Compliance to naltrexone treatment after ultra-rapid opiate detoxification: an open label naturalistic study

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.

Prediction of abstinence in opioid-dependent patients

OBJECTIVES

: Opioid detoxification with subsequent naltrexone is found to be an effective method as the first step in an abstinence-oriented approach. The aim of this study is to investigate the predictive value of variables for abstinence in opioid-dependent patients.

METHODS

: Opioid-dependent patients were followed up to 1 month after detoxification. Predictor variables were assessed at baseline, during detoxification, and at discharge. Primary outcome was abstinence assessed by analyzing urine samples and self-reports. Logistic regression was used to identify predictors of abstinence.

RESULTS

: Of 272 participants, 211 could be rated as abstinent (59.2%) or nonabstinent (40.8%) at 1 month follow-up. Significant baseline predictors were severity score of justice/police (ASI) and physical quality of life (SF-36); discharge predictors were general quality of health (SF-36) and sleeping problems (SCL-90); change in sleeping problems (SCL-90) during detoxification was also a predictor. The explained variance of these predictors was very low and clinical significance was limited.

CONCLUSIONS

: Considering the results it seems not possible to predict who will be abstinent or not 1 month after detoxification. Because rapid detoxification is found to be an effective detoxification method in selected patients, it seems warranted to recommend that patients with similar characteristics (ie, patients motivated for an abstinence-based treatment and low non-drug-related severity scores on the ASI) should be regarded as eligible for rapid detoxification.

Opioid detoxification and naltrexone induction strategies: recommendations for clinical practice

BACKGROUND

Opioid dependence is a significant public health problem associated with high risk for relapse if treatment is not ongoing. While maintenance on opioid agonists (i.e., methadone, buprenorphine) often produces favorable outcomes, detoxification followed by treatment with the μ-opioid receptor antagonist naltrexone may offer a potentially useful alternative to agonist maintenance for some patients.

METHOD

Treatment approaches for making this transition are described here based on a literature review and solicitation of opinions from several expert clinicians and scientists regarding patient selection, level of care, and detoxification strategies.

CONCLUSION

Among the current detoxification regimens, the available clinical and scientific data suggest that the best approach may be using an initial 2-4 mg dose of buprenorphine combined with clonidine, other ancillary medications, and progressively increasing doses of oral naltrexone over 3-5 days up to the target dose of naltrexone. However, more research is needed to empirically validate the best approach for making this transition.

Naltrexone maintenance for heroin dependence: uptake, attrition and retention

With naltrexone registered only recently in Australia in 1999, it is important to examine the rate of uptake of naltrexone treatment, early attrition and retention rates during treatment, in order to inform the way naltrexone is used in Australian practice. Of 317 people screened for the study, 97 participants were recruited post-withdrawal from opiates and were inducted to naltrexone after a period of at least 5 days of abstinence. While in treatment, participants received a 50-mg dose of naltrexone daily, with daily dispensing for the first 7 days, and weekly dispensing for the following 11 weeks. For the naltrexone-treated sample as a whole, the rate of uptake of naltrexone treatment was 30%, with 30% retained in treatment for the entire 12-week program. Attrition from treatment was found to be steady throughout the 12 weeks. The authors conclude that further research is required to improve withdrawal and naltrexone induction techniques and to improve medication compliance and treatment retention.

Effectiveness of low-dose naltrexone in the post-detoxification treatment of opioid dependence

BACKGROUND

The clinical use of naltrexone (NTX) in the treatment of opioid dependence has been limited because of poor compliance and inconsistent outcomes. In particular, the therapeutic benefit of extended treatment with NTX after opioid detoxification is unclear. The present study evaluated whether the augmentation with low-dose NTX during the post-detoxification treatment of opioid dependence would improve outcomes.

