DPB Publications - Naltrexone - a guide for carers

Glossary

abstinence - not using a particular drug; being drug-free.

antagonist - a drug which blocks the effects of opioid drugs.

dependence - the drug has become central to a person’s thoughts, emotions and activities. Stopping, or reducing the drug suddenly, can lead to physical withdrawal symptoms.

euphoria - feeling of well being - the ‘high’ or ‘rush’.

opioid - class of drugs including heroin, methadone, codeine, pethidine, morphine etc.

rapid opioid detox - this is an experimental technique to accelerate withdrawal from opioids while the person is under sedation.

receptors - nerve cells in the brain which are sensitive to particular drugs. The effects of a drug are experienced when the drug has attached itself to its corresponding receptor.

tolerance - requiring higher doses of the drug to experience the same effects.

This information has been written as an accompaniment to Naltrexone – A Guide for Users to inform the carer about: naltrexone medication, the carer’s responsibilities, side effects, risks.

Note: Some people will choose to undergo naltrexone treatment without any involvement from others except their doctor.

Naltrexone has received a lot of media attention in the last few years.

Often it has been hailed as a miracle drug for people dependent on heroin and other opioids.

This information provides clarification on the current use of naltrexone as a prescribed dose to help a person maintain abstinence from opioids such as heroin. It is not about the experimental use of naltrexone in rapid opioid detox.

Naltrexone is one treatment out of many options for an opioid-free life. Choosing the right option will depend on a number of factors such as the person’s:

motivation to be opioid free
their flexibility
level of support and care from friends and family
financial situation
housing situation
access to counselling.

There is some evidence to suggest that naltrexone has better outcomes for people who are highly motivated, receive counselling while taking naltrexone, and have a high level of support and care from family and friends.

What is naltrexone?

Until recently naltrexone was only available in clinical trials. It is now registered as a prescribed drug and is able to be prescribed by all medical doctors.

Naltrexone is a drug prescribed to help people maintain abstinence after they have successfully detoxified from heroin and other opioids. It does this by blocking the opioid receptors in the brain. If the person uses heroin or other opioids while taking naltrexone it is unlikely to produce any of the usual effects.

Receptors onding receptor.

Naltrexone is classified as an opioid antagonist because once it reaches the opioid receptor it will either push out any opioids, or if vacant, will occupy the receptor. Once it has done this it blocks any opioid entering the receptor.

Other uses of naltrexone

Naltrexone is sometimes used in the treatment of alcohol dependence. It appears to reduce the desire to drink alcohol in some people. It does not reduce the effects of alcohol, or other drugs except for opioids.

How do you get naltrexone?

Naltrexone is only available on prescription from a doctor.

Although any doctor can prescribe naltrexone, it is recommended that treatment comes from a doctor experienced in alcohol and other drug dependence. This may include:

doctors who specialise in naltrexone treatment
doctors in clinics providing alcohol and other drug treatment services
general practitioners experienced in alcohol and other drug problems.

It is important that the doctor chosen is able to offer a thorough assessment and make a provision for counselling and ongoing support.

Who can undergo naltrexone treatment?

There are a number of factors that need to be considered before a doctor can prescribe naltrexone.

Before starting medication the patient must be free from heroin for 7-10 days and up to 14 days if they have been using methadone. This means they must completely detox from opioids before they can begin taking naltrexone. The reason for this is that naltrexone will bring on immediate and possibly severe withdrawal symptoms if there are opioids in their body. The doctor may decide to them with Narcan (naloxone) to ensure they are opioid free. If they do have opioids in their body Narcan will immediately bring on withdrawal symptoms which can last approximately one hour.
Certain liver conditions may exclude them from naltrexone treatment. These include acute hepatitis and alcoholic liver disease. The doctor should be informed of any liver conditions that the patient has.

Pregnant and breastfeeding women should seek the advice of their doctor. It has not been established that using naltrexone during pregnancy is completely safe.
There are better outcomes from naltrexone treatment for people who are highly motivated to become opioid free and are well supported by friends and family.

What does naltrexone treatment involve?

The treatment involves taking a prescribed course of naltrexone tablets for up to one year. These tablets are taken by mouth, once a day or, every couple of days at a higher dose.

The doctor may initially monitor the patients progress quite closely.

Naltrexone is dispensed by retail or mail-order pharmacies.

One of the main responsibilities of the carer could be to provide the tablets to the person on a daily basis, or as instructed by the doctor. If this is the case then you should establish your role as a carer with the doctor.

The role of the carer

Taking naltrexone tablets is only part of the treatment. As in many other conditions, the treatment can be more effective when combined with counselling and ongoing support from friends and family.

It appears that patients who do have the involvement of a carer are more likely to complete the naltrexone treatment. For this reason doctors may encourage the patient to seek out people they can rely on for support and care during the treatment. This could include a family member, a partner, friend or a health practitioner such as nurse or pharmacist.

One of the key roles for the carer is to supervise the naltrexone dosage as prescribed by the doctor. Other involvement may include:

attending couples or family counselling
sensitivity to depression that may be associated with both opioid withdrawal and naltrexone use
being committed to this role, possibly for the duration of the treatment
knowing what to do in the event of an overdose.

