Naltrexone

REVIA

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What it isCompetitive mu opioid antagonist; alcohol and opioid use disorder.

Why this oneIt reduces heavy drinking days in alcohol use disorder without requiring abstinence to start, and the monthly injection removes adherence as a variable.

What limits itIt blocks opioid analgesia entirely and precipitates withdrawal, so seven to ten days opioid-free are required first.

FDA-approved for

opioid use disorder (1984)
alcohol use disorder (1994)

Off-label

self-injurious behavior
weight loss (low-dose)
impulse-control disorders

FDA label

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FDA dosing	Population	Start	Target	Max
Alcohol dependence	Adults	50 mg QD	50 mg QD	50 mg QD
Opioid dependence (blockade)	Adults	25 mg once; if no withdrawal, 50 mg QD	50 mg QD	50 mg QD

Renal Undefined

Hepatic Undefined

Higher risk of hepatocellular injury with single doses above 50 mg

Instructions

Patient must be opioid-free (incl. tramadol) 7–10 days before starting
Consider naloxone challenge test if occult opioid dependence suspected; do not start if positive
Do not start in acute opioid withdrawal or positive opioid urine screen
Alternative supervised schedules (e.g., 100 mg every other day, 150 mg every third day) reduce blockade

Contraindications

Patients receiving opioid analgesics
Current opioid dependence, incl. maintenance on agonists (methadone) or partial agonists (buprenorphine)
Acute opioid withdrawal
Failed naloxone challenge test or positive opioid urine screen

Cautions

Dose-related hepatocellular injury (esp. doses above recommended)
Precipitated / exacerbated opioid withdrawal in non-opioid-free patients
Vulnerability to opioid overdose after treatment (reduced tolerance) or attempts to overcome blockade
Depression and suicidality reported
Withdrawal/deaths reported with ultra-rapid opioid detoxification

Adverse reactions

Nausea
Headache
Dizziness
Nervousness
Fatigue
Insomnia
Vomiting
Anxiety
Somnolence
Abdominal pain/cramps (opioid-dependent patients)

Pregnancy Category C; increased early fetal loss in animals at high doses; use only if benefit justifies risk

Lactation Undefined

NO BOXED WARNINGS

Principal riskPrecipitated withdrawal; blocks opioid analgesia

Cost, est. cash$300–$5,000/dose or month

Generic entry2023

Classes and tags

Clinical profile

Therapeutic safety burden1 / 4

Overdose danger1 / 4

Weight-gain liability0 / 4

Sedation liability0 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism0 / 4

Embryofetal risk1 / 4

Legacy pregnancy categoryC

Defining liabilityGenerally tolerated at therapeutic doses; clinically important risks are agent-specific and increase with interactions or organ impairment.