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Naltrexone, opiates, self-injurious behaviors, and dissociation

From: "Joseph R. Volpicelli" <volp@cattell.psych.upenn.edu>
Subject: Naltrexone for self-injurious behaviors
Date: Tue, 28 Feb 1995 16:48:56 -0500 (EST)

I have anecdotally heard that opioid antagonists such as naltrexone have been reported as being helpful for self-mutilative behaviors. Travis Thompson at Vanderbilt has published some on this.

--Bob Swift

I have treated an alcohol dependent woman with borderline personality disorder who engaged in a variety of self-mutilative behaviors such as chronic arm cutting. While taking naltrexone (I believe at 150 mg/day) she stopped both her alcohol drinking and cutting. It is hard to tease out the effects of naltrexone on the arm cutting independently of naltrexone's effect on her alcohol drinking, but she reported she recieved less pleasure from both activities while on naltrexone.

From: Robert G Ruegg <ruegg@med.unc.edu>
Subject: Naltrexone for self-injurious behaviors
Date: Wed, 1 Mar 95 15:01:29 EST

I treated a severely cutting borderline lady with it. She said it now hurt when she cut. But she kept cutting. By the way, she is now much better on high dose SSRIs and dialectical behavior therapy.

Date: Fri, 9 Jun 1995 19:51:36 -0400
From: Aminadav_Zakai@brown.edu (Aminadav Zakai)
Subject: Opiates for dissociation

I have an interest in the association between dissociation and other PTSD sx and opiate use.

[In] Vietnam veterans with PTSD the history of opiate abuse is common. Many of my females with severe early abuse histories and multiple personality disorder, borderline personality disorder or PTSD have a pain syndrome that requires opiates. In many of these cases I see or hear a history of improvement of PTSD and dissociative symptoms while using an opiate. Other clinicians and researchers in the field seem to support this impression.

There is some research showing opiate mediated analgesia during traumatic arousal. It is clear that opiates are an important regulatory system that play some role in PTSD and therefore these patients seem to like it.

Subject: Naltrexone, opiates, self-injurious behaviors, and dissociation
From: eliot.gelwan@channel1.com (Eliot Gelwan)
Date: Sat, 10 Jun 1995 18:36:00 -0500

On the other hand, there is some data on naltrexone as a successful treatment for self-injurious behavior in patients with dissociative/borderline conditions. Van der Kolk and others postulate that the trauma victim is "addicted" to her/his endogenous opiates after the dramatic exposure to them during traumatic experiences. Thrill seeking and self-abuse are an attempt to re-engender high endorphin levels. If I understand correctly, naltrexone de-conditions the reinforcement associated with SIB over time, by blocking the "reward."

From: Tmortalc@aol.com (M. Meade, MD)
Date: Mon, 12 Jun 1995 12:29:44 -0400
Subject: Naltrexone, opiates, and self-injurious behaviors

About 10 years ago I was peripherally involved with some research on the drug buprenorphine (a partial mu opiate agonist). SL administration of this drug produced rapid and pronounced alleviation of chronic dysphoria in a small sample of pts diagnosed with borderline personality disorder. I believe this to be adjuntive evidence which might support a trial of naltrexone in such pts, and which also lends credence to [the] earlier suggestion that opiate agonism may relieve the "psychic" pain found in such pts, pain which, presumably, expresses itself in self-mutilatory behaviors.

Date: 26 Dec 95 15:40:20 EST
From: manish a fozdar <102563.3223@compuserve.com>
Subject: Opiate antagonists for self-injurious behaviors

A useful reference is:

The use of opiate antagonists for recurrent self-injurious behavior: Buzan RD, Thomas M et al. Journal of Neuropsychiatry and Clinical Neurosciences, 7 (4): 437-444.

From: RROUBAIX@aol.com (Robert Rubey MD)
Date: Wed, 27 Dec 1995 16:52:12 -0500
Subject: Naltrexone for self-injurious behaviors

We treated a series of five patients with borderline personality disorder and self-mutilation with naltrexone, and four out of five showed dramatic improvement. They were treated in an A-B-A design, and the results are due to be reported in the J of Nervous and Mental Disease. Parenthetically, a neurologist here became interested in this and tried naltrexone in a patient with Prader-Willi who was self-abusing, with negative results.

From: JASONR@vms.cis.pitt.edu (Jason Rosenstock)
Date: Fri, 25 Oct 1996 09:24:27 -0500 (EST)
Subject: Naltrexone for self-injurious behaviors

There's an article out in the Oct 96 J. Clin. Psychopharm, 16 (5): 389-394, by JA Casner et al. entitled "Naltrexone and Self-Injurious Behavior: A Retrospective Population Study" looking at naltrexone in 56 MR pts in Texas state schools. In this naturalistic sample, about half showed enough improvement to stay on the med indefinitely, and one-quarter showed clear and "unequivocal" response (measured as less self-injurious behavior). The authors were surprised to find that everyone in that latter group showed continued declines in SIB even after 3 years on the med. I thought the study was pretty suggestive (and well-written to boot).

