Adjunctive oral naltrexone for breakthrough craving in patients receiving extended-release injectable naltrexone for alcohol use disorder: Three cases

Craving is a subjective, poorly characterized phenomenon strongly associated with return to use in alcohol use disorder and remains difficult to manage. Extended-release naltrexone is a U.S. Food and Drug Administration–approved, evidence-based treatment, yet some patients experience brief, intense “breakthrough” craving despite adherence. Although expert guidance references oral naltrexone supplementation as an option during extended-release naltrexone maintenance, published peer-reviewed case descriptions documenting this clinical scenario are lacking. We describe three adults with severe alcohol use disorder receiving monthly extended-release naltrexone who reported late-cycle breakthrough craving and were offered adjunct, as-needed oral naltrexone. All patients reported subjective improvement in craving control and continued engagement in treatment. These cases highlight a clinically observed pattern of late-cycle breakthrough craving that warrants prospective evaluation.