Naltrexone

By Florin Onighi for GuardYourEyes

Does Naltrexone reduce problematic pornography use?

Summary

Review question

This review aimed to find out if Naltrexone treatment is better than nothing or CBT for reducing problematic pornography use in nonparaphilic, nonforensic individuals. The main outcome was the use of pornography.

Background

In treating individuals with problematic pornography use and Compulsive Sexual Behavior Disorder (CBSD), case reports studies suggest the efficacy of pharmacological interventions. Drugs targeting dopamine, norepinephrine, serotonin, and opioidergic systems have shown efficacy to varying degrees.

Naltrexone is an opioid receptor antagonist and an inhibitor that blocks dopaminergic release in the brain, acting on the reward system. Naltrexone has been FDA-approved for the treatment of alcohol and opioid use disorders and has been shown to be effective in the treatment of alcohol and opioid addiction (Capurso, 2017).

Search date

2015 to present.

Study characteristics

Two independent case reports and one prospective trial have examined Naltrexone effectiveness in treating problematic pornography use.

Key results

Study	Kraus et al. 2015	Capurso, 2017	Savard et al., 2020 (in press)
Participants	One patient: married, employed, heterosexual male veteran in his 30s who sought treatment for problematic Internet pornography viewing.	One  patient: 69-year-old single, retired male with a history of generalized anxiety disorder, alcohol use disorder in full sustained remission, tobacco use disorder, and problematic pornography use.	20 men aged 27-60 years (mean age = 38.8 years) with CSBD, seeking treatment in an outpatient nonforensic clinic.
Dropouts	0	1	0
Intervention	Individual cognitive-behavioral therapy with self-monitoring (daily worksheets assessing urges to view Internet pornography and whether the patient had viewed and masturbated to pornography). Naltrexone, 50 mg	Self-monitoring (2 weeks tracking time spent watching pornography and the number of cigarettes smoked). Naltrexone, 50 mg	Naltrexone, 50 mg
Treatment duration	18 weeks (Naltraxone treatment started at week 10)	4 weeks (2 weeks of treatment with Naltrexone)	4 weeks
Diagnostic criteria	Problematic internet pornography viewing (number of days using pornography each week) Urges/craving to masturbate to pornography (1 = no urge, 7 = intense urge)	Problematic pornography use (daily avarage time spent watching pornography; abstinence from watching pornography)	Hypersexual Disorder: Current Assessment Scale (HD: CAS) with baseline masturbation (95%) and pornography use (85%) Hypersexual Behavior Inventory (HBI) Compulsive Sexual Behavior Scale (SCS)
Outcome	70% reduction in baseline use of pornography with CBT but the patient continued to report frequent sexual urges to masturbate to Internet pornography. Within 2 weeks of initiating Naltrexone medication, the patiend reported subjective decreases in his urges to masturbate to pornography (see Figure 1 in the Appendix). 36% decrease in the intensity of sexual urges during the 9 weeks of naltrexone treatment. 70% reduction in pornography use (the patient also resumed regular, satisfactory sexual intercourse with his wife).	85% decrease in pornography use (from 105 minutes to 16 minutes daily). 67% reduction in the number of cigarettes smoked daily (from 30 to 10 cigarettes). Two weeks after naltrexone initiation, the patient was abstinent for 78% of the time (e.g. he  did not watch pornography for 11 of the 14 days of the treatment with Naltrexone). Pornography viewing and cigarette consumption returned to baseline within several days of stopping the medication.	54% decrease in HD:CAS scores with similar results on HBI and SCS. Some of the effects remained 4 weeks after discontinuation with naltrexone although worsening of CSBD symptoms overall after discontinuation of Naltrexone treatment was reported.
Adverse effects	No adverse effects were reported.	The patient discontinued Naltrexone after two weeks, citing the adverse effect of anhedonia (inability to feel pleasure in normally pleasurable activities). Note: anhedonia is not a typical side effect of naltrexone, although a large meta-analysis (N = 2564) did find a modest increase in neuropsychiatric effects compared to placebo (Capurso, 2017).	19 participants (95%) reported some adverse event. Most common: fatigue (55%) nausea (30%), vertigo (30%) abdominal pain (30%) No pathological raise of liver function tests. No serious adverse effects leading to discontinuation of naltrexone medication.
Adherence to treatment and tolerability	Not reported.	Adherence was not reported. The dose was decreased to 25 mg daily with the goal of mitigating side effects (anhedonia) with unsuccessful results (e.g. the patient  still reported experiencing anhedonia on the lowered dose and the medication was therefore discontinued). At a 25mg dose, pornography use was modestly decreased to 1.25 hours per night but smoking returned to baseline. (see also Figure 2 in the Appendix).	All participants declared that they had taken naltrexone during the study period of 4 weeks. When asked if interested in resuming naltrexone therapy, participants responded: yes (30%), no (15%) and, I don’t know (55%). The partially maintained reduction of CSBD symptoms at follow-up and thus less need for treatment may also contribute to the hesitation.
Implications for treatment	This case suggests that Naltrexone may be a useful adjunctive treatment for patients reporting difficulty managing sexual behaviors, such as excessive viewing of Internet pornography.	As the efficacy of naltrexone in treating both disorders in this patient is notable, this case suggests that this might be a fruitful approach in reducing problematic pornography use.	Despite side effects being common, this trial suggests that  naltrexone seems to be feasible in the treatment of CSBD.
Strengths & Limitations	The study did not employ a reversal design with the patient (e.g. CBT-naltrexone-CBT). Single case report.	Possible interactions of Naltrexone with patients’ anxiety treatment (imipramine 200 mg daily and lorazepam 0.5 mg twice daily) were not examined. Single case report.	Strengths: the first nonforensic prospective trial on naltrexone in CSBD. Limitations: small sample size, lack of a control group/ not placebo-controlled, relatively short treatment and follow-up periods

