Summary: One of the drugs used to treat substance abuse, naltrexone, is quite good for managing intractable pain and works at a low dose. Moreover, low-dose naltrexone (LDN) therapy works even better when used with other drugs like anti-inflammatory medications and drugs used to treat neuropathic pain. However, its concurrent use with opioids is not recommended due to severe side effects or interaction risk. Intractable pain is among the most challenging pain syndromes to treat. Quite often, doctors need to prescribe opioids to manage such pain. However, opioids cause many side effects.
Among chronic pains, nothing is more challenging to treat than intractable pain. As the name suggests, it is not just pain but a condition that is challenging to treat with traditional painkillers. People living with intractable pain continue to experience pain, even when the condition that caused pain initially has been cured. Doctors do not fully understand why some people continue to experience intractable pain. However, they think such pain occurs due to neuroinflammation, spinal inflammation, and changes in certain brain centers.
Hence, intractable pain requires quite a different treatment approach compared to pains that occur due to other reasons like low back pain, arthritis, or rheumatological conditions. However, very few options currently exist to provide satisfactory relief for intractable pain. That is why regulatory agencies in some US states have identified intractable pain as a distinct kind of health problem that is different from chronic pain and a condition that justifies prolonged opioid therapy.
However, issues related to prolonged opioid use are not a secret. First, people become addicted to these drugs. Not only that, these drugs cause hyperalgesia, and thus people need to increase their dose over time, further increasing the risk of side effects. However, it appears that researchers have now identified a novel way to manage intractable pain. Using low-dose naltrexone (LDN) is one of the emerging therapies for intractable and chronic pain treatment.
Naltrexone is an old and well-known medication used to treat substance abuse, and it is also good for treating opioid abuse and even reversing some of the side effects of opioids. However, now researchers have found that when used at lower dosages, it can be an excellent painkiller that also helps lower inflammation of spinal and brain tissues and even boost immunity.
This use of LDN to manage intractable pain is still an off-label use. It means the US FDA has still not approved it for such use. Nonetheless, its use is justified due to its excellent safety profile. Moreover, the clinical safety of the drug is well established. The only limitation of this drug is that it should not be used along with opioids since it would reduce the impact of opioids and may have certain unpleasant interactions with these drugs.
Doctors generally use 0.5 to 1 milligrams of Naltrexone medication twice daily to manage intractable pain. Using LDN may help intractable pain without the need for opioids. It seems that LDN is good to use along with other medications like gabapentin used for neuropathic pains, Adderall, Mucuna, and other medications. Doctors may also recommend low-dose naltrexone (LDN) for pain relief along with standard anti-inflammatory medications like ketorolac.
LDN can have significant results in case of complex regional pain syndrome (CRPS) treatment and sciatica nerve pain relief. It appears that LDN is quite beneficial when used consistently for a long period, along with other less toxic painkillers. In addition, unlike other drugs, LDN has the ability to modulate intractable pain by altering immune responses and reducing neuro-inflammation. Thus, in the long run, it may help achieve complete remission of intractable pain.
As already mentioned, it is not good to use LDN with opioids, as it can interact with these medications in an unpleasant way. However, doctors may use synthetic opioids in a low dose during pain flares. Its long-term use along with high-dose opioids, though, is not recommended due to the risk of some severe side effects. Those taking opioids can also be switched to LDN therapy. However, such patients would first need to discontinue opioid use. Studies show that some patients may become severely ill if they take LDN while using opioids.
Since LDN is still an experimental therapy, researchers say that if a person is experiencing satisfactory pain relief from opioids, then there is no reason to switch to LDN.
Frequently asked questions
Can naltrexone be used for pain?
Yes, at a low dose. Naltrexone is an old drug for substance abuse, but at low doses it works as a painkiller and lowers inflammation in spinal and brain tissue. This is an off-label use: the FDA has not approved naltrexone for pain. Doctors use it anyway because its clinical safety is well established, and it gives people with intractable pain an option that does not depend on opioids.
What kind of pain does low-dose naltrexone help?
Its main target is intractable pain, the kind that keeps going after the original injury or illness has healed and that ordinary painkillers do not touch. Doctors link that pain to neuroinflammation, spinal inflammation and changes in brain centers, and LDN works by calming that inflammation. It can produce significant results in complex regional pain syndrome (CRPS) and sciatica nerve pain, especially when taken consistently over a long period.
Can you take low-dose naltrexone with opioid painkillers?
No. Naltrexone reduces the effect of opioids, and taking the two together can cause unpleasant interactions; some patients become severely ill. A patient on opioids can be switched to LDN, but the opioids have to be stopped first. If opioids are already giving you satisfactory relief, researchers see no reason to switch.
Can low-dose naltrexone be combined with other pain medications?
Yes, and it often works better that way. LDN pairs well with gabapentin for nerve pain and with standard anti-inflammatory medications such as ketorolac. Using it alongside these less toxic painkillers, rather than opioids, is how it is meant to be used over the long term. Your physician chooses the combination based on the type of pain you have and the medications you already take.
Dr. Gurpreet Singh Padda, MD, MBA, MHP