If you are to take on the role of a carer there needs to be a clear agreement of what that role will be. Informed consent between you and the patient must outline your role in supervising the medication and informing the doctor if problems arise.

There is a potential for conflict to arise as some people may come to resent being supervised. Ultimately, whatever agreement you make, the responsibility for what happens in treatment rests primarily with the patient.

Why undergo naltrexone treatment?

It acts as a disincentive to continued drug use. Using heroin or other opioids while taking naltrexone will not produce any of the usual effects. This is because the opioid receptors have been blocked.
Naltrexone does not produce physical dependence
It reduces the stress and anxiety about when the person will next ‘score’.
As long as the person no longer injects, naltrexone reduces the risk of hepatitis C, HIV and other health problems.
It allows the person to stabilise their lifestyle.

What naltrexone doesn’t do

It is not a miracle cure for opioid dependence. This is why counselling and other support is important when taking naltrexone medication.
It does not produce any euphoric effects.

Side effects

Naltrexone is generally well tolerated by the human body. However, there have been some side-effects reported. Some of these may be withdrawal symptoms associated with heroin or other opioid dependence. Symptoms may include:

depression
sleep disturbances
headaches
loss of energy
nausea and vomiting
abdominal pain
constipation
loss of appetite
anxiety.

Risks

The grea danger associated with naltrexone is the risk of death by opioid overdose after either skipping a dose of naltrexone or stopping naltrexone. This is because abstinence from opioids while on naltrexone rapidly reduces the person’s tolerance to opioids.

If the person is considering taking heroin or other opioids once they stop or skip a dose of naltrexone, they must consider themselves as a new user. Overdose may occur if the person uses the same - or even a smaller - amount of heroin or other opioids that they used before taking naltrexone.

Risks while on naltrexone

If the person has a history of depression they should let their doctor know as withdrawing from opioids can be associated with depression.
As naltrexone blocks the opioid receptors, taking other opioid-based treatments such as codeine-based cough medicines and pain killers will be ineffective. Any emergency service provider (ambulance officers, casualty staff etc) or doctor needs to know that the person is taking naltrexone in case they need a powerful analgaesia. Non-opioid treatment can be used in these situations.

Skipping doses

After each dose of naltrexone, the blocking effect wears off gradually leaving receptor sites vacant. For example, a 50mg tablet can wear off between 24 and 72 hours. Higher doses may last longer. Any use of heroin or other opioids while on naltrexone is risky.

If the person is to use heroin or other opioids while on naltrexone there is a danger that these drugs can build up in the body. As the naltrexone leaves the receptor sites the site may be rushed with opioids in quantities greater than the person’s current tolerance level.

This situation is more critical when methadone is being used. This is because a dose of methadone can last in the body for 24 hours while heroin may last for only a few hours.

Opioid Overdose

How to recognise an overdose

slow breathing or no breathing
turning blue (look at their lips, fingernails)
not answering when you call their name or gently shake them
strange snoring sounds while they are sleeping

What to do if the person has overdosed

Stay calm - don’t panic.
Try and wake them up. Call their name, gently shake them. If they wake up - walk them around and stay with them.

If they don’t respond:

Put them on their side in the recovery position.
Clear their airway.
Get someone to call an ambulance (000).
If they are not breathing start mouth-to-mouth resuscitation.
If they don’t have a pulse, start CPR (cardiopulmonary resuscitation).

Choosing the right treatment

Naltrexone is one of a range of treatment options for opioid dependence. Other treatment options include:

methadone maintenance
detox, rehabilitation
counselling.

Deciding to undergo naltrexone treatment requires careful consideration. The important thing to remember is that the patient must detox first. Naltrexone is not a euphoric alternative to heroin or other opioids. It’s a drug which blocks euphoric effects and helps maintain the patient’s abstinence.

As a carer, let the person know that you will support and care for them and that they will not be undergoing the naltrexone treatment alone. Establish the fact that you may be supervising their dosage. Explain to them that it is not because you don’t trust them but because you are their carer and support person. If this a role that you have both agreed to then let the doctor know as early as possible.

24 hour confidential telephone counselling services

NSW
Alcohol and Drug Information Service (ADIS) - 24hr hotline
Ph: (02) 9361 8000 Toll free number: 1800 422 599

Victoria
Direct Line
Ph: (03) 9416 1818 Toll free number: 1800 136 385

Western Australia
Alcohol and Drug Information Service (ADIS) - 24hr hotline
Ph: (08) 9442 5000 Toll free number: 1800 198 024

Queensland
Alcohol and Drug Information Service (ADIS) - 24hr hotline
Ph: (07) 3236 2414 Toll free number: 1800 177 833

South Australia
Alcohol and Drug Information Service (ADIS) - 24hr hotline
Toll free number: 1300 131 340

Northern Territory
Amity Community Service
Ph: (08) 8981 8030 Toll free number: 1800 629 683

Tasmania
Alcohol and Drug Service South
Toll free number: 1800 811 994

ACT
24 hour Alcohol and Drug Help line
Ph: (02) 6205 4545

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