METHODS

In an open-label naturalistic design, 435 opioid-dependent patients who had completed inpatient detoxification were offered the choice of entering 1 of the 2 outpatient treatment arms: clonidine extended treatment (CET) (clonidine + psychosocial treatment), or enhanced extended treatment (EET) (oral NTX [1-10 mg/d] + CET) for 21 days. The primary outcome measure was retention in treatment. Secondary outcomes included abstinence from opioids, dropouts, and adherence to postdischarge care.

RESULTS

One hundred sixty-two patients (37.2%) accepted EET. Subjects receiving EET stayed longer in the program (F = 64.4; P = 0.000), were less likely to drop out, used less opioids, and followed through with referral to long-term outpatient treatment in a higher number, compared with patients in the CET arm (P = 0.000 in each case). The NTX + clonidine combination was safe and well tolerated.

CONCLUSIONS

This preliminary study indicates the potential benefit of augmentation with low-dose NTX to improve outcomes after opioid detoxification for a preferred group of patients. Randomized controlled trials are necessary to further evaluate the role of low-dose NTX in the outpatient treatment of opioid dependence.

Combating opiate dependence: a comparison among the available pharmacological options

Pharmacotherapies for heroin addiction may target opiate withdrawal symptoms, facilitate initiation of abstinence and/or reduce relapse to heroin use either by maintenance on an agonist or antagonist agent. Available agents include opioid agonists, partial opioid agonists, opioid antagonists and alpha 2 -agonists for use during managed withdrawal and long-term maintenance. Experimental approaches combine alpha 2 -agonists with naltrexone to reduce the time of opiate withdrawal and to accelerate the transition to abstinence. Recently, buprenorphine has been introduced in the US for office-based maintenance, with the hope of replicating the success of this treatment in Europe and Australia. Naloxone has been added to buprenorphine in order to reduce its potential diversion to intravenous use, whilst facilitating the expansion of treatment. Although comprehensive substance abuse treatment is not limited to pharmacotherapy, this review will focus on the rationale, indications and limitations of the range of existing medications for detoxification and relapse prevention treatments. The two major goals of pharmacotherapy are to relieve the severity of opiate withdrawal symptoms during the managed withdrawal of the opioid and to prevent relapse to heroin use either after abstinence initiation or after being stabilised on a long-acting opiate agonist, such as methadone.

Attenuation of ethanol self-administration and of conditioned reinstatement of alcohol-seeking behaviour by the antiopioid peptide nociceptin/orphanin FQ in alcohol-preferring rats

RATIONALE

Nociceptin/orphanin FQ (N/OFQ), the endogenous ligand of the opioid-like orphan receptor NOP, was shown to reduce home-cage ethanol consumption, ethanol-induced conditioned place preference and stress-induced reinstatement of alcohol-seeking behaviour.

OBJECTIVES

The present study, using genetically selected Marchigian Sardinian alcohol-preferring (msP) rats, was designed to evaluate the effect of this opioid peptide on 10% ethanol and 10% sucrose self-administration, under a fixed-ratio 1 (FR 1) or a progressive-ratio (PR) schedule of reinforcement. Furthermore, using an experimental model of relapse in which rats were trained to lever press for ethanol in the presence of the discriminative stimulus of an orange odour (S(+)) and a 1-s cue light (CS(+)) or for water in the presence of anise odour (S(-)) and 1-s white noise (CS(-)), the effect of N/oFQ on cue-induced reinstatement of extinguished ethanol responding was investigated.

RESULTS

Sub-chronic (6 days) intracerebroventricular (i.c.v.) injection of 0.5 microg or 1.0 microg N/OFQ per rat significantly reduced alcohol self-administration under both the FR 1 and PR schedules of reinforcement. Conversely, i.c.v. administration of 0.5, 1.0 or 4.0 microg of the peptide per rat did not affect sucrose self-administration. In addition, i.c.v. N/OFQ (1.0-2.0 microg per rat) significantly inhibited the reinstatement of extinguished ethanol responding under an S(+)/CS(+) condition, whereas lever pressing under S(-)/CS(-) was not altered.

