Stopping the Pain: Naltrexone for Self-injurious Behavior

Sarah Melton, PharmD

Disclosures

April 10, 2017

Question

Is oral naltrexone an effective pharmacologic option in the treatment and reduction of self-harm?

Response from Sarah T. Melton, PharmD
Professor of Pharmacy Practice, Gatton College of Pharmacy, East Tennessee State University; Clinical Pharmacist, Johnson City Community Health Center, Johnson City, Tennessee

According to the Diagnostic and Statistical Manual of Mental Disorders, nonsuicidal self-injury disorder is any deliberate behavior designed to cause destruction of one's own body surface.[1] Cutting, carving, scratching, burning, and punching/hitting are among the classic self-injurious behaviors (SIBs).[2]

Although not synonymous with suicidal behavior, self-harm has an associated risk for increased suicide attempts and is usually a sign of an inability to manage psychological pain.[1,2]

Through the act of self-injury, the person may be trying to relieve anxiety or distress or to feel a sense of control over his or her own body or life. Risk factors include young and impressionable age, having friends who participate in self-harming activities, history of physical or emotional abuse, or concomitant mental health disorders.[1,3] SIB among children and adolescents with intellectual and developmental disabilities is relatively common and often persistent.[4]

Approximately 4% of the general population and 35% of college students in the United States have reported experimenting with self-harm on at least one occasion.[2,5]

Treatment Intervention

Healthcare providers have the opportunity for treatment intervention by recognizing the behavior, providing referrals for psychotherapy, or prescribing evidence-based pharmacotherapy.

Psychotherapy, also known as talk therapy or psychological counseling, can help the patient identify and cope with the fundamental issues that caused self-harm in the first place, as well as provide the skills to manage stress and depression.[5]

While various forms of psychotherapy, including cognitive behavioral therapy, are the first-line treatment of SIB, medications may be beneficial in treating concomitant mental health disorders, such as borderline personality disorder, anxiety, and depression.[6]

SIB is a poorly understood condition; however, the endogenous opioid system plays a central role in repetitive self-injury. Elevated endogenous opioids are responsible for maintaining SIB, and it is thought that by blocking the reward experienced, SIB could be reduced.[7]

Naltrexone, although not indicated for SIB, acts as a competitive antagonist at opioid receptor sites, making it a possible pharmacologic option in the treatment and reduction of self-harm. Currently, naltrexone is approved by the US Food and Drug Administration only for the treatment of alcohol or opioid dependence.[8]

An open-label trial including seven female patients with SIB was conducted with all patients receiving 50 mg/day of naltrexone.[9] Throughout the 10-week follow-up period, all patients demonstrated a reduction in SIB, and six of the patients discontinued self-harm completely. Of note, four of the seven patients attempted self-mutilation while taking naltrexone and reported that the injurious acts no longer provided emotionally analgesic properties.

A case report of a male patient with SIB who was unresponsive to treatment with sertraline, doxepin, valproate, and risperidone described a response to naltrexone.[10] After starting 50 mg/day of naltrexone, the patient abstained from SIB during a 32-week follow-up period.

A recent Cochrane review of pharmacologic interventions for SIB in adults with intellectual disabilities evaluated outcomes in naltrexone trials.[4] The review reported conflicting evidence on the efficacy of naltrexone. A quantitative synthesis was performed evaluating peer-reviewed literature from 1983 to 2003 that documented the use of naltrexone for SIB in patients with developmental disabilities. Improvement relative to baseline (ie, SIB reduced) was reported in 80% of patients with naltrexone treatment; 47% of SIB was reduced by 50% or greater. In the studies that reported dosing in milligrams, males were more likely than females to respond.[11]

The off-label use of naltrexone for SIB is not free of potential dangers. Contraindications to naltrexone use include existing liver dysfunction and the use or possible use of opioids. Risks and benefits of naltrexone should be evaluated before prescribing.

Although commonly used empirically in clinical practice, evidence supporting the use of naltrexone for the treatment of SIB is scant. Overall, literature suggests consideration of naltrexone when self-injury is refractory to first-line psychopharmacologic and behavioral interventions. In current studies conducted in adults, 50 mg/day is the most common starting dose, while studies in children and adolescents most commonly used variable starting doses of 0.5-2 mg/kg/day.[12] In general, response is seen within days of initiation, but some studies reported symptoms decreasing after months of treatment.[12]

It is important to note that paradoxic increases of SIB following naltrexone treatment have been reported, so discontinuation is warranted if SIB does not decrease or resolve from baseline.[13]

Dr Melton acknowledges the research assistance of Kelley Fowler, PharmD candidate, and Holly Gilliam, PharmD candidate.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....