Extended-release naltrexone (Vivitrol) augmentation for compulsive sexual behavior disorder: a case report

Compulsive sexual behavior disorder (CSBD) was included in the ICD-11 as an impulse control disorder, yet pharmacological treatment options remain limited. Naltrexone, an opioid receptor antagonist approved for alcohol and opioid use disorders, has shown promise for compulsive sexual behaviors, though the extended-release injectable formulation has not been evaluated for this indication.

A 54-year-old married man with longstanding compulsive sexual behavior presented with acute symptom escalation following job loss, including compulsive pornography use, financial concealment, occupational impairment, and secondary depressive symptoms. Despite desvenlafaxine 50 mg and weekly psychotherapy incorporating motivational interviewing, cognitive-behavioral, and mindfulness-based techniques, he achieved inadequate symptomatic benefit. Extended-release naltrexone (Vivitrol) 380 mg intramuscular injection monthly was initiated as augmentation, chosen for more consistent receptor occupancy than oral formulations. Symptom severity was assessed using the Compulsive Sexual Behavior Inventory-13 (CSBI-13) and Hypersexual Behavior Inventory-19 (HBI-19) at baseline and monthly over three months. Hepatic function was monitored throughout.

The patient demonstrated substantial improvement on both measures. CSBI-13 scores decreased from 65/65 at baseline to 25/65 at one month (61.5% reduction), stabilizing at 35/65 by month three (46.2% total reduction). HBI-19 scores decreased from 91/95 to 49/95 at one month (46.2% reduction), remaining stable at 47/95 through month three (48.4% total reduction). Liver enzymes remained within normal limits and no adverse events were reported.

This case suggests extended-release naltrexone may be an effective augmentation strategy for CSBD unresponsive to antidepressant pharmacotherapy and psychotherapy. Controlled trials are needed to establish efficacy.