Naltrexone and Self-Injurious Behavior

Article excerpt

The Patient

You are working on an inpatient unit and treat a patient diagnosed with a psychotic and possible developmental disorder. After the patient takes a "fresh air" break, staff members notice that he has several cigarette burns on his fore arm. The patient says the burns were self-inflicted and gives a bizarre explanation for his actions, but assures you that he is done with burning. Nonetheless, you order one-to-one observation.' Subsequently, staffers report that although the patient has not burned himself, he has repeatedly brought the cigarette close to his skin, almost as if he is driven to burn. A peer tells you about naltrexone's potential efficacy in preventing self-injurious behavior.

The Question

What evidence exists for the use of naltrexone in reducing self-injurious behavior (SIB)?

The Analysis

PubMed (www.pubmed.gov) was searched using the phrase "naltrexone and self-injurious behavior."

The Evidence

SIB is a complex and difficult-to-treat behavioral phenomenon that occurs in a variety of psychiatric or developmental disorders. Its treatment can require extensive resources and frequent hospitalizations, and the behavior can frustrate even the best-laid discharge plans.

Dr. Vania Modesto-Lowe and Jeffrey Van Kirk reviewed the evidence for naltrexone in 2002, noting that most studies of naltrexone and SIB have examined patients with mental retardation or autism or both. They cited five open-label case reports with sample sizes of one or two patients in which SIB was reduced (Exp. Clin. Psychopharmacol. 10[3]:213-27, 2002).

Another open-label study by Augusta Roth and associates examined the rate of SIB in a sample of seven adult female psychiatric patients who were prescribed 50 mg/day of naltrexone. At 10.7 weeks, six of the seven patients entirely ceased SIB. Two patients who had discontinued naltrexone experienced resumption of SIB, with subsequent cessation upon naltrexone resumption. The seventh patient exhibited marked reduction of SIB (J. Clin. Psychiatry 57[6]:233-37, 1996).

In the largest retrospective study, J.A. Casner and associates drew on a population of 8,000 students at the Texas state schools for the mentally retarded and reviewed the cases of 56 individuals treated with naltrexone for SIB. The majority of these individuals had severe to profound mental retardation (J. Clin. Psychopharmacol. 16[5]:389-94, 1996).

Patients were treated with naltrexone at dosages of 25-300 mg/day (average 96.8 mg/day) for 3-87 months. According to the clinical impression of treating professionals, 57% of patients were considered responders. According to blind reviewers, 25% of patients were considered "objective responders." An objective responder was defined as an individual whose SIB decreased by at least 50% on naltrexone. …