Guideline for the Treatment of Alcohol Use Disorder in the Outpatient Setting with Intramuscular Naltrexone Assess Candidacy for IM Naltrexone Meets DMS-V criteria for alcohol use disorder Patient and/or clinician prefers monthly intramuscular injection Not pregnant or breastfeeding* Understands opioids cannot be taken while receiving naltrexone Assess Baseline Hepatic Function Obtain baseline LFTs and assess clinically for risk factors and signs/symptoms of decompensated cirrhosis or severe active hepatitis** AST or ALT < 150 AND no signs or symptoms of decompensated cirrhosis or severe active hepatitis**++ AST or ALT >/= 150 AND/OR signs or symptoms of decompensated cirrhosis or severe active hepatitis** Assess Current opioid Use Assess opioid withdrawal symptoms Assess last use of opioids Consider POCT utox if patient does not recall date of last use of opioids, or concern that opioids are still in the patient’s system Defer naltrexone treatment until hepatic function improves++ Active opioid withdrawal Not in active opioid withdrawal Defer naltrexone treatment until opioid withdrawal resolves Use of short-acting opioids </= 2-3 days ago, long-acting opioid use </= 7 days ago, and/or POCT utox positive for opioids Use of short-acting opioids > 2-3 days ago, long-acting opioid use > 7 days ago, POCT utox negative for opioids Discuss with patient risks of precipitated opioid withdrawal Discuss with patient that the risk of precipitated opioid withdrawal is of low likelihood High risk for opioid withdrawal (e.g. regular methadone use ended 2 days ago) Low risk for opioid withdrawal (e.g. regular opioid use ended 5 days ago) Consider PO Naltrexone Trial If patient or clinician prefers a trial of PO naltrexone with supervision due to concerns for precipitated opioid withdrawal, then give naltrexone 25mg PO once. Reassess in two hours. Defer naltrexone treatment until window of possible opioid withdrawal is over PO Naltrexone Trial Give naltrexone 25mg PO once. Reassess in two hours. Active opioid withdrawal Not in active opioid withdrawal Not in active opioid withdrawal Active opioid withdrawal Defer naltrexone treatment until opioid withdrawal window is over Defer naltrexone treatment until opioid withdrawal window is over Initiate IM Naltrexone Administer naltrexone 380mg IM x 1 and order SW consult for Urge to drink scale evaluation Provide and/or refer for psychosocial counseling Screen for and treat co-occurring mental illness and other substance use Assess candidacy for concomitant use of gabapentin Monitoring and Surveillance Administer naltrexone 380mg IM q4 weeks Frequently assess treatment efficacy, especially during stabilization period Assess LFTs: If baseline LFTs normal, LFTs q2-3 mo x 1, then consider q 6-12mo If baseline LFTs abnormal, LFTs q1-2 mo x 2 then q 3-6mo if stable * Naltrexone is Pregnancy Category C. Animal studies show that naltrexone has a potential for tumorigenicity and other serious adverse reactions in nursing infants. Naltrexone should be used in pregnant or breastfeeding women only if the potential benefits outweigh the risks. **Decompensated cirrhosis includes anyone with ascites, jaundice, hepatic encephalopathy, hepatic hydrothorax, or recent SBP/GIB related to cirrhosis. Severe active hepatitis includes anyone with acute abdominal pain, nausea, vomiting, fever, dark urine, and clay-colored stools. ++For patients whom the clinician and/or patient feels that the risk of hepatotoxicity is at least moderate, consider a trial of oral naltrexone prior to injectable naltrexone. Administer a short course (e.g. 1 week) of 25-50mg naltrexone orally daily with LFT monitoring and close follow-up (e.g. 1 week). If LFTs are normal and/or unchanged, can consider proceeding to IM naltrexone. Updated 8/02/17

Guideline for the Treatment of Alcohol Use Disorder in the Outpatient Setting with Oral Naltrexone Assess Candidacy for PO Naltrexone Meets DMS-V criteria for alcohol use disorder Patient or clinician prefers daily oral medication Not pregnant or breastfeeding* Understands opioids cannot be taken while receiving naltrexone Assess Baseline Hepatic Function Obtain baseline LFTs Assess clinically for risk factors and signs/symptoms of decompensated cirrhosis or severe active hepatitis** AST or ALT < 150 AND no signs or symptoms of decompensated cirrhosis or severe active hepatitis**++ AST or ALT >/= 150 AND/OR signs or symptoms of decompensated cirrhosis or severe active hepatitis** Assess Current opioid Use Assess opioid withdrawal symptoms Assess last use of opioids Consider POCT utox if patient does not recall date of last use of opioids, or concern that opioids are still in the patient’s system Defer naltrexone treatment until hepatic function improves++ Active opioid withdrawal Not in active opioid withdrawal Defer naltrexone treatment until opioid withdrawal window is over Use of short-acting opioids </= 2-3 days ago, long-acting opioid use </= 7 days ago, and/or POCT utox positive for opioids Use of short-acting opioids > 2-3 days ago, long-acting opioid use > 7 days ago, POCT utox negative for opioids Discuss with patient risks of precipitated opioid withdrawal Discuss with patient that the risk of precipitated opioid withdrawal is of low likelihood High risk for opioid withdrawal (e.g. regular methadone use ended 2 days ago) Low risk for opioid withdrawal (e.g. regular opioid use ended 5 days ago) Consider PO Naltrexone Trial If patient or clinician prefers a trial of PO naltrexone with supervision due to concerns for precipitated opioid withdrawal, then give naltrexone 25mg PO once. Reassess in two hours. Defer treatment until opioid withdrawal window is over PO Naltrexone Trial Give naltrexone 25mg PO once. Reassess in two hours. Active opioid withdrawal Not in active opioid withdrawal Not in active opioid withdrawal Active opioid withdrawal Defer naltrexone treatment until opioid withdrawal window is over Defer naltrexone treatment until opioid withdrawal resolves Initiate PO Naltrexone Prescribe naltrexone 50mg PO qdaily and order SW consult for Urge to drink scale evaluation Provide and/or refer for psychosocial counseling Screen for and treat co-occurring mental illness and other substance use Assess candidacy for concomitant use of gabapentin Monitoring and Surveillance Prescribe naltrexone 50mg PO qdaily Frequently assess treatment efficacy, especially during stabilization period. Assess LFTs: If baseline LFTs normal, LFTs q2-3 mo x 1, then consider q 6-12mo if normal If baseline LFTs abnormal, LFTs q1-2 mo x 2 then q 3-6mo if stable * Naltrexone is Pregnancy Category C. Animal studies show that naltrexone has a potential for tumorigenicity and other serious adverse reactions in nursing infants. Naltrexone should be used in pregnant or breastfeeding women only if the potential benefits outweigh the risks. **Decompensated cirrhosis includes anyone with ascites, jaundice, hepatic encephalopathy, hepatic hydrothorax, or recent SBP/GIB related to cirrhosis. Severe active hepatitis includes anyone with acute abdominal pain, nausea, vomiting, fever, dark urine, and clay-colored stools. ++For patients whom the clinician and/or patient feels that the risk of hepatotoxicity is at least moderate, consider a trial of oral naltrexone prior to injectable naltrexone. Administer a short course (e.g. 1 week) of 25-50mg naltrexone orally daily with LFT monitoring and close follow-up (e.g. 1 week). If LFTs are normal and/or unchanged, can consider proceeding to IM naltrexone. Updated 8/02/17