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Naltrexone has recently received considerable attention as a pure opiate antagonist used for "ultra-rapid" detoxification under general anesthesia. A significant fee (usually well in excess of $US 5,000) is generally charged. The procedure is not without risk: mortality can occur in association with the general anesthesia, and also in the initial period after detoxification if the newly detoxified, and thus no longer tolerant, individual returns to narcotic use. The latter risk, of course, is always present when narcotic use is resumed after a period of abstinence. In addition to its use as a rapid detoxification agent, Naltrexone has also been utilized for decades as a longer-term "blocking agent" in maintenance treatment.
Patients should be afforded the broadest possible choice of treatment options, but such choice must be truly "informed" - i.e., based on realistic expectations supported by experience. With respect to short-term detoxification, unless patients require that withdrawal be accomplished immediately (i.e., within a matter of hours), the Naltrexone-under-anesthesia procedure seems to have few if any benefits compared to traditional approaches utilizing opioid agonists or other medications. There appears to be neither empirical nor theoretical support for expecting abstinence, once achieved, to be maintained more readily than when any other detoxification method is employed.
The limitations of Naltrexone when used as a "maintenance" medication are perhaps best summarized by the manufacturer:
"There are no data that demonstrate an unequivocally beneficial effect of [Naltrexone] on rates of recidivism among detoxified, formerly opioid dependent individuals who self-administer the drug. ...The drug is reported to be of greatest use in good prognosis opioid addicts who take the drug as part of a comprehensive occupational rehabilitative program, behavioral contract, or other compliance enhancing protocol. [Naltrexone], unlike methadone or LAAM, does not reinforce medication compliance, and is expected to have a therapeutic effect only when given under external conditions that support continued use of the medication."
Reference: Physicians' Desk Reference, 2001, pp. 1146-1149
It is perhaps instructive to compare the mechanism of action of Naltrexone with that of Antabuse as employed in the treatment of alcoholism. Both medications affect the consequence of using the drug - Naltrexone, in opioid dependent individuals, by blocking the receptors and preventing the narcotic effects, and Antabuse by causing physical distress if alcohol is consumed. Both also share a very major limitation: they do not alter the "craving" (or however one chooses to describe the physical and/or psychological need) for the drug, thus making compliance extremely problematic.
In treating a condition as complex and potentially as life threatening as opioid dependence, all possible therapeutic interventions should be encouraged and made available. While no treatment approach that offers help and hope should be rejected, it is also imperative that none be advocated without full and objective disclosure to the patient of its possible benefits, risks and limitations.