Ultrarapid opiate detoxification: a review

Naltrexone Implant for Opioid Use Disorder

The continued rise in the availability of illicit opioids and opioid-related deaths in the United States has left physicians, researchers, and lawmakers desperate for solutions to this ongoing epidemic. The research into therapeutic options for the treatment of opioid use disorder (OUD) began with the introduction of methadone in the 1960s. The approval of oral naltrexone initially showed much promise, as the drug was observed to be highly potent in antagonizing the effects of opioids while producing no opioid agonist effects of its own and having a favorable side effect profile. Patients that routinely take their naltrexone reported fewer days of heroin use and had more negative drug tests than those without treatment. Poor outcomes in OUD patients treated with naltrexone have been directly tied to short treatment time. Studies have shown that naltrexone given orally vs. as an implant at the 6-month interval showed a higher non-compliance rate among those who used oral medications at the 6-month mark and a slower return to use rate. There were concerns that naltrexone could possibly worsen negative symptoms seen in opiate use disorder related to blockade of endogenous opioids that are important for pleasurable stimuli. Studies have shown that naltrexone demonstrated no increase in levels of anxiety, depression and anhedonia in participants and another study found that those treated with naltrexone had a significant reduction in mental health-related hospitalizations. The latter study also concluded that there was no increased risk for mental health-related incidents in patients taking naltrexone via a long-acting implant. Although not yet FDA approved in the United States, naltrexone implant has shown promising results in Europe and Australia and may provide a novel treatment option for opioid addiction.

Six-month follow-up study of ultrarapid opiate detoxification with naltrexone

Background:

Illicit opiate use has an increasing incidence and prevalence, which increases mortality and morbidity, marginalization, and criminal behaviors, and causes major adverse effects on society.

Objectives:

This study aimed to investigate and follow the outcome of patients who underwent ultrarapid opiate detoxification (UROD) prospectively.

Patients and Methods:

In this randomized clinical trial, 64 patients who underwent UROD were evaluated. The opiate antagonist regimen of naloxone was administered intravenously under general anesthesia, and detoxification was confirmed by naloxone challenge test. All patients were cared in intensive care unit (ICU) for 24 hours, and oral naltrexone was prescribed the next day, after recovery and discharge. Patients were followed up for one month after the procedure. Relapse was considered if routine use of opiates (daily use for at least two weeks) was reported by the patient after detoxification. The data was analyzed by SPSS 16.5 and the study was performed using descriptive analysis and Chi square test.

Results:

All 64 participants were opiate-dependent males (ASA physical status of I or II) who aged over 18 years with a mean age of 31.11 ± 8.93 years at the time of UROD. One month after UROD, 48 patients (75%) reported relapse and 16 (25%) reported abstinence; however, four patients of the non-relapsed group reported one episode of opiate use. There was no significant difference between relapsed and non-relapsed patients regarding their marital status, level of education, and family history of opiate dependency (P > 0.05).

Conclusions:

Although UROD by naloxone is a safe and effective method of detoxification, if used alone, it has a very high relapse rate in long term.

Comparison of sodium diclofenac, ketamine and propofol with fentanyl and midazolam in balanced anaesthesia

Context:

Analgesia is based on balanced anaesthesia, which is usually maintained by administration of narcotic agents. In some patients, it is not possible to use narcotics. We compared hemodynamic changes, anaesthesia depth, emetic sequelae and post-operative pain between sodium Diclofenac, Ketamine-Propofol (DKP) and Fentanyl-Midazolam (FM).

Aims:

The effectiveness of an anaesthetic technique employing sodium was compared against in patients undergoing elective surgery.

Settings and Design:

In a clinical trial study, 82 patients who attended for an elective surgery were randomly divided into two groups.

Materials and Methods:

In DKP group pre-medication included Sodium Diclofenac 1 mg/kg and Midazolam 0.02 mg/kg, whereas, in FM group they were Fentanyl 2 μg/kg and Midazolam 0.02 mg/ kg. Anaesthesia induction in both groups was the same. Anaesthesia was conserved in DKP group by using Propofol plus Ketamine infusion plus N₂O 50% and in FM group with Fentanyl plus Midazolam plus N₂O 50%. Hemodynamic changes, depth of anaesthesia, nausea and vomiting, post operative analgesic effects were recorded.

Results:

Hemodynamic changes and depth of anaesthesia were similar throughout the maintenance phase in two groups. In FM group, significant increase in heart rate was recorded in recovery room. Pain score according to visual analogue scale (VAS) and need for analgesics, was significantly more in FM group compared to DKP group (P = 0.000). No patient suffered from nausea, vomiting or hallucinations.

Conclusions:

This study revealed that intravenous administration of Sodium Diclofenac along with Ketamine and Propofolplus N₂O 50% for general anaesthesia provides a balanced anaesthesia as well as hemodynamic stability, and adequate depth of anaesthesia. It also reduces the postoperative pain and need for narcotics. We recommended DKP plus N₂O 50% method for patients prohibited from opioid administration. It will be an acceptable method in sensitive patients.

[Anesthesia in drug addiction]

The growing social problem of drug abuse has increased the likelihood that anesthesiologists will find acute or chronic drug users among patients requiring anesthesia for elective or emergency surgery. We must therefore be aware of the effects drugs have on the organism and their possible pharmacokinetic and pharmacodynamic interactions with anesthetic agents in order to prevent complications during surgery and postoperative recovery. Such knowledge is required for the management of abstinence syndrome or overdose, which pose the greatest potential dangers for the hospitalized drug addict.

