Ultra-rapid, antagonist-precipitated opiate detoxification under general anaesthesia or sedation

Ultra-rapid opiate detoxification in hospital

Aims and method

To evaluate ultra-rapid opiate detoxification under sedation. Symptom control was analysed in the first 12 hours of detoxification in 20 patients and case notes were examined 12 weeks later for outcome.

Results

Good symptom control was achieved, except for restlessness. At 12 weeks 25% patients were abstinent.

Clinical implications

While long-term outcome is similar to conventional methadone detoxification, the ultra-rapid technique is safe, more acceptable to patients and more cost-effective.

English and American Drug Clients' Views of the Acceptability, Advantages, and Disadvantages of Treatment and Harm Reduction Interventions

Although drug abusers present to clinics and drop-in centers requesting various treatments and harm reduction interventions, clinicians and administrators have little direct empirical evidence of the degree to which clients find various therapies acceptable or the perceived advantages and disadvantages of specific interventions. A structured interview was administered to 48 male and female outpatient or detoxification ward clients in Nottingham, England, and 40 female residential treatment program clients in Northwest Ohio, to assess the acceptability of and related attitudes regarding a broad range of interventions. Large proportions of respondents in both samples, and especially in the English sample, reported somewhat or complete acceptance of various abstinence-oriented treatments and harm reduction interventions for those still taking drugs. Respondents also discriminated among these interventions, as evidenced by differing levels of acceptance of many and outright rejection of other interventions. Although there were differences in acceptance and experience of the specific interventions between the two samples, respondents in both countries provided balanced appraisals of the advantages and disadvantages of each intervention.

Rapid opiate detoxification and antagonist induction under general anaesthesia or intravenous sedation is humane, sometimes essential and should always be an option. Three illustrative case reports involving diabetes and epilepsy and a review of the literature

When abstinence is an appropriate goal, controlled studies and systematic reviews confirm that rapid, antagonist-precipitated opiate withdrawal procedures are the most effective and cost effective methods of initiating abstinence, and naltrexone (NTX) maintenance. While 'rapid' withdrawal, better conceptualised as Rapid Antagonist Induction (RAI), can often be humanely achieved with modest sedation levels, we present three case histories to support our argument that for some patients, general anaesthesia (GA), or techniques of intravenous sedation (IVS) that approach GA, are essential for safety and success. This includes patients with intercurrent disease (e.g. epilepsy or insulin-dependent diabetes) but also those with severe withdrawal phobia after previous distressing experiences. We discuss the history of the procedure. The dangers of RAI under GA or IVS in experienced hands have been exaggerated and the appropriate expertise should be more easily available. Patients and clinicians readily accept risks of major surgery for the excessive intake of food that causes most obesity. Similar risk-acceptance exists in cosmetic surgery and obstetrics. The increasing use and effectiveness of long-acting implants or depot-injections of NTX for relapse-prevention have largely solved compliance problems that undermined the potential of oral NTX. Their ability to prevent opiate overdose in abstinent, non-tolerant patients also strengthens arguments both for offering RAI as a therapeutic option and for reducing psychological, professional and practical barriers to using it.

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.

[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.

Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal

BACKGROUND

Withdrawal (detoxification) is necessary prior to drug-free treatment or as the end point of long-term substitution treatment.

OBJECTIVES

To assess the effectiveness of opioid antagonists to induce opioid withdrawal with concomitant heavy sedation or anaesthesia, in terms of withdrawal signs and symptoms, completion of treatment and adverse effects.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2009), Medline (January 1966 to 11 August 2009), Embase (January 1985 to 2009 Week 32), PsycINFO (1967 to July 2009), and reference lists of articles.

SELECTION CRITERIA

Controlled studies of antagonist-induced withdrawal under heavy sedation or anaesthesia in opioid-dependent participants compared with other approaches, or a different regime of anaesthesia-based antagonist-induced withdrawal.

DATA COLLECTION AND ANALYSIS

One reviewer assessed studies for inclusion, undertook data extraction and assessed quality. Inclusion decisions and the overall process were confirmed by consultation between all authors.