CONCLUSIONS

The present study demonstrates that the reinforcing effects of ethanol are markedly blunted by activation of the opioidergic N/OFQ receptor system. Moreover, the data provide evidence of the efficacy of N/OFQ to prevent reinstatement of ethanol-seeking behaviour elicited by environmental conditioned stimuli.

Hypericum perforatum CO2 Extract and Opioid Receptor Antagonists Act Synergistically to Reduce Ethanol Intake in Alcohol-Preferring Rats

BACKGROUND

Hypericum perforatum extracts attenuate ethanol intake in alcohol-preferring rats. The opioid receptor antagonists, naloxone and naltrexone, reduce ethanol intake in rats and humans. The combination of different agents that reduce ethanol intake has been proposed as an approach to the pharmacotherapy of alcoholism. This study evaluated the effect on ethanol intake of the combined administration of a CO2 H. perforatum extract and naloxone or naltrexone in genetically selected Marchigian Sardinian alcohol-preferring rats.

METHODS

Ten percent (v/v) ethanol intake was offered 2 hr per day at the beginning of the dark phase of the reverse light-dark cycle. H. perforatum CO2 extract was given intragastrically, 1 hr before access to ethanol. Naloxone or naltrexone was given by intraperitoneal injection 10 min before the extract.

RESULTS

H. perforatum CO2 extract reduced ethanol intake at 31 or 125 mg/kg, but not 7 mg/kg. These doses neither modified food or water intake during access to ethanol, nor reduce 0.2% saccharin intake. Naloxone reduced ethanol and food intake at 3 or 5 mg/kg, but not 1 mg/kg. When naloxone 1 mg/kg was combined with the three doses of H. perforatum CO2 extract, the attenuation of ethanol intake was more pronounced than that observed after the administration of the extract alone. Alcohol intake was also significantly reduced by 7 mg/kg of H. perforatum CO2 extract combined with naloxone 1 mg/kg. The combined treatments never modified the rat's locomotor activity nor the simultaneous intake of food, water or 0.2% saccharin. Naltrexone reduced ethanol intake at 1 and 3 mg/kg, but not at 0.5 mg/kg. When naltrexone 0.5 mg/kg was combined with H. perforatum CO2 extract 7 mg/kg, ethanol intake was markedly reduced.

CONCLUSIONS

These findings provide evidence that H. perforatum CO2 extract and opiate receptor antagonists act synergistically to induce a pronounced and selective reduction of voluntary ethanol consumption in alcohol-preferring rats.

Prolonged activation of mesolimbic dopaminergic neurons by morphine withdrawal following clonidine: participation of imidazoline and norepinephrine receptors

The alpha2 adrenoceptor (alpha2R) agonist clonidine is used as a treatment for heroin addiction. Substantial evidence indicates that dopaminergic and noradrenergic systems have key roles in opiate dependence and withdrawal but the possible interactions between these two pathways remain unclear. The objective of this study was to establish the effects of clonidine pretreatment on ventral tegmental area dopaminergic (VTA DA) neuronal activity during morphine withdrawal. Responses of VTA DA neurons to withdrawal precipitated by naltrexone were characterized in anesthetized rats using extracellular recordings. As expected, withdrawal produced a marked inhibition of VTA DA neuronal activity. However, pretreatment with clonidine prevented this inhibition induced by withdrawal, and instead produced a long-lasting activation of firing rate (+50%) and burst firing (+19%). In contrast, pretreatment with a more selective alpha2R agonist, UK14304, did not prevent the inhibition of VTA DA neuron activity during withdrawal. We tested whether the high affinity of clonidine for imidazoline-1 receptors (I1Rs) was responsible for the difference between these two alpha2R agonists. In morphine-dependent rats pretreated with rilmenidine (mixed alpha2R/I1R agonist), precipitation of withdrawal elicited a 22% increase of VTA DA impulse activity. The action of clonidine on I1Rs was studied by coadministering clonidine with RX821002, a specific alpha2R antagonist. Pretreatment with RX821002 plus clonidine prevented the inhibition of VTA DA activity during withdrawal but failed to produce excitation. These results indicate that the pharmacological effects of clonidine on VTA DA neurons during morphine withdrawal is related to actions on I1Rs as well as alpha2Rs.

