In the East opium is consumed (usually by opium pipe) as seeking pleasure, analgesic, and hypnotic and also for treatment of premature ejaculation. Opium is a naturalproduct and an opioid mu agonist which is acquired from opium poppy. Opium has a long of history of medicinal, social and recreational acceptance in some areas of the world specially the Middle East since many centuries ago^[1-3].

  Disturbances of mental health are exhibiting globally^[4,29]. Thinking of mental diseases, substance related disorders, especially opioids and stimulants joined problems have been specified as puzzle. Opioids and stimulants induced mental diseases have now caused more referrals to outpatient and inpatient centers^[30,98]. In Iran opioids and psychostimulants ill-use and resulted problems have obtained more concern than the past era so that have resulted in more referrals to centers for substance abuse^[99,121].

  The Food and Drug Administration (FDA) approved naltrexone for the relapse prevention of opioids and alcohol dependence^[4]. The goal of this study was to present a case study of a patient with trichotillomania who stopped pulling hair shortly after starting pharmacotherapy with naltrexone, an opioid antagonist. It was argued that naltrexone may be effective in the treatment of trichotillomania. In the current study we administered naltrexone with the dosage of 25 mg daily for the management of trichotillomania.

Patient introduction
  We define a patient with trichotillomania and opium dependence who improved with a daily dose of 25 mg of naltrexone. Our rationale for the use of the naltrexone for trichotillomania is that naltrexone is an antagonist of mu opioid receptor and decreases or block the reward (effects of endorphins and enkephalins) followed by hair pulling.

  Our patient was a married 35 years old worker with middle school education. He inhabited with his family in Khafr city of Fars province placed in southern Iran. ER developed trichotillomania, obsession, aggression, agitation, irritability, insomnia, depressed mood, anhedonia, and suicidal thoughts since about 4 years prior to admission. His symptom were exaggerated since several weeks prior to admission.

  Due to the stated complaints he was referred and admitted in psychiatric ward. It should be noted that ER began smoking opium and tobacco since one year prior to admission. In psychiatric interview and detailed examination, he had trichotillomania of hair of head and beard, irritability, aggression, agitation, insomnia, anhedonia, depressed mood and suicidal thoughts. During precise neurological examinations we could not observe any abnormal findings. Urine drug screening test was positive for morphine only. Tests of serology for viral markers (HIV, HCV and HB Ag) were within normal limit. Considering medical, psychiatric, substance use history and DSM-5 criteria, he was diagnosed as trichotillomania and “opioid induced depressive disorder with mild use disorder”.

  We administered citalopram 20 mg and valproate 600 mg per day for the treatment of his symptoms.

  Two days later we began naltrexone 25 mg per day for the treatment of trichotillomania. One day after naltrexone administration, he stopped pulling his hairs and five days later his trichotillomania was treated, so he was discharged with follow up appointment. We should mentioned he had previously received citalopram and valproate without any improvement of his trichotillomania.

  Overall, after 8 days of hospital admission patient was discharged without any signs and symptoms of trichotillomania. We followed him for 3 weeks. He still did not report any hair-pulling.

Discussion

  There are a few existing randomized controlled trials that investigated the safety and efficacy of naltrexone in trichotillomania. For example, interestingly, in an open-label study of naltrexone in trichotillomania in a small sample of children, most participants reported significant improvement^[122]. Grant et al found that subjects (N = 51) did not show reduced pulling after an 8-week trial of the agent (they did however report reduced urges to pull – which is interesting and which could have been relevant in the current reviewed manuscript)^[123]. In another review of trials assessing the effect of opioid antagonists in behavioural addictions (which included trichotillomania), it was concluded that there is not enough evidence to support the use of opioid antagonists such as naltrexone or nalmefene in trichotillomania^[124]. Similarly, there was a Cochrane review published in 2013 which also noted that the literature do not provide strong evidence of a treatment effect for naltrexone in trichotillomania^[125].

  Regarding our case – it would have been interesting to know that this patient’s hair-pulling condition only started in his 30s. This is very unusual. We administered naltrexone as the first choice to treat not only opioid withdrawal craving but also the trichotillomania. We infer that reduced / cessation of the pulling was due to the treatment with naltrexone and not perhaps to the other medications that were started at the same time. It should be emphasized that he had previously received citalopram and valproate without any change of his trichotillomania.

  Our work clarifies that 25 mg of naltrexone could be effective in the treatment of trichotillomania. So this result may be a significant addition to the literature.

Conclusion

  Our patient stopped pulling hair shortly after starting pharmacotherapy with naltrexone, an opioid antagonist. However, we require a larger sample size to be able to generalize this finding. It looks that naltrexone is very valuable and practical for the treatment of trichotillomania. This is an original finding and a new addition to the literature.

Acknowledge:
  None to be noted

Conflict of interest:
  None to be commented.

References