Co-administration of ultra-low dose naloxone attenuates morphine tolerance in rats via attenuation of NMDA receptor neurotransmission and suppression of neuroinflammation in the spinal cords

Although mechanisms underlying ultra-low dose naloxone-induced analgesia have been proposed, possible interactions with glutamatergic transmission and glial cell activation have not been addressed. In the present study, we examined the effect of ultra-low dose naloxone on spinal glutamatergic transmission and glial cell activity in rats chronically infused with morphine. In male Wistar rats, intrathecal morphine infusion (15microg/h) for 5days induced (1) antinociceptive tolerance, (2) downregulation of glutamate transporters (GTs) GLT-1, GLAST, and EAAC1, (3) increasing of NMDA receptor (NMDAR) NR1 subunit expression and phosphorylation, (4) upregulation of protein kinase C gamma (PKCgamma) expression, and (5) glial cell activation. On day 5, morphine challenge (15microg/10microl) caused a significant increase in the concentration of the excitatory amino acids (EAAs) aspartate and glutamate in the spinal CSF dialysates of morphine-tolerant rats. Intrathecal co-infusion of ultra-low dose naloxone (15pg/h) with morphine attenuated tolerance development, reversed GTs expression, inhibited the NMDAR NR1 subunit expression and phosphorylation, and PKCgamma expression, inhibited glial cell activation, and suppressed the morphine-evoked EAAs release. These effects may result in preservation of the antinociceptive effect of acute morphine challenge in chronic morphine-infused rats. Ultra-low dose naloxone infusion alone did not produce an antinociceptive effect. These findings demonstrated that attenuation of glutamatergic transmission and neuroinflammation by ultra-low dose naloxone co-infusion preserves the lasting antinociceptive effect of morphine in rats chronically infused with morphine.

Evidenced-based treatment of opioid-dependent patients

OBJECTIVE

To provide an overview of treatment options for opioid-dependent patients.

METHOD

We screened all published studies on the treatment of opioid dependence, with a special focus on systematic literature reviews, formal metaanalyses, and recent trials.

RESULTS

Both clinical experience and neurobiological evidence indicate that opioid dependence is a chronic relapsing disorder. Treatment objectives depend on the pursued goals: crisis intervention, abstinence-oriented treatment (detoxification and relapse prevention), or agonist maintenance treatment. The high quality of solid evidence in the literature demonstrates that there are numerous effective interventions available for the treatment of opioid dependence. Crisis intervention, frequently necessary owing to the high overdose rate, can be effectively handled with naloxone. Abstinence-oriented interventions are effective for only a few motivated patients with stable living conditions and adequate social support. Agonist maintenance treatment is considered the first line of treatment for opioid dependence. Numerous studies have shown efficacy for methadone and buprenorphine treatment, while maintenance with other agonists is also becoming available to a greater extent. Maintenance treatment with diamorphine should be made available for the small group of treatment-resistant, severely dependent addicts. Other harm-reduction measures can serve to engage individuals with opioid addiction who are not in treatment.

CONCLUSION

Opioid dependence is a chronic relapsing disease that is difficult to cure, but effective treatments are available to stabilize patients and reduce harm, thereby increasing life expectancy and quality of life.

A systematic review of the effectiveness of naltrexone in the maintenance treatment of opioid and alcohol dependence

This systematic review summarises evidence of the effectiveness of naltrexone (NTX) and the added value of psychosocial treatment in the maintenance treatment of opioid and alcohol dependence. Studies were selected through a literature search conducted in March 2004. Seven opioid and seventeen alcohol studies were identified. When possible, meta-(regression) analyses were performed. There is lack of evidence about the effectiveness of NTX in the maintenance treatment of opioid dependence. There is evidence for the effectiveness and applicability of NTX in the management of alcohol dependence. The opioid studies combined NTX with a variety of psychosocial interventions, which plagued the evaluation of their value. Concomitant psychosocial interventions used in the alcohol studies were mainly cognitive behavioural, which seems to be more effective than NTX combined with supportive therapy. Available data do not allow firm conclusions regarding the added effect of psychosocial interventions. However, the data suggest that a combination of naltrexone with cognitive behavioural relapse prevention therapy is beneficial in alcohol dependent patients.

Anesthetic management of the illicit-substance-using patient

PURPOSE OF REVIEW

During the last few years, drug abuse has risen to the point that almost 20 million Americans are current abusers of illicit substances. These patients present to us as anesthesiologists in a variety of circumstances: in obstetrics for labor and emergencies, in trauma for emergency surgeries or life-saving (resuscitative) situations and in everyday elective surgeries. Therefore it is important for anesthesiologists to know about the most common illicit drugs being used, to know their side effects and clinical presentation if abused or intoxicated, and to know what anesthetic options would be beneficial or detrimental.

RECENT FINDINGS

In this article we will review some of the most commonly used illicit drugs, their effects on the organ systems and some tips to take into consideration when providing anesthesia for these patients. We will discuss marijuana, cocaine, opioids, hallucinogens, solvents and the newer so-called rave or club drugs. Newer treatment options for opioid detoxification will also be discussed.

SUMMARY

Illicit substance abuse is a major health concern in the United States. Drug use, either acute or chronic, has potentially grave consequences which include changes affecting the pulmonary, cardiovascular, nervous, renal and hepatic systems. Anesthesiologists come into contact with these patients in emergency and everyday situations. Due to the diverse clinical presentations that may arise from single substance or polysubstance abuse, anesthetic management should be tailored to each individual and universal precautions should always be followed when providing care.