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There is experimental evidence of µ‐opioid receptor upregulation following antagonist
withdrawal (Millan et al, 1988) and abrupt discontinuation of naltrexone may therefore lead
to a period of increased opioid sensitivity (Vickers & Jolly, 2006). As the effect of naltrexone
diminishes after it has been ceased, the amount of opioid required to maintain analgesia may
also need to be decreased in order to avoid signs of excessive opioid dose (in particular,
respiratory depression).
Reintroduction of naltrexone should be done in consultation with the prescribing practitioner.
11.8.5 Recovering patients
Patients in drug treatment programs or in drug‐free recovery may be concerned about the risk
of relapse if they are given opioids for the management of their acute pain. However, there is
no evidence that the use of opioids to treat acute pain increases the rate of relapse; a more
likely trigger is unrelieved pain (Alford et al, 2006). Effective communication and planning, the
use of multimodal analgesic strategies, reassurance that the risk of reversion to an active
addiction disorder is small, and information that ineffective analgesia can paradoxically lead to
relapses in recovering patients, are important and help avoid under treatment (Mitra & Sinatra,
2004).
Key messages
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
Naltrexone should be stopped at least 24 hours prior to elective surgery (U).
Patients who have completed naltrexone therapy should be regarded as opioid naive; in
the immediate post‐treatment phase they may be opioid‐sensitive (U).
Maintenance methadone regimens should be continued where possible (U).
Buprenorphine maintenance may be continued; if buprenorphine is ceased prior to surgery
conversion to an alternative opioid is required (U).
There is no cross‐tolerance between central nervous system stimulants and opioids (U).
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