Ultra-rapid opiate detoxification using deep sedation and prior oral buprenorphine preparation: long-term results

BACKGROUND

New methods of ultra-rapid opiate detoxification (URD) under intravenous sedation have been criticized because of limited data on safety and long-term follow-up. Premedication with buprenorphine has been advocated to improve safety by decreasing vomiting. Prior research has not explored URD in socially impaired patients.

METHOD

Sixteen patients were detoxified with URD and prospectively evaluated over at least 30 months. Data of this procedure were compared with those of our previous study without buprenorphine preparation (Drug Alcohol Depend. 52(3) (1998) 243). The 16 patients were followed up by a general practitioner (GP) before and after URD. The GPs also supervised the 7-day course of buprenorphine treatment prescribed for the 16 patients prior to URD.

RESULTS

During the procedure, only one episode of vomiting occurred instead of 13 out of 20 in our previous study. Post-procedure, only two patients experienced moderate withdrawal symptoms, such as persistent nausea, abdominal cramps and vomiting lasting from 24 to 48 h, in comparison with most patients in the previous study without buprenorphine. After a period of at least 30 months (36.0+/-6.38), the 16 patients were still alive and were regularly monitored by their GP. Only two of the 16 never relapsed after URD and reported total opiate abstinence. Fourteen patients relapsed; 12 of these were prescribed a licensed methadone substitution program and two were still using heroin.

CONCLUSION

In this small sample, the data indicated that URD with buprenorphine preparation was safe and that it markedly decreased post-procedure morbidity. No patient died over a minimum 30-month follow-up period. Furthermore, the procedure was employed with socially impaired patients. In the long term, a few patients were still free of opiates, while the majority opted for a methadone maintenance program, showing that URD can serve as one possible step in a long-term treatment program.

Treatment of heroin (diamorphine) addiction: current approaches and future prospects

New pharmacological treatments for heroin (diamorphine) addiction include drugs that reduce opiate withdrawal symptoms and agents that are given during the maintenance phase of treatment. A variety of different types of pharmacological agents (opioid agonists, partial opioid agonists, opioid antagonists and alpha(2)-adrenoreceptor agonists) are reviewed and the evidence of their use during managed withdrawal and maintenance are presented. Experimental approaches attempting to reduce the time of opiate withdrawal and to accelerate the transition to abstinence are being developed. The combination tablet of buprenorphine and naloxone that is to be introduced for office-based maintenance is currently undergoing intense evaluation in the US. This new approach may facilitate the expansion of treatment while reducing the potential for medication diversion and intravenous use.

Lofexidine versus clonidine in rapid opiate detoxification

The aim of the present study is to evaluate lofexidine and clonidine, in an accelerated opiate detoxification procedure (3 days), without anaesthesia. Forty heroin-dependent individuals were detoxified, evaluating withdrawal symptoms, craving levels, mood changes, urine toxicologic screens, and dropout during therapy with either (1) clonidine, oxazepam, baclofen, and ketoprofene, with naloxone and naltrexone for 3 days (20 subjects) or (2) lofexidine, oxazepam, baclofen, and ketoprofene with naloxone and naltrexone for 3 days (20 subjects). Both clonidine and lofexidine rapid detoxifications were found effective. The subjects treated with lofexidine showed significantly lower levels of withdrawal symptoms, fewer mood problems, less sedation and hypotension. No significant differences in craving levels, morphine metabolites in urine, or dropout rate were evidenced between the two groups. The early use of naltrexone during detoxification in combination with either alpha-2-agonist facilitated the acceptance for long-term naltrexone treatment. Lofexidine appeared to be more useful than clonidine in a 3-day accelerated opiate detoxification, not only to counteract withdrawal symptoms, but also in the treatment of dysphoria and mood changes. Because lofexidine does not produce hypotension, safe outpatient treatment, without hospital support, could be possible.

