1. 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

2. 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