Ultra Rapid Detox Programs

Study Finds Opiate Withdrawal No Easier With Ultra Rapid Detox Programs

Three serious adverse events among 35 ultrarapid procedures were all related to unreported preexisting medical conditions. BY LORI WHITTEN, NIDA Staff Writer.

Heroin-addicted patients who undergo so-called ultrarapid, anesthesia-assisted detoxification suffer withdrawal symptoms as severe as those endured by patients in detoxification by traditional methods, according to a NIDA-funded clinical trial. Researchers Dr. Eric Collins and colleagues at the College of Physicians and Surgeons of Columbia University concluded that there is no compelling reason to use general anesthesia in the treatment of opiate dependence, especially as it presents particular safety concerns. The new findings corroborate those of three international studies.

The ultrarapid detox program technique, developed about 15 years ago by clinicians who hoped to mitigate the discomfort of opiate withdrawal and speed the initiation of relapse prevention therapy, relies on a general anesthetic to sedate the patient for several hours while an opiate blocker precipitates opiate withdrawal. The method is not covered by insurance, which makes it difficult to determine how many patients have participated in the anesthesia-assisted opiate detox program.

To compare anesthesia-assisted detox with other detox approaches, Dr. Collins and colleagues enrolled 106 people seeking heroin detox at Columbia University Medical Center's Clinical Research Center. The patients, aged 21 through 50, had abused heroin every day during the past month. All spent 3 days as Center inpatients during opiate detox, then were scheduled for twice-weekly outpatient relapse prevention psychotherapy and naltrexone maintenance (50 mg/day) for 12 weeks.

The investigators randomly assigned the participants to one of three detox program methods. The goal of each method was to minimize patients' discomfort during opiate withdrawal. In the ultrarapid approach, physicians put patients under anesthesia for 4 to 6 hours while administering naltrexone, a medication that precipitates opiate withdrawal by blocking opiate molecules from their receptors in the brain. In the second method, patients remained awake and took a single dose of buprenorphine, a medication that eases opiate withdrawal symptoms by moderating and smoothing the rate of opioid clearance from the brain. In the third approach, patients also remained awake and received clonidine and other nonopioid medications as needed to counter opiate withdrawal symptoms for all 3 inpatient days. These medications were available to all groups as needed for the duration of the inpatient addiction treatment phase. Throughout detox, the researchers closely monitored patients for complications, assessed physical indications of withdrawal, and asked the participants to rate their subjective experiences.

Once awakened from anesthesia, patients in the ultrarapid detox group demonstrated and reported symptoms of discomfort comparable to those experienced by participants receiving the buprenorphine- and clonidine-assisted methods. Three patients receiving the anesthesia-assisted method experienced serious adverse events—pulmonary and psychiatric complications as well as a metabolic complication of diabetes, all of which required hospitalization. The complications were related to preexisting medical conditions that the patients had failed to reveal when they were screened for admission into the study. No adverse events occurred with the other detox methods.

Treatment outcomes among the three groups were similar. Following the detox program, the researchers offered all the patients relapse prevention therapy consisting of outpatient counseling and naltrexone, which counteracts the pleasurable effects of subsequently administered opioids. More than 90 percent of the patients who received the anesthesia- and buprenorphine-assisted detox completed naltrexone induction; only 21 percent of those receiving clonidine completed induction. By the third week, more than half the patients in all three groups had dropped out of the study; only 18 percent remained in drug addiction treatment the full 12 weeks. The percentages of patients submitting opiate positive urine samples during outpatient addiction treatment also were comparable, roughly 63 percent, across the three opiate detox program methods.

No Advantage

"Although providers advertise anesthesia-assisted detox as a fast and painless method to kick opiate addiction, the evidence does not support those statements," says Dr. Collins. "Patients should consider the many risks associated with this approach, including fluid accumulation in the lungs, metabolic complications of diabetes, and a worsening of underlying bipolar illness, as well as other potentially serious adverse events," he says. Those with preexisting medical conditions—including some psychiatric disorders, elevated blood sugar, insulin-dependent diabetes, prior pneumonias, hepatitis, heart disease, and AIDS—are particularly at risk for anesthesia-related adverse events. "Careful screening is essential with the anesthesia-assisted method, because the thought of sleeping through withdrawal is so compelling that some patients may conceal their medical histories," says Dr. Collins.

"We now have several rigorous studies indicating that anesthesia-assisted detox— a costly and risky approach—offers no advantage over other methods," says Dr. Ivan Montoya of NIDA's Division of Pharmacotherapies and Medical Consequences of Drug Abuse. Dr. Montoya notes, "The low retention of patients in subsequent outpatient treatment in the present study, which is not unusual for the opiate-addicted population, highlights the need to engage people in long-term recovery after detoxification." Naltrexone can help motivated patients stay off opiates, but many do not stick to the regimen of daily tablets because of the medication's side effects of anxiety and restlessness. Long-acting monthly injections of naltrexone, which are now available for alcoholism treatment, may work better for patients and show promise in NIDA-supported clinical trials.

Dr. Montoya also points out that with the current epidemic of prescription painkiller abuse, clinicians need more research on cost effective opiate detox methods (see "2003 Survey Reveals Increase in Prescription Drug Abuse, Sharp Drop in Abuse of Hallucinogens"). Some clinics are using buprenorphine for this purpose, and NIDA-funded investigators are studying various methods to improve prescription opiate detox programs and help patients engage in longer term addiction treatment.

Source

Collins, E.D., et al. Anesthesia-assisted vs buprenorphine- or clonidine-assisted heroin detoxification and naltrexone induction: A randomized trial. Journal of the American Medical Association 294(8):903-913, 2005. [Abstract].