MAIN RESULTS

Nine studies (eight randomised controlled trials) involving 1109 participants met the inclusion criteria for the review.Antagonist-induced withdrawal is more intense but less prolonged than withdrawal managed with reducing doses of methadone, and doses of naltrexone sufficient for blockade of opioid effects can be established significantly more quickly with antagonist-induced withdrawal than withdrawal managed with clonidine and symptomatic medications. The level of sedation does not affect the intensity and duration of withdrawal, although the duration of anaesthesia may influence withdrawal severity. There is a significantly greater risk of adverse events with heavy, compared to light, sedation (RR 3.21, 95% CI 1.13 to 9.12, P = 0.03) and probably with this approach compared to other forms of detoxification.

AUTHORS' CONCLUSIONS

Heavy sedation compared to light sedation does not confer additional benefits in terms of less severe withdrawal or increased rates of commencement on naltrexone maintenance treatment. Given that the adverse events are potentially life-threatening, the value of antagonist-induced withdrawal under heavy sedation or anaesthesia is not supported. The high cost of anaesthesia-based approaches, both in monetary terms and use of scarce intensive care resources, suggest that this form of treatment should not be pursued.

Emergency management of inadvertent accelerated opiate withdrawal in dependent opiate users

Six opiate-dependent drug users presented to the local emergency department within a 10-day period with symptoms of severe opioid withdrawal immediately following intravenous use of recently acquired street 'heroin'. The withdrawal picture was similar to that described in patients undergoing rapid opioid detoxification, suggesting that the substance injected was contaminated with an opiate antagonist. A number of potential compounds are discussed, including naltrexone and buprenorphine, and recommendations for the medical management of severe opiate withdrawal within an emergency setting are outlined. [Lubman DI, Koutsogiannis Z, Kronborg I. Emergency management of inadvertent accelerated opiate withdrawal in dependent opiate users.

Pharmacologic treatments for opioid dependence: detoxification and maintenance options

While opioid dependence has more treatment agents available than other abused drugs, none are curative. They can, however, markedly diminish withdrawal symptoms and craving, and block opioid effects due to lapses.

The most effective withdrawal method is substituting and tapering methadone or buprenorphine, α-2 Adrenergic agents can ameliorate untreated symptoms or substitute for agonists if not available. Shortening withdrawal by precipitating it with narcotic antagonists has been studied, but the methods are plagued by safety issues or persisting symptoms. Neither the withdrawal agents nor the methods are associated with better long-term outcome, which appears mostly related to post-detoxification treatment.

Excluding those with short-term habits, the best outcome occurs with long-term maintenance on methadone or buprenorphine accompanied by appropriate psychosocial interventions. Those with strong external motivation may do well on the antagonist naltrexone. Currently, optimum duration of maintenance on either is unclear. Better agents are needed to impact the brain changes related to addiction.

Novel depots of buprenorphine have a long-acting effect for the management of physical dependence to morphine

Buprenorphine is a promising new pharmacotherapy for the management of physical dependence to opioids. The aim of the study was to evaluate the duration of action of several novel depots of buprenorphine in the treatment of physical dependence to morphine in mice. Following intramuscular injection, the duration of action of several novel oil-based depots of buprenorphine base in morphine-dependent mice were evaluated. The traditional dosage form of buprenorphine hydrochloride in saline was used as control. We found that the depot of buprenorphine base in sesame oil produced a dose-related long-lasting effect. On an equimolar basis of 6 micromol kg(-1), its effect was 5.7-fold longer than that of buprenorphine hydrochloride in saline. When prepared in several other oleaginous vehicles (castor oil, cottonseed oil, peanut oil and soybean oil), buprenorphine base also produced a long-lasting effect, which was similar to buprenorphine base in sesame oil. In conclusion, buprenorphine base, when prepared in oleaginous vehicles and injected intramuscularly in mice, produced a long-lasting effect on physical dependence to morphine.

Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal

BACKGROUND

Withdrawal (detoxification) is necessary prior to drug-free treatment. It may also represent the end point of long-term opioid replacement treatment such as methadone maintenance. The availability of managed withdrawal is essential to an effective treatment system.

OBJECTIVES

To assess the effectiveness of interventions involving the administration of opioid antagonists to induce opioid withdrawal with concomitant heavy sedation or anaesthesia, in terms of withdrawal signs and symptoms, completion of treatment and adverse effects.

SEARCH STRATEGY

We searched the Drugs and Alcohol Group register (October 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2004), Medline (January 1966 to January 2005), Embase (January 1985 to January 2005), PsycINFO (1967 to January 2005), and Cinahl (1982 to December 2004) and reference lists of studies.

SELECTION CRITERIA

Controlled trials comparing antagonist-induced withdrawal under heavy sedation or anaesthesia with another form of treatment, or a different regime of anaesthesia-based antagonist-induced withdrawal.

DATA COLLECTION AND ANALYSIS

One reviewer assessed studies for inclusion and undertook data extraction and assessed quality. Inclusion decisions and the overall process were confirmed by consultation between all three reviewers.

MAIN RESULTS

Six studies (five randomised controlled trials) involving 834 participants met the inclusion criteria for the review.Antagonist-induced withdrawal is more intense but less prolonged than withdrawal managed with reducing doses of methadone, and doses of naltrexone sufficient for blockade of opioid effects can be established significantly more quickly with antagonist-induced withdrawal than withdrawal managed with clonidine and symptomatic medications. The level of sedation does not affect the intensity and duration of withdrawal, although the duration of anaesthesia may influence withdrawal severity. There is a significantly greater risk of adverse events with heavy, compared to light, sedation (RR 3.21, 95% CI 1.13 to 9.12, P = 0.03) and probably also other forms of detoxification.

AUTHORS' CONCLUSIONS

Heavy sedation compared to light sedation does not confer additional benefits in terms of less severe withdrawal or increased rates of commencement on naltrexone maintenance treatment. Given that the adverse events are potentially life-threatening, the value of antagonist-induced withdrawal under heavy sedation or anaesthesia is not supported. The high cost of anaesthesia-based approaches, both in monetary terms and use of scarce intensive care resources, suggest that this form of treatment should not be pursued.

Chronic Pain and Ultrarapid Opioid Detoxification

Availability of opiate substances through physicians and on the street has led to a rise in dependence and in addiction resulting in countless numbers of people hooked on these drugs. Long-term use of these agents results in reduction of endogenous supply of opiate replaced by these exogenous compounds. A technique known as Ultrarapid Detoxification (UROD) has been developed and appears more promising than conventional modalities. UROD has been modified over 3 decades resulting in a safe and an effective general anesthetic that results in hemodynamically stable withdrawal without manifestation of central nervous system hyperarousal. A cornerstone of this technique involves clonidine, which stimulates reuptake of catecholamines and allows for large doses of opioid antagonist to be delivered without significant changes in heart rate or blood pressure, displacing the opiate. Though techniques vary from center to center, safety should be paramount with the technique performed in an intensive care unit with trained professional anesthesiologists. Psychosocial issues should be evaluated by a trained addictionalist and most people will succeed from the UROD procedure without experiencing the horrible withdrawal syndrome. Patients must have realistic goals and be prepared to deal with psychosocial issues post-procedure.

General anaesthesia does not improve outcome in opioid antagonist detoxification treatment: a randomized controlled trial

AIM

Opioid detoxification by administering opioid-antagonists under general anaesthesia has caused considerable controversy. This study is conducted to determine whether rapid detoxification under general anaesthesia results in higher levels of opioid abstinence than rapid detoxification without anaesthesia.

DESIGN

Randomized controlled open clinical trial from September 1999 to August 2001.

SETTING

Four addiction centres in collaboration with three general hospitals in the Netherlands.

PARTICIPANTS

A total of 272 opioid-dependent patients whose previous attempts to abstain were unsuccessful.