Conclusions

Naltraxone can be a feasible and tolerable treatment that may reduce pornography use and symptoms of CSBD by more than 50%. However, significant side effects were reported by almost all participants (95%), most commonly fatigue. Moreover, a large number of participants were uncertain when asked about interest in resuming treatment with naltrexone at the end of the prospective trial; in one case report (Capurso, 2017), the patient discontinued the medication with Naltrexone after two weeks of treatment.

The decrease of CSBD symptoms with a Naltrexone treatment in the trial by Savard et al. (2020) corresponds to the decrease after CBT therapy group intervention reported by Hallberg et al. (2019). Savard et al. (2020) reported that many participants in the trial were keen on having information on other available treatments, including CBT. These results suggest that CBT should be a first-line treatment, if accessible and suitable.  

In conclusion, the effectiveness of Naltrexone for the treatment of problematic pornography use should be treated with caution as double-blind, randomized, placebo-controlled trials evaluating Naltrezone’s efficacy and tolerability have not yet been conducted.  

References

• Capurso, N.A., 2017. Naltrexone for the treatment of comorbid tobacco and pornography addiction. The American journal on addictions, 26(2), pp.115-117.
• Hallberg, J., Kaldo, V., Arver, S., Dhejne, C., Jokinen, J. and Öberg, K.G., 2019. A randomized controlled study of group-administered cognitive behavioral therapy for hypersexual disorder in men. The journal of sexual medicine, 16(5), pp.733-745.
• Kraus, S.W., Meshberg-Cohen, S., Martino, S., Quinones, L.J. and Potenza, M.N., 2015. Treatment of compulsive pornography use with naltrexone: A case report. American Journal of Psychiatry, 172(12), pp.1260-1261.
• Savard, J., Öberg, K.G., Chatzittofis, A., Dhejne, C., Arver, S. and Jokinen, J., 2020. Naltrexone in Compulsive Sexual Behavior Disorder: A Feasibility Study of Twenty Men. The Journal of Sexual Medicine.
• Appendix
• Figure 1. Mean Scores of Craving for Pornography and Number of Days Viewed Pornography Each Week Pre- and Post-Naltrexone (50 mg/day) in Kraus et al. (2015) case report
• Figure 2. Response to treatment with naltrexone in Capurso (2017) case report: time spent watching pornography decreased in a dose-dependent manner in response to naltrexone.  The number cigarettes smoked per day decreased only on the higher dose of naltrexone.
• Figure 3. HD:CAS mean scores at baseline and after treatment (n = 20) in Savard et al. (2020) study (HD:CAS = Hypersexual Disorder: Current Assessment Scale)