It was very gratifying to see Benjamin* for his naltrexone implant follow up appointment earlier this month. He first came to the Coleman Institute-Richmond for his rapid opioid detox about eight months ago to get off methadone.

Ben is in his thirties and works full time in a job that he doesn’t love, but suits him well enough for now. He lives with his 2 year old daughter and her mother. He goes to the gym most days. He did some counseling when he was newly sober and he attends the occasional 12-step recovery meeting. He avoids contact with people he knows who are actively using drugs.

He said the first 3 to 4 months were not easy. He says he drank a lot of alcohol and smoked a lot of pot in those first months. And then, at his counselor’s suggestion, he decided to see how he felt without using anything. He admits to being somewhat surprised to realize that he actually felt pretty good- he was able to sleep, had a good appetite and plenty of energy for work, family and fun.

In short, life is really, really good. He can’t believe how great it is to be off methadone.

His big question now: When to stop the naltrexone?

Currently Ben gets a naltrexone implant every two months. Naltrexone is a pure opioid antagonist, or blocker. With the Coleman Institute’s naltrexone implant, all the opiate (mu) receptors are filled continuously for about two months. Therefore, the body actually feels no cravings for opiates. Even if someone took the random pain pill with the naltrexone pellet intact inside them, there would be no effect.

When the naltrexone wears off, there is no withdrawal because it is not an opioid like methadone or a partial agonist like buprenorphine. However, because the body has not had opiates for at least two months, tolerance is reduced, and a person can be very susceptible to overdose if they choose to use opioids again, particularly if they are injecting.

There is not a one-answer-fits-all for when to stop naltrexone and it is important to consider many factors.

Just wanting to stay clean and feeling passionate about it may not be enough. Many of our successful patients come to realize that often when they used their drug of choice, they were avoiding dealing with some kind of problem, big or small. When the drug use stopped, they were left with the reality of their problems. Learning coping skills and problem solving while dealing with the physical aspects of early sobriety can be challenging. (I asked Ben what it was like to parent a 2 year old while he’s sober—he laughed and said, a lot harder!)

This is why we strongly encourage our patients, and assist them to find meaningful counseling/therapy/support while keeping naltrexone on board as the brain heals and begins to create its own endorphins again. For many people, we recommend using naltrexone for at least a year. That’s Ben’s plan right now, but he is open to suggestions. He doesn’t want to go back to a life of opiate dependence.

Please feel free to call me or any of our team if you have any questions about the pros and cons of using naltrexone therapy.

Joan R. Shepherd, FNP

v*Not his real name