After assessing the appropriateness of the patient for the outpatient treatment the clinician needs to determine which treatment may be most appropriate at that time and engage the patient in a shared decision-making. I would start with evaluating prior treatment history, have they previously tried any of the medication(s), was it effective and well-tolerated? If people were treated in the past with buprenorphine and were successful then that might be your first line of treatment. For those with difficulty adhering to daily buprenorphine, and those that did not stabilize (still had cravings, continued to use on top of the buprenorphine) or were misusing or diverting the medication then you might consider treatment with XR-naltrexone. Alternatively you may try a higher dose of buprenorphine or buprenorphine under supervision. Another issue is the frequency of monitoring, many patients cannot come to the clinic weekly (if necessary), and since XR-naltrexone is given once a month that gives you more flexibility for patients living in a remote areas. Insurance coverage always has to be considered as well. It’s important to explain the differences to the patient so they have a clear understanding of the differences between the medications.
Patients tend to overestimate the risk of painful conditions that would necessitate acute treatment with opioids. For acute pain, the anesthesiologist can mange pain well using high-potency opioids or non-opioid strategies. For non-acute pain, blocks work extremely well and should be recommended. For most patients we’ve treated they didn’t need acute opioid analgesia and could wait if they had to have scheduled surgical procedures.
There have been controlled trials done where patients were unaware if they are receiving active naltrexone or placebos. Within the first week, patients treated with naltrexone reported less craving, even though they did not use opioids so they had no way to tell if they were treated with active naltrexone. We often see patients with very little cravings during the first week after the injection, though they are certainly patients who continue to have cravings, albeit diministed, since they do not experience opioid withdrawal. Not every patient on naltrexone will have reduction of cravings just as not every buprenorphine patient will have reduction of cravings.
