Letters
Substance‐related disorders
Volume 189 - Issue 8

Unplanned admissions to two Sydney public hospitals after naltrexone implants

Author:  D Martyn Lloyd-Jones

Med J Aust 2008; 189 (8): 468-471. || doi: 10.5694/j.1326-5377.2008.tb02127.x
Published online: 20 October 2008
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To the Editor: In their recent case series, Lintzeris and colleagues state that the symptoms leading to hospital presentation were “associated” with naltrexone implants.1

In half of the 12 cases, the symptoms were related to the induction of withdrawal rather than the presence of naltrexone — an important distinction that may not be apparent to all, but of which the authors would be aware. Three of the remaining cases reflect the complexities of pain management in patients being treated with naltrexone, which are not restricted to those with implants. This dilemma is also encountered in patients taking buprenorphine. Patient 8 had an anxiety disorder, and his symptoms probably related to an absence of opiate; and Patient 9 had symptoms that were probably due to cocaine use.

Abstinence is a patient’s choice, and naltrexone can be effective in minimising the risks associated with the consequent lowered tolerance to opioids.2

I am concerned that undue emphasis appears to have been placed on the association of adverse outcomes with implants, with such statements as: “This case series identifies severe adverse events associated with the use of naltrexone implants”. In fact, the causal condition is usually the induction of opiate withdrawal rather than the presence of a naltrexone implant.3

The statement that “Most of these cases (8/12) can be attributed to the naltrexone implant or implantation procedure” is true, but it would be more appropriate to acknowledge that the procedure appeared to be the cause in most cases and that only in one case (Patient 7) could the implant be conclusively implicated.

It is not appropriate to refer to difficulties in pain management as “severe adverse events”, as the blockade of the μ opioid receptor is the reason naltrexone is used. In addition, it is important to note that a trial of injectable naltrexone has shown promising results.4

While these facts are acknowledged by the authors, their emphasis on the association of adverse events with the presence of a naltrexone implant, rather than demonstrating causality, is concerning. Similarly, this approach appeared in Gibson and colleagues’ earlier commentary on overdose deaths in patients with naltrexone implants.5

Nonetheless, I commend the authors for raising the issues relating to the need to examine the role of naltrexone implants in treating opioid dependence and exploring alternatives to the use of rapid detoxification. I also endorse the need for thorough assessments, treatment planning and evaluation in patients undergoing such therapies.

Author

  • D Martyn Lloyd-Jones1
  • 1. St Vincent’s Hospital, Melbourne, VIC.

Correspondence: martyn.lloydjones@svhm.org.au

References

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