Plasma naltrexone during opioid detoxification

Orogastric naltrexone is used for opioid detoxification, but it is not known how gastric absorption affects plasma concentrations of the drug. We measured plasma naltrexone during orogastric naltrexone, given in repeated doses of 12.5 mg, 25 mg, 50 mg and 50 mg. Plasma naltrexone was measured after each naltrexone dose. The increase in plasma naltrexone was highly variable between patients during orogastric administration. Adequate detoxification was questioned in 4 of 10 patients because plasma naltrexone did not increase above 5 ng/ml. There was a negative correlation between plasma naltrexone and the presence of withdrawal symptoms on the day after the procedure (r = -0.78, P < 0.05). These results show that the increase in plasma naltrexone is variable during orogastric administration and this may impair successful detoxification.

Ultrarapid opioid detoxification: effects on cardiopulmonary physiology, stress hormones and clinical outcomes

This study explored the acute and long-term consequences of ultrarapid opioid detoxification (URD) in individuals with opioid dependence. In an open case series, seven patients underwent URD and subsequent treatment with daily naltrexone. Structured interviews, integrated rehabilitation and hair sampling were employed in the 12-week course of longitudinal follow-up. Cardiac and pulmonary physiology did not change significantly during the anesthesia phase of URD, but plasma ACTH and cortisol levels increased 15- and 13-fold, respectively. Marked withdrawal and tachypnea in all patients and respiratory distress in one patient occurred during the acute post-anesthesia phase. Withdrawal scores were significantly elevated for 3 weeks compared with baseline in the face of minimal self-reported craving for opioids. Anxiety, depression and vegetative symptoms improved gradually. Four patients remained abstinent of opioid use, two reported a brief period of opioid intake and one relapsed into daily opioid consumption. Given its effect on breathing and stress hormones, this procedure should be conducted by experienced anesthesiologists. The fact that URD and subsequent naltrexone treatment appears to cause a dissociation effect in the usual relationship between withdrawal and craving has implications for behavioral pharmacology. Further research is needed on the efficacy, safety, mechanisms and neurobiological sequelae of the procedure.

A compressed opiate detoxification regime with naltrexone maintenance: patient tolerance, risk assessment and abstinence rates

Opiate detoxification using methadone programmes are inefficient and expensive. Rapid and ultra-rapid detoxification using precipitated withdrawal under heavy sedation or anaesthesia provide increased efficiency and speed, but are limited by the requirement for high-dependency facilities and are perceived as high-risk procedures. Procedures using precipitated withdrawal over longer periods with lower sedation are safer, but 20% of patients fail to tolerate these. Here we evaluate a naltrexone compressed opiate detoxification (NCOD) protocol. We investigated patient acceptance, organ function and abstinence rates on 504 consecutive patients undergoing treatment at the Harrogate Detox5 centre between February 1996 and January 1999. Ninety-eight per cent of patients completed the procedure; 81% of patients reported withdrawal was "better than expected". Only 3% of patients reported any pain. Laboratory investigations demonstrated no organ dysfunction. Abstinence rates post-detox were high with 71%, 61% and 51% of patients free of opiates 3, 6 and 12 months post-detox, respectively. Compliance with the naltrexone maintenance in abstinent patients was 66%, 68% and 30% at these time points. This NCOD protocol provides an efficient method of detoxifying opiate abusers with little patient discomfort or risk to health. Abstinence rates are better than those in comparable studies using other programmes.

Outcome and six month follow up of patients after Ultra Rapid Opiate Detoxification (UROD)

OBJECTIVES

(1) Evaluate the safety and efficacy of Ultra Rapid Opiate Detoxification (UROD); and (2) evaluate six month outcome data of patients choosing this method.

