LDN Social Media
Get connected with us on social networks
Pain - Samyadev Datta, MD (2021 Conference) (LDN, low dose naltrexone)
LDN Research Trust 2021 Conference - Friday Morning
Dr. Samyadev Datta is the Director, Center of Pain Management in Hackensack, NJ, USA. He is an anesthesiologist by training, but currently devotes himself full-time to pain management.
In his presentation, Dr. Datta shares his experience with using naltrexone in pain management. He has used three main dosage levels for pain treatment in different situations: ultra low dose, microgram dose, and low dose.
Dr. Datta starts by explaining a bit about the background of naltrexone, which is a very powerful opioid antagonist. It is a competitive antagonist on opioid receptors and has the maximum effect on MU receptors. The max peak of the drug is at 60 minutes after taking it. However, it fully metabolizes from the body, leaving no medication accumulation.
Dr. Datta’s main focus for using naltrexone is its effect on glial cells and how that impacts pain. Also, its reversal of activation of TLR4 cells, reduction of inflammatory, and increase in the function of the immune system all help with pain management. In addition, the temporary blockage of opioid receptors by the LDN causes the brain to produce more endogenous endorphins, helping relieve pain (especially in the absence of opioids).
Dosing Structure of Naltrexone for Pain Management:
Nanogram dosing of naltrexone (also called ultra-low-dose naltrexone which tends to be a dose of 2 micrograms (or 2000 nanograms per day) is used for patients who already are using opioids for pain management. Dr. Datta explains that because opioids are known to require more and more medication to produce the same relief, introducing nano dosing of naltrexone helps to reduce the amount of opioids needed. He goes on to explain that the patient will most likely require an increase of naltrexone to keep up the effect, but he warns to titrate very slowly. He explains research from 1997, which showed that patients who just received morphine, had much shorter and less effective pain relief than when given morphine in combination with a nano dose of naltrexone. The chart he used showed the combo gave much longer and higher levels of pain relief. (As an aside statement: a recent research paper is saying there are similar effects when using Fentanyl, but he couldn’t give details of the paper.)
Nano Dosing Example Cases:
A 55-year-old, female nurse, who had transverse myelitis and post-laminectomy pain syndrome, was on high doses of opioids via a pain pump, with the addition a fentanyl patch and oral morphine, due to poor pain management. Dr. Datta introduced a nano dose of naltrexone, and in a few weeks she had great pain relief and improved functioning. He began to lower the levels of opioids, but the good results were not sustained. After moving to South Carolina, she reported that the better weather was letting her take fewer opioids, yet, he reports that she isn’t in a highly functional state but can take care of herself.
A 60-year-old man with severe congenital rickets was taking high levels of opioids and had very limited functionality. Dr. Datta introduced a nano dosing of naltrexone, which let him have better functionality. He had an amazing turnaround in pain control that led to a substantial lowering of opioid usage. Due to losing more control of his mobility, he moved to assisted living. The staff there called Dr. Datta with grave concerns about the nano dose of naltrexone prescription. Dr. Datta goes on to explain that there is a need for educating medical staff who don’t understand the huge difference between naltrexone (used for opioid addiction) and nano dosing of naltrexone.
Dr. Datta reviews concerns he has with ultra-low dose naltrexone: 1. The dose range isn’t consistent from patient to patient; 2. It can be hard to compound at that dosage level, so it can be expensive; 3. Very few medical personnel are familiar with it; 4. Not all patients respond to it; he’s had the best response using it with morphine, but not as good with other opioids. He says that working with LDN-experienced pharmacists is very helpful.
Microgram dosing of naltrexone is used for helping patients rapidly wean off opioids due to addiction or pain management. The dosage is 100 microgram/ 2-3 times a day with daily (or every 2-3 days) reduction of opioids. You can expect to wean off opioids in the space of 7-10 days with little to no side effects. At that point, the patient would be fully on naltrexone. However, if the patient has chronic pain, it may take longer. At this point, he explains to get to the 4.5mg to 6mg for chronic pain or 50-100mg for opioid/alcohol addiction.