INTERVENTION

Patients received rapid detoxification with general anaesthesia (RD-GA) or without general anaesthesia (RD).

MEASUREMENTS

Urine screens and an interview (EuropASI) to assess opioid abstinence; two questionnaires (SOOS, OOWS) to measure withdrawal symptoms and one to measure craving (VAS).

FINDINGS

One month after the intervention 62.8% of the patients in the RD-GA group and 60.0% in the RD group were abstinent for opioids (P = 0.71). No adverse events or complications occurred during RD; however, in the RD-GA group, five adverse events necessitated admission to a general hospital. The average 1-month cost for RD was Euros 2517 versus Euros 4439 for RD-GA.

CONCLUSIONS

Rapid detoxification under general anaesthesia did not result in higher levels of opioid abstinence than rapid detoxification without anaesthesia. The cost of the former intervention was much higher.

Antagonist-precipitated heroin withdrawal under anaesthetic prior to maintenance naltrexone treatment: determinants of withdrawal severity

This study sought to characterize antagonist-precipitated heroin withdrawal during and immediately following anaesthesia and to identify the determinants of withdrawal severity and duration in 48 dependent heroin users. Objective withdrawal signs decreased significantly with each naloxone bolus administered under anaesthetic. The cost (amount) of the final heroin administration and the number of hours between last heroin use and commencement of anaesthesia were significant, independent predictors of the severity of withdrawal symptomatology. While 83% (40/48) of participants completed withdrawal according to objective criteria and commenced maintenance naltrexone treatment, almost half (22/48) were unable to commence naltrexone on the day of the procedure due to residual withdrawal signs. Fourteen of these 22 participants subsequently commenced naltrexone (median number of days between admission and commencement of naltrexone was 2, range 1 - 6) while eight left treatment prior to initiation of naltrexone. Significantly fewer of those with more severe withdrawal signs during anaesthesia commenced naltrexone (40% vs. 60%). While the severity and duration of withdrawal symptomatology may be moderated by encouraging participants to reduce (or cease) heroin use close to the time of withdrawal, for a substantial proportion of participants in this study, heroin withdrawal by this antagonist-precipitated procedure was neither rapid nor painless. [Ali R, Thomas P, White J, McGregor C, Danz,C, Gowing L, Stegink A, Athanasos P. Antagonist-precipitated heroin withdrawal under anaesthetic prior to maintenance naltrexone treatment: determinants of withdrawal severity.

Rapid detoxification from opioid dependence under general anaesthesia versus standard methadone tapering: abstinence rates and withdrawal distress experiences

The aim of this work was to study abstinence rates and withdrawal effects of rapid detoxification of opioid-dependents under general anaesthesia (RD-GA) compared to standard methadone tapering (SMT) using a prospective clinical trial with a follow-up of 3 months, as a preliminary study at the Novadic addiction centre in St Oedenrode and St Joseph Hospital in Veghel, the Netherlands. Thirty opioid-dependent patients took part. Outcome measures included urine toxicology screening for opiates to determine abstinence and presence of objective and subjective opioid withdrawal distress symptoms. Statistically significant differences in abstinence rate between RD-GA and SMT were present after one (RD-GA 100% vs. SMT 40%, p < 0.01) and 2 months (RD-GA 93% vs. SMT 33%, p < 0.01). After 3 months the difference in abstinence was still substantial, but no longer statistically significant (RD-GA 67% vs. SMT 33%, p = 0.14). Objective and subjective withdrawal symptoms showed largely identical outcomes and were equally low in the two groups for those who remained in the study. There was a considerably higher percentage of abstinence in the RD-GA group after 1, 2 and 3 months of follow-up accompanied by relatively mild withdrawal symptoms of shorter duration. However, if one completes SMT the data suggest a greater chance of staying clean in the long term than those completing RD-GA.