DESIGN

Two center parallel group clinical trial. No grant funding.

SETTING

Two academic medical centers.

PARTICIPANTS

Ninety-three men and 27 women, aged 18 to 55 years, with opiate dependency self selected to undergo detoxification.

INTERVENTIONS

UROD followed by naltrexone maintenance and an aftercare program. UROD and aftercare costs were the responsibility of the patients and/or their significant others.

MAIN OUTCOMES MEASURE

(1) Completion of UROD as determined by a non reactive response to a naloxone challenge test under anesthesia and non reactive response to naltrexone administration before discharge. (2) Patient outcome as determined at six month follow up of UROD patients' self reported relapse free status confirmed by urine drug screen, significant other reports, and/or therapist reports.

RESULTS

One hundred percent successful detoxification with UROD with low morbidity and no mortality. Relapse data were available for 111/123 procedures performed (90%), with 61/111 patients (55%) with reported relapse free status at the six month follow up interval.

CONCLUSIONS

For individuals who are addicted to opioids, the Ultra Rapid Opiate Detoxification method appears to be a viable treatment option.

Pharmacologic treatment of heroin-dependent patients

Patients with heroin dependence frequently present to internists and other physicians for heroin-related medical, psychiatric, and behavioral health problems and often seek help with reducing their heroin use. Thus, physicians should be familiar with the identification and diagnosis of heroin dependence in their patients and be able to initiate treatment of heroin dependence both directly and by referral. Recent research has provided much information concerning effective pharmacologically based treatment approaches for managing opioid withdrawal and helping patients to remain abstinent Methadone maintenance and newer approaches using L-alpha acetylmethadol and buprenorphine seem to be particularly effective in promoting relapse prevention. Although these treatments are currently provided in special drug treatment settings, recent and ongoing research indicates that the physician's office may be an effective alternative site for these treatments.

Nociceptin/orphanin FQ and drugs of abuse

Nociceptin/orphanin FQ (NC) binds with high affinity to the opioid receptor-like1 (ORL1) receptor. NC has been reported to block opioid-induced supraspinal analgesia, and it has been proposed that it may represent a functional antiopioid peptide in the control of brain nociceptive processes. The wide distribution of NC and of its receptors in the central nervous system suggests, however, that it may be involved in the control of a variety of biologic functions. Increasing evidence indicates that it may influence the rewarding and reinforcing properties of drugs of abuse. NC has been shown to abolish the rewarding properties of ethanol and morphine in the place conditioning paradigm, to reduce ethanol consumption in alcohol-preferring rats and to inhibit stress-induced alcohol-seeking behavior. These findings suggest that drugs directed at central NC receptors may represent an interesting approach to the treatment of ethanol and opiate abuse.

The physical and psychosocial consequences of opioid addiction: an overview of changes in opioid treatment

This paper examines a selection of the current literature to gain information concerning opioids, addiction profiles, public opinion, legal issues and withdrawal protocols. Hundreds of Australians have died at a young age due to the complications of their own opioid misuse. This paper outlines what has been achieved in recent times in the management of people withdrawing from opioid misuse, as well as reviewing the new evidence that offers hope for faster opioid withdrawal and rehabilitation.

Rapid opiate detoxication in outpatient treatment: relationship with naltrexone compliance

