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Naltrexone is an agonist used to block the effects of opiates and most recently alcohol (Hudson, 1998). It can be an effective adjunct to a quicker reentry time since it places another level of confidence in the aftercare process. To begin therapy, the patient must be narcotic free for seven to 10 days. It is dispensed in tablet form for oral use. Because some addicts have been known to "cheek" their drug by slipping the pill inside their buccal mucosa rather than swallowing it, some advocate that the tablet be crushed and given in a small amount of liquid. The manufacturers recommend a simple syrup solution in this situation so that the drug is not altered by the pH of acidic juices. Dosing begins with a test dose of 25 mg, increased in increments up to 150 mg/day by the third day. One 50 mg tablet will block the euphoric effects of 25 mg of heroin. Liver enzymes should be followed up during the course of treatment, which may extend several years. The screening costs to check liver enzymes and the blood level or naltrexone, plus the cost of the treatment drug, make it somewhat expensive.
Side effects are minimal, with the exception of a 13 percent incidence of nausea. The remaining effects of insomnia, fatigue, dizziness, and/or vomiting average around 2 percent. The benefits include ease of administration (oral), rapid gastric absorption, and a good narcotic-negating effect should the patient use. Like any drug treatment, an addict may learn to use the drug of abuse in an amount sufficient to override the effects of naltrexone. Naltrexone does not block the effects of cocaine or benzodiazepines. Addicts who try to override the narcotic blockade by using while taking the drug often experience profound respiratory depression. Random screens and close supervision should be adequate to determine whether an individual is attempting to override the naltrexone block. Individuals receiving naltrexone should wear a Medic-Alert device.
The person's condition should be stabilized on naltrexone therapy at least one week prior to return to work. This therapy is initiated and maintained under medical direction and should not be terminated suddenly. A contract that is written with naltrexone as an adjunct should include a board hearing (attorney, chief anesthesiologist/CRNA), be a three- to five-year contract that begins upon reentry, and should include a staff in-service (operating room, postanesthesia care unit, others). Naltrexone administration should continue for two years and be discontinued only upon the agreement of an evaluating team.
The issue of whether to utilize naltrexone as part the recovery process requires considerations beyond the risks and benefits of the adjunctive therapy. CRNAs often relapse within two weeks, even after a year or more off from work, despite excellent intentions, a rigid contract, and being cleared for return to work. For the first six months to a year, naltrexone or disulfiram may be used as an adjunct to the return-to-work program. The certified addictionologist or primary physician in charge of the medical and psychological care of the recovering CRNA should determine the advisability of these two drugs, as well as other medications prescribed for the anesthetist.
Managers should always remember that naltrexone is only an adjunct to quality aftercare. It is also important to have a highly functional narcotic policy that requires returning unused narcotics to a central drop box, periodic audit of anesthesia and narcotic records, random drug screens, and frequent performance evaluations. The benefits of utilizing this technique can be great for both addicted CRNAs and their coworkers. The CRNA is able to return to work sooner and administer narcotics to patients with added confidence. The anxiety for the staff should be reduced with these checks in place. It is perhaps the best option for recovered opiate abusers who are able to reenter, and it can be individually tailored over time to fit the situation.
Reference
Quinlan, D. Peer Assistance - Part 2. In: A Professional Study and Resource Guide for the CRNA. Foster S, Faut-Callahan M, eds. Park Ridge, Ill: AANA Publishing, Inc.; 2001; 473-474.
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