Acceptability and availability of harm-reduction interventions for drug abuse in American substance abuse treatment agencies

This study assessed acceptability, availability, and reasons for nonavailability of interventions designed to prevent drug use related harm by substituting pharmaceuticals for illicit drugs; facilitating detoxification; and reducing the occurrence of HIV transmission, relapse, and opiate overdose. A survey was mailed to a sample of 500 randomly selected American substance abuse treatment agencies. Of 435 potentially eligible respondents, 222 (51%) returned usable data. A subset of interventions--including harm reduction education, cue exposure therapy, needle exchange, substitute opiate prescribing, various detoxification regimes, and complementary therapies--were rated as somewhat or completely acceptable by 50% or more of the respondents. Regardless of their acceptability, listed interventions were generally not available from responding agencies; respondents typically attributed unavailability to lack of resources and inconsistency of an intervention with agency philosophy.

Ultrarapid opiate detoxification: a review

PURPOSE

This review on ultrarapid detoxification examines the pharmacology, techniques, and efficacy of this potentially promising technique and contrasts it with conventional treatment modalities.

SOURCE

The information found here is derived from experiences at the Texas Tech University, government reports, and peer reviewed journals.

PRINCIPLE FINDINGS

Incidence and prevalence of heroin use is on the rise. Social and treatment costs suggest that this problem is staggering. Approximately 400,000 patients are enrolled in or are actively seeking methadone therapy. While many of these individuals want to undergo detoxification, traditional techniques, including methadone tapering are usually unsuccessful. The withdrawal syndrome is extremely unpleasant, may be fatal, and deters patients from completing the detoxification process. Ultrarapid detoxification entails general anesthesia in conjunction with large boluses of narcotic antagonists. This combination allows the individual to completely withdraw from the opiate without suffering the discomfort of the withdrawal syndrome. Unless performed properly, this procedure can be dangerous due to the sympathetic outflow. However, with proper support, this danger can be mitigated.

CONCLUSION

Ultrarapid opiate detoxification, performed under the proper circumstances, is associated with few adverse events and is relatively comfortable for patients who seek treatment for their addition.

Ultra-rapid opiate detoxification: from clinical applications to basic science

Rapid or ultra-rapid opiate detoxification has become increasingly popular in both private and public addiction centres. These techniques seem to facilitate the transfer of opiate-dependent patients from opiate agonist to opiate antagonist. Despite the probable complex neuropharmacological aspects involved in these procedures, their development over nearly three decades is notable for the almost complete absence of clinically relevant animal studies. This paper discusses the historical background of this occurrence, and reviews the small number of animal studies that have been conducted. Many discussions and arguments about the techniques seem to underscore their true purpose, which is not "simply to detoxify" opiate-addicted patients but to initiate long-term management with naltrexone. For this reason, it may be better to conceptualize these techniques not as "rapid detoxification" but as "rapid antagonist induction".

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.

A comparison of antagonist-precipitated withdrawal under anesthesia to standard inpatient withdrawal as a precursor to maintenance naltrexone treatment in heroin users: outcomes at 6 and 12 months

To compare two methods of heroin withdrawal, 51 heroin users were randomised to undergo a 1 day precipitated withdrawal procedure using naloxone under anaesthetic. About 50 participants were randomised to receive the current standard inpatient withdrawal treatment using clonidine plus symptomatic medication. Following withdrawal, both groups were offered 9 months of naltrexone treatment and supportive counselling. Outcome measures were: commencement of naltrexone, retention in treatment and heroin use at 6 and 12 months. Significantly more of the precipitated withdrawal group completed withdrawal, commenced naltrexone and stayed in treatment for the first 3 months. Overall, there was a significant reduction in both self-reported heroin use and morphine concentration in hair over the 12 month study period, with participants in the precipitated withdrawal group showing significantly lower morphine concentration at 6 months. Being younger and having a lower level of dependence were predictors of abstinence at 6 and 12 months. The advantage of precipitated withdrawal under anesthesia did not persist beyond 3 months with respect to retention in naltrexone treatment or beyond 6 months with respect to heroin use. Long-term follow-up is crucial in assessing the effects of treatment interventions for heroin dependence.