A variety of detoxification methods have been utilized for the treatment of heroin withdrawal before individuals begin long-term opiate-free and naltrexone programs. While methadone in decreasing doses is still widely used for detoxication procedures, rapid and ultrarapid protocols including clonidine and opiate receptors antagonists have been proposed. This study compares the efficacy of different detoxification methods and investigates possible changes in naltrexone compliance. Ninety-eight heroin-addicted individuals were studied to evaluate withdrawal symptoms, craving, mood, urine toxicologic screens, and drop-out rate during therapy with: Group A: clonidine only (5 days); Group B: clonidine, oxazepam, baclofen, and ketoprofene with naloxone and naltrexone (2 days); and Group C: methadone in decreasing doses (10 days). Naltrexone compliance and relapse rates were evaluated during a 6-month follow-up period. Rapid detoxification with opiate antagonists (Group B) induced slight and transient withdrawal symptoms, and resulted in a significantly lower percentage of heroin catabolites in urine controls during the detoxification procedure, lower negative and positive craving, less mood problems, and higher compliance in extended naltrexone treatment. In comparison with clonidine only (Group A) and methadone (Group C), the early use of naltrexone during detoxification in combination with benzodiazepines and clonidine facilitated extended naltrexone acceptance and improved the recovery outcome in outpatients.

Safety, efficacy, and long-term results of a modified version of rapid opiate detoxification under general anaesthesia: a prospective study in methadone, heroin, codeine and morphine addicts

BACKGROUND

In the present study a method of rapid opiate detoxification under general anaesthesia has been evaluated regarding the safety, the efficacy in preventing withdrawal symptoms, and the long-term results. In addition, it was investigated whether the profile and severity of withdrawal symptoms depend on the type of opiate abused (methadone, heroin, codeine, morphine).

METHODS

Seventy-two opiate addicts were detoxified in an intensive care unit (ICU). Anaesthesia was induced and maintained using propofol infusion. Patients were endotracheally intubated. The opiate receptor antagonist naltrexon was administered into the stomach via a nasogastric tube. Withdrawal symptoms before and after the detoxification treatment were assessed using an objective and a subjective opiate withdrawal scale (OOWS, SOWS). After detoxification patients entered a long-term naltrexone maintenance programme as well as a supportive psychotherapy programme. Vital organ function was monitored using haemodynamic and respiratory parameters as well as body temperature.

RESULTS

Organ function parameters were stable during the whole treatment in all patients and no anaesthetic complications were registered. Minor side effects such as bradycardia or hypotension were observed in 20 patients. Compared to patients with pre-existing heroin, codeine, or morphine abuse respectively, patients from the methadone maintenance programme had significantly higher (P<0.01) OOWS as well as SOWS values after the treatment. Twelve months after the detoxification 49 patients (68%) were abstinent from opiates whereas 17 patients had relapsed during the period of follow-up. Six patients were lost during follow-up.

CONCLUSIONS

Rapid opiate detoxification under general anaesthesia is a safe and efficient method to suppress withdrawal symptoms. This treatment may be of benefit in patients who particularly suffer from severe withdrawal symptoms during detoxification and who have failed repeatedly to complete conventional withdrawal. Methadone patients have more withdrawal symptoms than other opiate addicts.

A method of reducing the opioid withdrawal intensity using progressively increasing doses of naloxone

We assessed the withdrawal intensity in acutely morphine-dependent mice using a pretreatment with escalating doses of naloxone. All animals received a single dose of morphine (100 mg/kg) for the induction of acute opioid dependency. Group 1 (control) received three injections of normal saline and then naloxone 0.8 mg/kg. Group 2 received increasing pretreatment doses of naloxone (0.1, 0.2, and 0.4 mg/kg) and a challenge dose of 0.8 mg/kg. Group 3 received three injections of naloxone 0.1 mg/kg and a challenge dose of 0.8 mg/kg. Groups 4 and 5 were used to verify whether ED(50) found in previous studies was comparable with values obtained in the current experiments. The withdrawal intensity was determined by the number of jumps. The mice of group 1 exhibited significantly more jumps after 0.8 mg/kg of naloxone as compared with group 2. The number of jumps in response to naloxone between groups 1 and 2 and groups 2 and 3 was not significantly different. The results show that pretreatment with increasing naloxone doses significantly reduced the withdrawal intensity as compared with the control group; whereas pretreatment with repeated low antagonist did not reduce it significantly.