From: cprice@mem.po.com (Charles Sowle Price, MD)
Date: Sat, 26 Oct 1996 01:17:34 -0400
Subject: Naltrexone, opiates, and self-injurious behaviors

Because it has been hypothesized that dysregulation of opiatergic systems may play a role in aggression, the opiate antagonists naloxone and naltrexone have been tested for treatment of self-injurious behavior unrelated to suicidality.

Candilis P. The Pharmacology of Violence. American Society of Clinical Psychopharmacology Progress Notes 1996, 7 (2).

Konicki PE, Schulz C. Rationale for clinical trials of opiate antagonists in treating patients with personality disorders and self-injurious behavior. Psychopharmacol Bull 1989, 25: 556-563.

Date: 30 Oct 96 09:08:36 EST
From: manish a fozdar <102563.3223@compuserve.com>
Subject: Naltrexone for self-injurious behaviors

Naltrexone is generally used for self-injurious behaviors, i.e., self-directed, as opposed to externally-directed, aggression. There are no controlled or good studies available. Most are case reports or case series reports.

In our own experience at Allegheny General Hospital's PADD (Program for Adults with Developmental Disabilities) unit, we have had little success with naltrexone use in pts with MR and SIB.

From: Magdeburg1@aol.com (Marilyn Walls)
Date: Wed, 30 Oct 1996 11:58:06 -0500
Subject: Naltrexone for self-injurious behaviors

There were several controlled studies investigating the effects of naltrexone on SIB in mentally retarded adults a few years ago. The results were mixed, but in general SIB was reduced. See Sandman, Hetrick, and Taylor for the studies.

Date: 31 Oct 96 08:28:25 EST
From: Stephen Bazire <101326.1546@compuserve.com>
Subject: Naltrexone for self-injurious behaviors

At the UK Psychiatric Pharmacy Conference in London in October there was a pharmacist from Sunderland (Senior Lecturer at Sunderland University) who has a son with autism. He has been doing a lot of research on the topic. His main thought about naltrexone was that it definitely reduced SIB but that you didn't need any more than 12.5-25 mg/d. Higher doses can be counterproductive. Most of the case studies and trials in fact use 50-100 mg/d.

I myself recall a chap who did very well on 50 mg/d and then continued OK on 25 mg/d.

From: Magdeburg1@aol.com (Marilyn Walls)
Date: Sat, 2 Nov 1996 12:09:31 -0500
Subject: Naltrexone for self-injurious behaviors

Here are those references. Most of these studies were conducted at Fairview State Developmental Center in Costa Mesa, California (I worked in Curt Sandman's lab there as an undergraduate). It is quite possible that Dr. Sandman is still investigating in this area.

Sandman C, Hetrick W. (1993) Naltrexone reduces self-injury and improves learning. Experimental & Clinical Psychopharmacology, 1, 242-258

Taylor D, Sandman C. (1993) Naltrexone improves learning and attention in self-injurious individuals with developmental disabilities. Special Issue: Pharmacotherapy: I Journal of Developmental & Physical Disabilities, 5, 29-42

Ricketts RW, Goza A. (1992) Effects of naltrexone and SIBIS on self injury. Behavioral Residential Treatment, 7, 57-63

Sandman C. (1990-91) The opiate hypothesis in autism and self-injury. Journal of Child & Adolescent Psychopharmacology, 1, 237-248

Sandman C, Barron J. (1990) An orally administered opiate blocker, naltrexone, attenuates self-injurious behavior. American Journal on Mental Retardation, 95, 93-103

Sandman C et al. (1983) Naloxone attenuates self-abusive behavior in developmentally disabled clients. Applied Research in Mental Retardation, 4, 5-11

Date: Sun, 01 Dec 1996 20:57:53 -0600
From: "Richard Rubin, MD" <rdoc@mindspring.com>
Subject: Naltrexone for alcoholism and self-injurious behaviors

The only two patients to whom I've prescribed naltrexone were both female alcoholics with OCD and self-injurious behaviors approaching excoriation.

One patient has been clean and sober for about 16 months, attends AA, takes fluvoxamine 600 mg per day and naltrexone 50 mg per day, and says this is the first time as an adult that she has not felt insane.

The other lady takes fluoxetine 80 mg per day along with her naltrexone 50 per day and is also clean and sober. At first, she thought that she was not getting any relief from the naltrexone and discontinued using it. Within 3 days the SIB (picking) was so bad that she resumed the naltrexone immediately. She continues to pick but not nearly so extensively. Somnolence keeps us from increasing the naltrexone.

BTW, the first time I wrote this I prescribed Trexan. The pharmacist told my patient they didn't make that medicine any more and that when they did it was for the treatment of narcotics addicts. It took most of the next session to convince her to try the medication.

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[dr. bob] Dr. Bob is Robert Hsiung, MD, dr-bob@uchicago.edu

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