Extended-Release Naltrexone Decreases Return to Opioid Use Among Individuals Involved with the Criminal Justice System

Release from incarceration poses a vulnerable time for return to opioid use, overdose, and death among people with opioid use disorder (OUD). Barriers to widespread implementation of opioid agonist treatment (OAT) in this population include lack of availability and patient preference. Researchers examined the effectiveness of 24 weeks of extended-release naltrexone compared with usual care (brief counseling and referral to community treatment) among 308 community-dwelling criminal justice offenders who were at high risk for return to opioid use. Participants had OUD, were opioid-free at the time of randomization, and preferred non-OAT approaches to treatment. All participants were encouraged to access community treatment and resources to prevent return to opioid use, including buprenorphine or methadone treatment if preferred or indicated during the trial and after the 24-week treatment phase.

• During the 24-week treatment phase, participants assigned to extended-release naltrexone had a longer median time to return to ≥ 10 days of opioid use (10.5 versus 5 weeks), a lower rate of return to such use (43% versus 64%), and a higher rate of opioid-negative urine samples (74% versus 56%), compared with usual care.
• Compared with the extended-release naltrexone group, more participants in the usual care group pursued OAT during the trial (11% versus 37%), primarily after returning to opioid use.
• At week 78, the proportions of opioid-negative urine samples were equal (46% in each group).
• There were more medication-related adverse events in the treatment group including injection site reaction, GI upset, and headache. Opioid overdose (fatal and non-fatal) was examined as an adverse event over 78 weeks of observation. There were no overdose events reported in the extended-release naltrexone group and 7 (3 fatal) in the usual care group.

Comments:

This trial demonstrated the effectiveness of extended-release naltrexone in decreasing return to regular opioid use during the 24-week treatment phase, which did not persist beyond the active treatment phase. Studies investigating the use of extended-release naltrexone immediately upon release from incarceration and studies directly comparing the use of extended-release naltrexone with OAT in this population are needed, but may not be feasible due to patient preference for treatment modality.

Jeanette M. Tetrault, MD

Reference:

Lee JD, Friedmann PD, Kinlock TW, et al. Extended-release naltrexone to prevent opioid relapse in criminal justice offenders. N Engl J Med. 2016;374(13):1232–1242.