A pilot study of naltrexone-accelerated detoxification in opioid dependence

OBJECTIVE

1. To determine whether naltrexone-accelerated detoxification with minimal sedation is an acceptable and effective form of induction onto naltrexone. 2. To monitor outcomes of detoxified patients.

DESIGN

Observational study.

SETTING

Medical ward of a general hospital (for detoxification) and a community clinic (for follow-up) in Sydney, NSW, 1998.

PATIENTS

15 heroin users and 15 people seeking withdrawal from methadone.

INTERVENTION

Detoxification used naltrexone (12.5 or 50 mg), with flunitrazepam (2-3 mg), clonidine (150-750 micrograms) and octreotide (300 micrograms) for symptomatic support. Patients remained awake and were discharged when they felt well enough. Follow-up was daily for four days and then weekly for up to three months for supportive care.

MAIN OUTCOME MEASURES

Acute side effects; patient ratings of severity and acceptability of withdrawal; nights of hospitalisation; rates of induction onto naltrexone; retention in treatment over three months; and relapse to opioid use.

RESULTS

Acute withdrawal with delirium lasted about four hours. Octreotide was crucial for controlling vomiting; with octreotide no patient required intravenous fluids. There were no major complications. Eighteen patients (60%) reported that it was a "quite" acceptable procedure, 18 (60%) required only one night's hospitalisation, and 24 (80%) were successfully inducted onto naltrexone (defined as taking naltrexone on Day 8). Three months later, six (20%) were still taking naltrexone (with four of these occasionally using heroin) and seven (23%) were abstinent from opioids, including five not taking naltrexone. Eleven had gone onto methadone maintenance, seven had relapsed to heroin use, and one had died of a heroin overdose.

CONCLUSIONS

Rates of induction onto naltrexone were comparable with those reported for accelerated detoxification under sedation, suggesting that it can be performed successfully with minimal sedation. As in other studies of naltrexone maintenance, retention was low, and relapse to heroin use was common.

Ultra-rapid opioid detoxification increases spontaneous ventilation

STUDY OBJECTIVE

To evaluate the effect of ultra-rapid opioid detoxification on spontaneous respiration.

DESIGN

Prospective study.

SETTING

University of Illinois, Chicago, Hospital.

PATIENTS

20 ASA physical status I and II patients undergoing ultra-rapid opioid detoxification, and 5 ASA physical status I and II control patients undergoing surgical procedures.

INTERVENTIONS

Ultra-rapid opioid detoxification patients were anesthetized with propofol, intubated, and spontaneously ventilating. Opioid detoxification was achieved by giving repeated increasing intragastric doses of naltrexone. Control patients were anesthetized with propofol and 70% nitrous oxide and were time-based controls for opioid detoxification.

MEASUREMENTS AND MAIN RESULTS

Respiratory rate and minute ventilation were measured and increased 80% to 100% during opioid detoxification (p < 0.05). Respiratory rate and minute ventilation did not change in controls. Oxygen consumption and carbon dioxide (CO2) production were measured in separate studies and increased during ultra-rapid opioid detoxification with increases in spontaneous ventilation, but not when the patients were paralyzed.

CONCLUSIONS

Spontaneous ventilation increases during opioid detoxification without a change in end-tidal CO2. An increase in metabolism is produced in opioid withdrawal that is mediated by elevated muscle activity.

Endogenous opiates: 1997

This paper is the twentieth installment of our annual review of research concerning the opiate system. It summarizes papers published during 1997 that studied the behavioral effects of the opiate peptides and antagonists, excluding the purely analgesic effects, although stress-induced analgesia is included. The specific topics covered this year include stress; tolerance and dependence; eating and drinking; alcohol; gastrointestinal, renal, and hepatic function; mental illness and mood; learning, memory, and reward; cardiovascular responses; respiration and thermoregulation; seizures and other neurologic disorders; electrical-related activity; general activity and locomotion; sex, pregnancy, and development; immunologic responses; and other behaviors.