generally benign, although 5 to 10 percent of detoxified opioid addicts experience immediate, intolerable levels of withdrawal-like effects including agitation, anxiety, insomnia, light-headedness, sweating, dysphoria, and nausea. Most patients on naltrexone experience few or no symptoms after the first 1 to 2 weeks of treatment; for a substantial minority (20 to 30 percent) protracted discomfort is experienced. Persisting affective distress related to naltrexone may account for individuals taking the drug who drop out of treatment. Naltrexone has been reported to reduce feelings of social connection. Studies on whether naltrexone can decrease the pleasurable effects of listening to music are conflicting. Besides humans, naltrexone has been found to produce aversive effects in rodents as assessed by conditioned place aversion. Liver damage Naltrexone has been reported to cause liver damage when given at doses higher than recommended. It carries an FDA boxed warning for this rare side effect. Due to these reports, some physicians may check liver function tests prior to starting naltrexone, and periodically thereafter. Concerns for liver toxicity initially arose from a study of nonaddicted obese patients receiving 300 mg of naltrexone. Subsequent studies have suggested limited or no toxicity in other patient populations and at typical recommended doses such as 50 to 100 mg/day. Overdose No toxic effects have been observed with naltrexone in doses of up to 800 mg/day in clinical studies. The largest reported overdose of naltrexone, which was 1,500 mg in a female patient and was equivalent to an entire bottle of medication (30 × 50 mg tablets), was uneventful. No deaths are known to have occurred with naltrexone overdose. Pharmacology Pharmacodynamics Opioid receptor blockade Naltrexone and its active metabolite 6β-naltrexol are competitive antagonists of the opioid receptors. Naltrexone is specifically an antagonist preferentially of the μ-opioid receptor (MOR), to a lesser extent of the κ-opioid receptor (KOR), and to a much lesser extent of the δ-opioid receptor (DOR). However, naltrexone is not actually a silent antagonist of these receptors but instead acts as a weak partial agonist, with Emax values of 14 to 29% at the MOR, 16 to 39% at the KOR, and 14 to 25% at the DOR in different studies. In accordance with its partial agonism, although naltrexone is described as a pure opioid receptor antagonist, it has shown some evidence of weak opioid effects in clinical and preclinical studies. By itself, naltrexone acts as an antagonist or weak partial agonist of