CEimpact Podcast

What Should Pharmacists Know about Low-Dose Naltrexone?

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Low-dose naltrexone (LDN) is generating growing interest as a potential therapy for conditions such as chronic pain and immune-related disorders. This episode offers a foundational overview of what LDN is, how it’s thought to work, where current evidence stands, and how pharmacists may encounter it in practice. Learn what pharmacists need to know to confidently approach patient questions about LDN and how it fits into current conversations in pharmacy and patient care.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Michelle Moser, RPh
Retired Compounding Pharmacist

Joshua Davis Kinsey has no relevant financial relationships to disclose.

Michelle Moser was a volunteer board member for LDN Research Trust (ended June 2025), a board member for Alliance for Pharmacy Compounding (ended September 2024), and an employee of Revelation Pharma (ended June 2024). All relevant financial relationships have been mitigated.   

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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Define low-dose naltrexone (LDN) and describe how it differs from traditional naltrexone dosing.   
2. Identify proposed mechanisms of action and areas of emerging interest related to LDN use in practice.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-275-H01-P
Initial release date: 8/25/2025
Expiration date: 8/25/2026
Additional CPE details can be found here.

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Speaker 1:

Hey, ce Impact subscribers, welcome to the Game Changers Clinical Conversations podcast. I'm your host, josh Kinsey, and as always, I'm excited about our conversation today. Low-dose naltrexone, also known as LDN, has been gaining attention as a potential option for patients managing chronic pain, inflammation and autoimmune-related conditions. Yet many pharmacists have questions about what it is and how it works. In this episode, we'll break down the basics of LDN therapy and explore how pharmacists can stay informed and engaged in patient conversations about the topic, and it's so great to have a true expert in this space. If you Google her name at all, you will see that that is the case.

Speaker 1:

Michelle Moser is our guest for this episode, so thank you so much for being here. Michelle, thank you so much for having me. Yeah, we're really excited to talk about this. This has been a topic that a lot of our listeners have asked about, and so we're really excited to have some discussions on LDN therapy. So, michelle, for our listeners that don't know you and didn't take the second to Google you when I said it a minute ago, if you'll take just a couple minutes to tell us a little bit about yourself and maybe your practice site I know your current practice site is retired, but if you can tell us about your career and everything and maybe a little bit about why you're passionate about the topic.

Speaker 2:

Absolutely so. Thank you again. I'm really excited about presenting on this topic. It's a true passion of mine. So I've been a pharmacist for about 38 years, all over in retail, hospital, specialty pharmacy, but primarily focusing on compounding, and I own my own compounding store. I've been a member of a variety of networks and compounding accredited areas. What's really amazing is that it gives you an opportunity to network with people who are also really engaged and passionate about a lot of the things you are as well. So, as a lot of times we become very aware of certain areas when it hits close to home, right.

Speaker 2:

So if there's something going on at home or with our immediate family, then we tend to focus on that and that's where we really build our specialty areas.

Speaker 1:

Yeah, that's great, very good. Well, again, thank you so much for taking time to be with us today and, as I always say, I'm excited about today's topic, and it's definitely this, because this is I just don't know that much about this topic, so I'm really looking forward to learning more. So let's jump right in. One of the things I always like to do is set the stage, the foundational stage, for our listeners, to make sure everybody's on the same page as to what we're talking about. So again, ldn is what we're going to call it throughout the episode, but low dose naltrexone. So tell us a little bit. What does that mean, define it for us. What does low dose mean? What kind of range is that? And then we'll just kind of go from there.

Speaker 2:

Absolutely so. Naltrexone as an entity was FDA approved back in 1964 in a typical dose that we see in a retail pharmacy, which is anywhere from 50, 100, up to even 300 milligrams. We usually use that for alcohol, overuse syndrome or a variety of other addictions methadone, heroin, etc. But when we use this medication in a low dose we actually see very different properties. So the one thing that so this is a term that goes way back to when we were in pharmacy school, right? So naltrexone is a hormesis drug. Well, what does that mean? It means that at high dose it works very differently than it does at low dose. That is really, really important. So when we're dealing with low dose naltrexone, we're usually typically looking at doses of oh, anywhere from 0.1 milligram to about four and a half milligram. We might go up a little bit higher and we do see this in six, nine, even a few more milligrams, maybe up to 32. When we're dealing with weight loss, we see it combined with bupropion in other realms, other medications for weight loss, and that is also FDA approved. But when we're dealing with low dose, we're going to see that this medication works very, very differently. So we have low dose, then we have very low dose and ultra low dose. So ultra low dose goes down to microgram dosing with narcotics to enhance the narcotic work so that we can actually help people get off of their medications.

