Managing Sedation, Analgesia in Critically Ill Patients Receiving Naltrexone

Long-acting naltrexone is a promising approach for opioid use disorder (OUD), but its use has clinical implications in critically ill patients who are receiving sedation and analgesia, according to a review article published in the Annals of the American Thoracic Society.

Naltrexone may interfere with or complicate sedation and analgesia in patients who are critically ill, and recommendations are needed to manage long-acting naltrexone use in this patient population.

Therefore, a small group of researchers from Boston convened to develop recommendations on management of sedation and analgesia in critically ill patients receiving naltrexone for OUD. Recommendations were based on a literature view, consultation with pharmacists and clinical chemists, and information from the researchers’ own experience as critical care physicians.

Assessment of a patient’s medical history, medical records, and/or physical examination is critical for early identification of patients receiving long-acting naltrexone, the authors suggested. Developing an analgesia strategy relies on understanding the timing of the last naltrexone exposure. This can also help in prediction of potential risks of opioid administration. To confirm exposure, laboratory testing may be necessary. Laboratory testing, however, does not offer insight into duration of naltrexone exposure.

Healthcare professionals should work to maximize non-opioid analgesia, if possible, when providing analgesia. Opioids may be helpful in cases where severe pain is present or when sedation is required; however, the researchers suggested they should only be used “with substantial caution and diligent monitoring.” The initial administration of short-acting opioids is favored to test the patient’s response.

For patients within 4 weeks of their last naltrexone injection, the authors of this review also recommended close monitoring with waveform capnography, low-ratio nursing, and consideration of nasal trumpet placement to maintain airway patency in patients not already intubated. A controlled mode of ventilation was recommended for patients with a secure airway in place already receiving mechanical ventilation. Frequent assessment of pain was also recommended for all patients receiving long-acting naltrexone because of concerns regarding hyperalgesia.

While the review authors suggested updated clinical practice guidelines are needed, they “encourage case reporting of management of patients on long-acting naltrexone given the limited evidence regarding optimal management of these patients in the critical care setting.”

Reference

Petri CR, Richards JB. Management of sedation and analgesia in critically ill patients receiving long-acting naltrexone therapy for opioid use disorder. Published online August 31, 2020. Ann Am Thorac Soc. doi:10.1513/AnnalsATS.202005-554CME