi M, Martinelli-Boneschi F, Sacerdote P, Solaro C, Zaffaroni M, Cavarretta R, Moiola L, Bucello S, Radaelli M, Pilato V, Rodegher M, Cursi M, Franchi S, Martinelli V, Nemni R, Comi G, Martino G (2008). "A pilot trial of low-dose naltrexone in primary progressive multiple sclerosis.". Multiple Sclerosis 14 (8): 1076–83. doi:10.1177/1352458508095828. PMID 18728058.
  19. Template:Url=http://www.lowdosenaltrexone.org/ldn and cancer.htm
  20. Addiction Drug May Help Ease Fibromyalgia. 2009-04-16. http://www.forbes.com/feeds/hscout/2009/04/17/hscout626187.html.
  21. Fernández-Guasti A, Rodríguez-Manzo G. Pharmacological and physiological aspects of sexual exhaustion in male rats. Scand J Psychol. 2003 Jul;44(3):257-63. PMID 12914589
  22. King A, de Wit H, Riley R, Cao D, Niaura R, Hatsukami D (2006). "Efficacy of naltrexone in smoking cessation: A preliminary study and an examination of sex differences". Nicotine & Tobacco Research 8 (5): 671–82. doi:10.1080/14622200600789767. PMID 17008194.
  23. Smith J, Stock H, Bingaman S, Mauger D, Rogosnitzky M, Zagon I (2007). "Low-Dose Naltrexone Therapy Improves Active Crohn's Disease". American Journal of Gastroenterology 102 (4): 820–8. doi:10.1111/j.1572-0241.2007.01045.x. PMID 17222320. http://www.amjgastro.com/showContent.asp?DID=4&SessionGUID=086C08FE-7A5E-45FC-B076-7245A7BE14FA&id=ajg_104542007&type=abstract.
  24. Smith, Stanley G.; Gupta, Krishan K.; Smith, Sylvia H. (June, 1995). "Effects of naltrexone on self-injury, stereotypy, and social behavior of adults with developmental disabilities". Journal of Developmental and Physical Disabilities 7 (2): 137–146. doi:10.1007/BF02684958.
  25. Manley, Cynthia (1998-03-20). "Self-injuries may have biochemical base: study". The Reporter. http://www.mc.vanderbilt.edu/reporter/index.html?ID=461.
  26. Naltrexone Appears Safe and Effective for Heroin Addiction
  27. Grant (2009-04-03). "Drug Suppresses The Compulsion To Steal, Study Shows". Science daily. http://www.sciencedaily.com/releases/2009/04/090401101900.htm.
  28. url=http://clinicaltrials.gov/ct2/show/NCT00711477
  29. Grandin, Temple; Johnson, Catherine (2005). Animals in Translation. New York, New York: Scribner. pp. 114–116. ISBN 0743247698.

External links

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