Speaker 2:

So we do see, yeah, we see naltrexone used in very small doses, for we still use it for alcohol overuse or even opiate overuse, even though naltrexone binds intermittently binds to the opiate receptor. That's how it works on some of its mechanisms. So another mechanism is that it also helps to decrease the interleukin cytokine production. So interleukin 6, 1212, those are pro-inflammatory cytokines, and we heard about interleukin 6 a lot back oh you know, five, six years ago when we were in the middle of the pandemic because covid actually elicits interleukin 6. Well, with naltrexone in small doses not in higher doses, but in small doses we can actually block that receptor. So that's where we see some hormesis working. But we also can use it in autoimmune situations because of how it works on one and TH2 pathways and so we can actually reduce inflammation through those pathways as well. So we're really dealing with three primary mechanism of actions, with when we're dealing with low dose or ultra low dose, very low dose, that sort of thing.

Speaker 1:

Yeah, wow, okay, very good, that's a lot of great information, thank you. So, as I mentioned, we've had some learners ask about this. It's been some topic, so is it also a growing awareness within the public sector, like within the? Do patients? Are patients starting to hear about this and being like, oh, what is LDN? What can it treat? You know, what are that kind of thing? I guess maybe just talk a little bit about its public interest, the prevalence of LDN therapy yeah, so low-dose naltrexone is not necessarily a medication that is in the commercial space, right?

Speaker 2:

So we compound this. And because LDN has very few side effects and it has even fewer drug interactions, it can be used in a wide variety of circumstance. It can be used in a wide variety of circumstance. So, for example, if someone has an autoimmune disease, multiple sclerosis, fibromyalgia, even when we're dealing with thyroid disorders, there's many, many, many more that we use scleroderma. I mean, this list is longer than my arms.

Speaker 2:

Yes, it really is Because of one of the mechanism of action that it works. We can actually see it reducing inflammation, but we can also see it reducing antibodies, which I have not found a drug out there that will actually reduce antibodies that the body's producing to cause this issue going on in the body, and we know that there are so many different side effects that can be absolutely debilitating, whether they are related in the gut or they pop up on the skin, or even if it's a muscle issue where someone just doesn't feel great and it decreases their ability to work. So we're dealing with a medication that is really well tolerated. It's in little, tiny doses.

Speaker 2:

One of the key points that I want people to understand, especially pharmacists, is that this medication doesn't have a typical dosing schedule. So we have a start point and we have a kind of sort of end point. But usually when we're dosing low dose naltrexone LDN, we're looking at a sweet spot for that one individual. So for some people, even with similar disease states, the dose might be three milligram. Others it might be 4.5. But what we found is that a lot of times less is more when we're dealing with LDN. So, yeah, we have a typical schedule on how we start to increase the dose. We usually start really low, go slow, increase the dose every seven to 14 days. So patients are going to need some type of a document, right?

Speaker 2:

to help them track all of that and help them track their symptoms as well. But what we also see is that a lot of people are looking for a quick fix right. Well, this isn't like popping Advil or sorry, ibuprofen or Tylenol or you know acetaminophen. We're not dealing with gabapentin and nerve pain. We're not looking for a quick fix here. This is something that might work quickly, but probably is going to take months before we see really big changes.

Speaker 1:

Yeah.