This method is advantageous because of its efficacy, with minor side effects. However, it does require compounding to get the microgram dosage, thus it can be cost-prohibitive for some patients at ($20-$60 a month).
Microgram dosing cases:
A 42-year-old woman with a history of breast cancer had pain due to bilateral mastectomy and implants, which were the wrong size. She was taking 1000mg of morphine per day. She was referred to Dr. Datta for a possible pain pump, but she wanted to be off opioid use. She was weaned off all opioids in 12 days with no symptoms of withdrawal, and isn’t using any other pain medication other than the LDN. Dr. Datta emphasizes that this was a perfect case for using microgram dosing of naltrexone but reminds us that this patient was highly motivated to get off opioid use. He also states that the doctor must be prepared to interact with the patient daily during the process, and that an LDN-trained pharmacist is necessary for proper implementation of the treatment.
Low dose naltrexone in pain management has been used for about 20 years, with success in many different forms of pain: CRPS, fibromyalgia, peripheral/diabetic neuropathy, post-laminectomy pain syndrome, and other pain conditions. In Dr. Datta’s practice, he’s used LDN in over 1,000 cases over 10-12 years with a success rate of about 70%. He confesses that being able to use an opioid antagonist for pain management has been eye-opening for him, and that once he found success in using it as a treatment, it is now his first go-to for all pain management situations.
LDN Cases:
A 50-year-old woman who had four knee replacement surgeries came to Dr. Datta for help. She had a pain pump that provided high amounts of opioid medication with little pain relief and side effects from the drugs. Dr. Datta removed the pump and prescribed oral opioids, but she wanted to be off them due to their side effects. He placed a DLR stimulator leads at L3 & L4 and switched her over to LDN of 4.5mg. Now she is doing very well and is living a productive life. Dr. Datta said that she is a prime example of how LDN with DLR stimulator can be a very effective combination.
A 70-year-old woman was referred to him for possible Ketamine infusions for complex regional pain syndrome (CRPS). She had been living with this pain for 20+ years. He started her at 1.5mg with very good pain relief and no ill effects. He decided to up her to 3.0mg, but she contacted him as her pain had increased. He reduced her back to 1.5mg, titrating to 1mg in the morning and 2.5mg in the evening. She had been using 600-1000mg of ibuprofen a day before this, which she’s stopped completely. Now, she takes the occasional acetaminophen. She has no pain in the morning and a bit in the evening. She will have a knee replacement due to joint issues.
Dr. Datta goes on to describe a case in which he thought LDN would work and didn’t. One patient, a 44-year-old woman with a history of lung cancer, ended up using Tramadol and had surgery to remove breast implants (due to cancer) that had moved and were causing pain.
Dr. Datta explains that using LDN for treating pain needs some considerations: 1. Use only in the absence of opioids; 2. Start after opioids have stopped, usually 2-3 days after (except for methadone, which is 5-7 days after stoppage); 3. Start at 1.5mg orally in the morning on an empty stomach; 4. Increase every 10-15 days by 1.5mg; 5. Once at 4.5mg-6.0mg, switch to night dosing; 6. May still take an occasional opioid pill. He goes on to list some of the side effects that patients could experience: headaches, gastritis, insomnia, withdrawal symptoms from opioids if introduced too early, IBS issues, occasional allergy, and candidiasis (rare).
For the best success rate, Dr. Datta suggests to have PATIENCE (it may take up to 3 months for results). Those patients who have had chronic pain for many years take longer to see the pain-relieving results. He uses Ketamine for breakthrough pain, while waiting for LDN to fully kick in (20-60mg via nasal spray or oral troche). Also, he allows the occasional opioid pill for breakthrough pain. He will use topical LDN for those who cannot take it orally, and has found this to work well. Dr. Datta said to persevere; if a patient says that LDN isn’t working for them, take them off of it for two weeks and then have a consult. Often the patient will ask to go back on it because they hadn’t realized how much it was helping them.
KEYWORDS: naltrexone, opioids, pain management, pain, low dose naltrexone, opiates, dosing, morphine, ketamine