Thursday, August 19, 2010

Low Dose Naltrexone (LDN)



Naltrexone seems to be a pretty amazing drug. At regular strength it is able to completely block the opiate receptors which decreases the craving for a number of addictive drugs and prevents relapse back to opiates. At lower doses it seems to be able to help with a number of conditions ranging from helping with infections and immune disorders and even helping body builders recover from an intensive workout.

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Here at TCI, we have been using oral Naltrexone for over 20 years now. For over 12 years we have been using Naltrexone in our implants. The Naltrexone implants block all of the opiate receptors and this dramatically decreases cravings and prevents patients relapsing back to addictive opiate use. It helps both alcoholics and opiate addicts stay in recovery.

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But lately there has been a lot of interest in whether this medicine can also have beneficial effects at very low doses - beneficial effects in a whole variety of diseases. To understand why Naltrexone may help with other conditions, and why it may help at very low doses, it is necessary to understand a little about how Naltrexone works.

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The body has an endorphin system that is made up essentially of endorphin molecules and their receptors. The word endorphin is derived from endo (from within) and morphine. These endorphin molecules (natural morphine) exert their effect by attaching to receptors and turning on the switch like a key in a lock. Initially it was thought that the endorphin system was there to provide natural pain relief in case of accidents and acute pain – possibly to allow us to continue to function somewhat if we are injured and need to get out of danger. No question it does do this, but the more we learn about this intricate and elegant system, the more it is apparent that endorphins do much more than just provide pain relief. The endorphin system is very involved with our sleep cycle, our energy levels and our general sense of well being. Endorphin receptors have also been found in a variety of tissues including the immune system, the intestines, and cardiac and vascular tissues. The placenta even makes large amounts during pregnancy – which may explain some cases of post partum depression.

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Naltrexone is an opiate antagonist, a blocker at the endorphin system. There are two ways that Low Dose Naltrexone (LDN) may be beneficial. It could block the endorphin system for short periods in order to block unwanted effects. Or it could block the endorphin system for a short period of time so that the endorphin system will build itself back up in response and be “supercharged” after the LDN wears off. This could even increase the amount of endorphin in the body. The endorphin system is very intricate and it may be that LDN both blocks some parts of the endorphin system and supercharges other parts. It may help to regulate itself.

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Low dose Naltrexone (LDN) is being used and studied in a number of conditions involving the immune system. We know that opiates can cause immune-suppression in conditions such as cancer and HIV/AIDS. So could blocking the opiate system with Low Dose Naltrexone (LDN) actually lead to an improvement in the immune system and help patients? Some HIV infected patients are using it. Some patients with Multiple Sclerosis are using it. There are lots of case reports and patients who swear that it has been helpful, but not a lot of controlled research studies have been done. That is changing, and just this year a well controlled study was reported on patients with Crohn’s disease – an immune disorder effecting the GI system. Dr Jill Smith from Pennsylvania State University studied 40 patients with Crohn’s disease and showed quite dramatic results. In her study, 82% of the patients receiving LDN achieved a large drop in their symptoms scores and 45% achieved clinical remission. This was much higher than the placebo (sugar pill) group.

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Fibromyalgia and Chronic Fatigue Syndrome are conditions that are frequently characterized by chronic pain. A number of patients are using LDN for these conditions and reporting good results. This could easily make sense because often chronic pain affects the body’s ability to deal with pain so modulating the endorphin system could have very beneficial effects.

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I have personally used LDN for patients with irritable bowel syndrome (IBS) and have had good results. IBS is a condition where the bowel seems to be alternating between over stimulation and under stimulation. The bowel has more opiate receptors than the brain, and so it is not hard to imagine that blocking these receptors could help the GI system regulate itself.

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Another condition that could be related to over production of endorphins is autism. Some researchers believe that some cases of autism are caused by an over stimulation of the body’s endorphin system. These children could be almost high on their own natural morphine and so have problems interacting socially and functioning in the world. Some physicians are using LDN to tone down the endorphin system and help it to re-regulate.

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Recently a patient came to ask if I would prescribe LDN to help him in his body building regimen. It seems there is evidence that LDN helps the body recover more quickly from vigorous workouts.

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I have also recently used Naltrexone combined with Wellbutrin in a couple of patients who have weight problems. So far the response has been very powerful. They have lost a lot of their cravings for food and have also lost quite a lot of weight. We will see if the changes continue.

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So what do we make of all of this? There is a popular website at Lowdosenaltrexone.org with lots of personal testimonials and case reports. There are books written about patient’s personal experience with LDN. The truth is that we just don’t know how effective LDN is for these conditions. It makes sense, given how extensive and how powerful the endorphin system is, that it could have dramatic effects in a number of conditions. The good news is that there are a number of well qualified researchers who are beginning to conduct the kind of research that will give us more answers.

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Peter Coleman MD

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