Speaker 2:

Yeah, and it has. And I will say this is where the pharmacist can really play a pivotal role is that when a patient has questions, if there's some knowledge that can be shared, that's when we're going to see better compliance, better efficacy, because sometimes it might be four to six months. Now there's a wide variety of books that are available. So I'm going to mention the LDN Research Trust. So this is a nonprofit organization that is based in the UK. They have a variety of seminars. They have a variety of opportunity for learning that may have CE most of the time does not but they also hold conferences where a pharmacist can network and really learn about. Well, I've got a large autoimmune population. Maybe it's primarily MS. So where I live in Northwest Washington, we have this band of MS diagnoses. It's really crazy, but we all know that autoimmune diagnoses are very much on the uptick Unfortunate, but very much so and a lot of them are based in the gut. So LDN actually helps to reduce inflammation. So if you have somebody with irritable bowel or Crohn's disease ulcerative colitis.

Speaker 1:

Those are the two I was going to ask about, if that's something that you've seen treatment for?

Speaker 2:

Yeah absolutely, and there are providers in Missouri that have been studying this for quite some time. So there's, with low dose naltrexone, a lot of information. We all know that during the 80s we just didn't have a lot of information. What we did know is that alcoholism was a huge impact, with a lot of individuals who were diagnosed with HIV before it was full-blown AIDS. So he was handing out naltrexone not naloxone but naltrexone sister drugs. But they work very differently. So he was handing out 50 milligram naltrexone. Well, back in the 80s we didn't have insurance companies to pay for this. It was all cash and then you had to bill your own insurance if you had insurance. Very different game back then. But what he realized is that his patients were breaking tablets and they were taking parts of tablets and he was actually watching these T-cell scores go up which was unheard of back then.

Speaker 2:

So through Dr Bahari's work, and then other physicians have and other scientists have brought up this continual body of work Dr Zygon, dr McCandless, I mean there's so many doctors out there that have really, really worked on this. So to date there are over 930 published articles and research material on low-dose naltrexone.

Speaker 1:

A lot.

Speaker 2:

I've been a pharmacist for 38 years. I haven't found a drug that is that well studied. Is it in the general public? Well, kind of sort of. Usually a patient is going to bring this material to the pharmacy or to their provider and say, hey, I want to try this, and a lot of times the providers are going to go. I don't know.

Speaker 1:

Right, because they don't know.

Speaker 2:

It's not commercially available, right? So where are they getting this information? Well, they're getting this from providers that have information and videos, podcasts like this, a wide variety of other recorded materials that are out on other platforms, and then you've also got a series of LDN research books.

Speaker 2:

So there's literally the LDN book volume one, two, three and four, and the fourth book recently came out just a few months ago and it centers primarily on pain, and when we're dealing with individuals who have acute pain or chronic pain, we're dealing with microgram dosing, not milligram dosing. Microgram, right, it's like well, and we literally start with one microgram and we can use it side by side with oxycodone, hydrocodone morphine. It does intermittently block those receptors, but what it does is it actually enhances the ability for that narcotic to work in microgram dosing.

Speaker 1:

Microgram dosing yeah.

Speaker 2:

And then we can actually see the medication working better and faster and people have better pain control and perhaps they use less and less often. So we don't necessarily see the habit formation. So we don't necessarily see the habit formation. However, we can still use microgram dosing to help people get off and wean off of their potential habit for opiates as well. Wow, wow, it's a cool drug.

Speaker 1:

Yeah, I mean, it just seems so versatile and, as you said, I mentioned in our green space before we came on the recording that there wasn't a lot of clinical evidence that you have, you know. Put that to the contrary because there is. There's a lot of studies and a lot of guidance out there, which is great. So one of the things that you've touched on is, I guess, the pharmacist role. So let's just reiterate that, highlight that, since our listeners are pharmacists, just making sure that they understand.

Speaker 1:

So, if I heard you correctly, one of the things obviously is, if you're in a compounding space, you can be the individual that's compounding this, but also just having knowledge about it, because either in passing or directly, your patient may question you about it and whether they're on it, whether they're looking to be on it, whether they're trying to find a provider that will prescribe it. You know that kind of thing. So what other space can the pharmacist have other than just having some general knowledge about it and finding out more, just so that they're in the know? Do you have any other thoughts for the pharmacist, so that they understand their space.

Speaker 1:

Okay, please share Absolutely.

