Do you use naltrexone in your patients with fibromyalgia?

I do not use low-dose naltrexone as a first-line agent for patients with fibromyalgia. Well-designed RCTs (Due Bruun et al., PMID 38258677; Bested et al., PMID 38226027) have not shown significant improvements in pain or other outcomes in the overall population of patients with fibromyalgia. That said, fibromyalgia is a heterogeneous condition, and I believe there may be sub-groups of patients for whom low-dose naltrexone could have a clinically meaningful benefit. There is a nice editorial on this in Lancet Rheumatology by Häuser and Fitzcharles, PMID 38258679. Thus, for patients with fibromyalgia who have tried one or two other agents and do not have any contraindications, I think it is reasonable to initiate a trial of low-dose naltrexon...

Anecdotally, I've found LDN helpful in patients with FM who also have prominent dysautonomia symptoms -- as the usual agents [cyclobenzaprine, gabapentin, pregabalin, milnacipran, etc] can often exacerbate their dysautonomia symptoms.

I have also used with patients with FM who may have addictive behaviors [esp alcohol use] who are considering cutting back but would benefit from some support

I let the patient know it is not covered by insurance, and could be around $30-60 monthly, and we can use a compounding pharmacy that ships the med straight to them.

The other less expensive option would be for them to use a 50 mg tablet (from a regular pharmacy, not a compounding pharmacy), and make a slurry at home as below, especially for the titrat...