Speaker 2:

So a lot of times in the retail space, even in the hospital space, we will see prescriptions come through right, and so they're going to arrive in the pharmacy and it's going to say naltrexone. And sometimes it will say like naltrexone powder 100%, and a pharmacist in a retail setting has got seconds right, and usually I mean the technician is going to see it first. Right, let's be real. So what do you do with that? Well, there's two different ways to go about this. So I've been compounding for well over 25 years.

Speaker 2:

At this point, can you use a commercially available tablet to make low dose naltrexone? Well, let's let's talk about this a little bit, because there are some forums out there where patients have chimed in and even providers have chimed in and said, oh yeah, you can definitely do this, and this is what they're telling patients. Even providers and this makes my hair curl so docs are providers are writing prescriptions for 50 milligram tablets and telling patients to dilute them. There's also a couple of people out there that think that you can separate the lactose in the naltrexone tablet from the active ingredient by dissolving it in water, and I'm you're up.

Speaker 2:

Anyway no, I don't think that really works very well. So let's talk a little bit about that area, because we will see that everywhere. Talk a little bit about that area because we will see that everywhere. So generic drugs that are made in the United States are allowed to vary plus or minus 10%, right? So they're never a 50 milligram tablet. Very rarely it's going to be 50 milligrams, very rarely, right. It could be as little as 45 and it could be as high as 55, which I doubt it's really ever going to be a lot more, but it's usually less.

Speaker 2:

So if we're dealing with a medication that the patient has to dial in on a very, very, very small dose, how are you going to know if that tablet that you're asking them to dump in a milligram tablet dump, dump in 50 mils of water? First of all, how are they going to measure that? How are they going to store it? What kind of water are they really using? Are there contaminants? Are there impurities? Okay, so you see where I'm going with this. So it really, really, really needs to be compounded, because accuracy is so important. It literally will mean the difference between a patient's success and not with this medication, and we're all here to help patients. We're all here to ensure that a patient's questions are being answered, but really, by the time they come to low dose naltrexone, they have probably spent years, if not decades.

Speaker 1:

Right and how many providers?

Speaker 2:

right, because they're dealing with these chronic issues that they really don't get a lot of answers to. So, really important. Have it compounded. Please find a really good compounder that understands that is sending their materials out for testing and also understands that when they are using a bulk powder active ingredient, are they using the base or are they using the hydrochloride salt, because you've got to correct for the salt as well.

Speaker 2:

So, then we can also meet the patient where their needs are are need to be fulfilled. Do they need a liquid? Because you can actually manipulate that liquid a little bit better. So let's find a base that's going to work for them. Because, by the way, naltrexone powder is bitter. It is bitter, so a good compounder is going to find a base that's going to work for the patient. A lot of times it's an oil, because you're going to have a great or a better beyond use state. You can extend it out 90 days versus 30. Patients are not very happy about having to buy a prescription every 30 days compounded a lot of times is out of pocket we can

Speaker 2:

flavor it. We can use a bitter block, we can use all kinds of things to help make it a little bit more palatable. Or we can compound little itty bitty capsules, little tiny dose capsules. Yeah, they're going to end up taking a handful of them, but we can find that very specific dose for them Because, like I mentioned earlier a lot of times, with naltrexone, less is more. So again, this is where the pharmacist plays a key role. Patients are going to have questions. All of a sudden, they're going to have these. What they assume are side effects associated with the last medication that they just started, which is LDN. Or I've got a rash, and maybe it's the LDN, maybe it's not. Maybe it's the autoimmune disease that's popping up and it's flaring. Maybe they actually have a yeast infection, a fungal infection. If they're using LDN for Lyme, they may actually have reduced the inflammation enough where the underlying disease pops up and they have a bloom, and this happens with fungal infection and yeast infection as well.

Speaker 2:

So, what happens is the patient feels yucky right. They all of a sudden they've got this outbreak of something that they're not very happy about and oh, that was that drug that caused that. I'm just not going to take it anymore. Well, you don't, you don't necessarily know about it. The doc will never know about it, unless you tell them.

Speaker 2:

Because they'll just be taking it and then they won't go back or it will be months or years before the patient actually gets back in contact with the provider. Up program that can allow for the patient to interact with someone at the pharmacy. Pharmacy team. Member. Ask questions, answer questions, and there are some. There are some platforms, some electronic platforms that are available that the patient can actually use. So it's not necessarily a phone call that's, you know, going to take an hour and a half of your time, which we don't have.

Speaker 1:

Right.

Speaker 2:

There are some electronic platforms that allow for that. So it's really about building that relationship. The provider's not going to have the time, the nursing staff's not going to have the time, but that's where, again, we are forefront in dealing directly, one-on-one with that patient.

Speaker 1:

Yeah, so even you know, even if it's as simple as you see a naltrexone prescription come across your desk, maybe questioning that you know, like, is it maybe having that conversation with the patient?

Speaker 1:

What is the doctor prescribing this for, what are you using it for? And finding out if they're going to be putting it in water at home, and then, you know, circling back to making sure that they're getting that through a compounding facility instead. So that you know, I think is the simplest step where a pharmacist can be involved is just making sure that they're aware of the prescriptions that are coming across, what the patients are taking, and then, like you said, if it is something that they have officially been prescribed, or the pharmacist learns that they've been on it, it's a good idea just to be in the know so that you're aware of it. You can have the conversations, you can continue to promote compliance and adherence and things like that. So, yeah, that's great. So let's you've touched on a little bit of the mechanism of action and how there's at least it's different with the low dose and whatnot. Is there anything else in that space that you want to be sure you convey to the listeners?

Speaker 2:

Absolutely so. Again, we're dealing with a hormesis drug. So at a typical 50 milligram dose we do use it for alcohol overuse syndrome, methadone withdrawal, that sort of thing. When we're dealing with low dose naltrexone we don't have the same side effects. We don't see the liver impairment that is a potential issue. With a larger dose we're dealing with doses that are perhaps up to 50%, up to four and a half milligrams. Sometimes we'll go up to six. It just really depends.

Speaker 2:

So there's a wide variety of guidelines and written materials that are really easy to access and again, through the LDNresearchtrustorg you can definitely access even some of the calls that are available. The first chapter of each of the four books literally goes over step-by-step the three main areas of action with low dose, very low dose and ultra low dose naltrexone. So I really encourage people to to dig. I had reference copies in the pharmacy because if somebody came in and they were dealing with chronic pain I could go to. Somebody came in and they were dealing with chronic pain, I could go to those chapters. If they were dealing with cancer, I could go to those chapters. If we're dealing with ulcerative colitis or Crohn's, again different chapters, different providers.

Speaker 2:

But when we're dealing with thyroid. You know, if somebody has autoimmune Hashimoto Graves, we can use low-dose naltrexone to help with those situations as well. But again, the pharmacist needs to know at what point do we start looking at other labs. For example, if someone is on levothyroxine and hopefully lyofilamine as well T4 and T3, and they start low-dose naltrexone, those labs need to be drawn four to six weeks after starting LDN. Well, why? Well, because the thyroid will act very differently if the antibodies decrease and function of the thyroid starts to normalize. So T3 is the only active component of thyroid, right? So T4 is hopefully being converted to T3. That's another enzymatic issue that may or may not happen. However, again, this is where the knowledge becomes very, very important, because you don't want to swing somebody from a hypothyroid state to a hyperthyroid state right.

Speaker 2:

That's because we're usually dealing with people who and a lot of times are women, men are affected by thyroid issues as well. However, the majority of them are. We don't want to all of a sudden have their doses really want. We don't want to add to the potential of osteoporosis, so you can kind of see the cascade and the ball starting to roll downhill and become a bigger issue. Yeah, knowing when that needs to happen is very important.

Speaker 1:

Yeah. So, michelle, you've given us so much information and I just kind of want to recap some of the challenges that we've seen, because you've given us so many strategies to overcome those challenges. And so one of them is one of the things that a pharmacist can be available for and can be there to support the patients is ensuring that when it is being compounded, when LDN is being prescribed and compounded, that it's being used appropriately, helping with adherence and pushing that forward as well, because, as you said, sometimes that's a challenge with a patient and it does take a long time sometimes to see those results. So, again, just the pharmacist understanding that and being there for supporting the patient and kind of cheering them along, I think goes a long way. And then the other thing that you had mentioned, obviously, was being aware of, you know, if we see a prescription come across our desk and we maybe are concerned that it's going to be compounded at home or something like that, to really step in discuss, you know the necessity of having that officially compounded by a compounding pharmacy so that we can ensure, maintain product quality and get the right formulation.

Speaker 1:

And I love how you shared about all the different formulations, because that was one of my questions and I think that is to me that is one of the beauties of compounding is that customization for the patient, and I know that that's something that you're passionate about too. You love that whole idea of customizing, so that's great. So so much good information here. Before we wrap up, I just want to reiterate you set me straight earlier on, because I said there was limited research and you made sure that I knew there was lots of research, and that is fantastic, because that's a misconception, and so I think that that's important that our listeners hear that. So just reiterate if our listener is wanting to know more, what next steps should they do? Where should they go to learn more about LDN?

Speaker 2:

There's so many resources, you know. There's other online platforms, there's social media. There are materials available in print, you know. Like I said earlier, there's well over 930 articles and some of them go back to the 80s, and that's okay, but really most of these are maybe, maybe 20 years old, so this is fairly recent material as well. What's amazing is that there is one summary document and I call it the Dartmouth article because it was written by two researchers at Dartmouth University. It was published in 2007 and it's available online, and it talks about how LDN works mechanism of action, dosing range, patient outcome, that sort of thing. So it's a great tool to have, not just in the pharmacy but also to hand out to providers. But really, the low dose naltrexone or the LDN Research Trust this is a nonprofit organization based in the UK that really is the go to for a wide variety of information. There are several books out there LDN book volume one, two, three and four catchy names.

Speaker 2:

They're available on Amazon. You can get them through the research trust as well. They are easy to read. They're all patient studies. They're not a sales gimmick. In other words, these books were written by case studies, by the providers that actually made or developed the case studies. Real patients, real pictures, and they talk about what to do, what not to do.

Speaker 1:

Yeah.

Speaker 2:

And they also talk about the dosage range, which is cool. Yeah you, and they also talk about the dosage range which is cool.

Speaker 2:

Compounding meets patients where they need to be, so if they need a tablet, a capsule, a liquid, a ready dissolve wafer, anything like that. We even use naltrexone topically. Well, actually, we use it topically for like itching and things like that. We can use it transdermally for children, and there's also eye drops to help with a wide variety of of issues. So this is where compounding is cool. But the real message is that low dose naltrexone is one of those medications that can literally deliver hope, and that is something that, as a knowledgeable pharmacist or at least knowing where to find research materials, where to find resources, that sometimes is enough. But if you can give hope to someone who's been battling, suffering, dealing with issues for years, maybe even decades, been through many, many, many, many providers, but if you're that one person that can deliver a message of you know there might be something there might be something.

Speaker 2:

it might. It's going to get better and this is how it may not be tomorrow that you're feeling 100%. It might be four months down the road, but we're not. We probably aren't going to get you to 100%, but if you're at 75%, it's a whole lot better than being at 20%, isn't it? Exactly, exactly.

Speaker 1:

Yeah, I love that. So that is, listeners. If you couldn't tell, that's Michelle's game changer for the day. So, being that person, you actually she's empowering you to be the game changer. Learn more about LDN, be in the know and be able to talk to your patients. You know it's also something.

Speaker 1:

This is low-hanging fruit, we didn't even talk about it, but you know, if you have patients that you know have an autoimmune disorder, you know, maybe you bring up the subject with them, especially if you know that they've been struggling with their quality of life or if they've been struggling with specific issues or adverse events. So, again, being in the know and offering that hope, that's our game changer for this topic. So, yeah, thank you so muchelle again for giving him your time and your expertise. You can just I can tell that there's still about six hours at least of content in your head to share with us. So, yeah, so we'll definitely have to look at extending this and I'm I'm anxious to see the response we get from our listeners, because I know it's just, it's just a topic that keeps coming up but nobody really knows a lot about it. So thanks for shedding some light on it. Really appreciate it.

Speaker 2:

Happy to Thank you so very much for having me and again, if there's anything else I can do to help, please let me know.

Speaker 1:

Thank you so much. Thank you If you're a CE Plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at CEimpactcom. And, as always, have a great week and keep learning. I can't wait to dig into another game-changing topic with you all again next week.