24-Hour opiate detoxification and antagonist induction at home--the 'Asturian method': a report on 1368 procedures

The technique of domiciliary rapid opiate detoxification (ROD) developed in Asturias since 1994 enables patients dependent on heroin and/or methadone (or other opiates) to start antagonist maintenance with a full dose of naltrexone (50 mg) and largely recover from the acute opiate withdrawal syndrome in a few hours at home without direct medical or nursing involvement. Detailed information on 1368 procedures is presented but in Asturias, over 3000 procedures have been completed to date without any deaths or serious medical or psychiatric complications. We also describe some recent modifications to the procedure involving the use of octreotide as an antidiarrhoeal and the insertion of subcutaneous naltrexone implants to prevent early relapse. Rather than domiciliary ROD, we think the procedure is more usefully conceptualized as domiciliary rapid antagonist induction (RAI), because treatment with well-supervised naltrexone is known to be effective in reducing relapse rates. Now that controlled studies uniformly describe greatly increased rates of transfer to naltrexone maintenance treatment following RAI, compared with conventional slower withdrawal and naltrexone induction procedures, it is important that the safety, acceptability and simplicity of this 'Asturian' RAI/ROD technique become more widely known.

Acceptability and availability of pharmacological interventions for substance misuse by British NHS treatment services

AIMS

Despite their potential advantages, many of the pharmacological interventions available to treat substance misuse are controversial and their acceptability within the United Kingdom (and other countries) has only recently begun to be investigated.

DESIGN

A questionnaire mailed to British National Health Service (NHS) alcohol and drug treatment services asked respondents to rate the acceptability and availability of 11 pharmacological interventions for substance misuse employed to relieve withdrawal, reduce the likelihood of relapse and opiate overdose and substitute pharmaceuticals for illicit drugs.

PARTICIPANTS

A sample of NHS substance misuse services (n = 265) listed in one or more directories of services in England, Wales and Scotland.

FINDINGS

Substitute methadone for opiate addiction, substitute benzodiazepines for benzodiazepine-dependent patients, lofexidine for opiate detoxification, naltrexone for opiate relapse prevention and acamprosate for alcohol relapse prevention were widely acceptable and available interventions. Another subset of medications-buprenorphine for opiate detoxification, take-home naloxone for overdose prevention and substitute prescribing of levo-alpha-acetyl-methadol (LAAM), heroin and dexamphetamine-garnered less support, but the majority of participants rated even these therapies as acceptable. Ultra-rapid detoxification under sedation was the intervention rated as least acceptable to, and was one of the two least frequently available from, responding NHS services.

CONCLUSIONS

Differences among specific medications notwithstanding, a wide range of harm-reduction and abstinence-orientated interventions were acceptable to and available from NHS services. Acceptance and availability are probably limited by a combination of practical, economic, safety, efficacy and theoretical considerations.

Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal

BACKGROUND

Withdrawal (detoxification) is necessary prior to drug-free treatment. It may also represent the end point of long-term opioid replacement treatment such as methadone maintenance. The availability of managed withdrawal is essential to an effective treatment system.

OBJECTIVES

To assess the effectiveness of interventions involving the administration of opioid antagonists to induce opioid withdrawal with concomitant heavy sedation or anaesthesia.

SEARCH STRATEGY

Multiple electronic databases (including MEDLINE, EMBASE, PsycLIT, Australian Medical Index, Cochrane Controlled Trials Register, and CINAHL) were systematically searched. Reference lists of retrieved studies, reviews and conference abstracts were handsearched.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared the administration of opioid antagonists under heavy sedation or anaesthesia with another form of treatment.

DATA COLLECTION AND ANALYSIS

One reviewer assessed studies for inclusion and undertook data extraction. Inclusion decisions and the overall process were confirmed by consultation between all three reviewers.

MAIN RESULTS

As yet, no studies have been published comparing treatment regimes involving the administration of opioid antagonists under heavy sedation or anaesthesia with other approaches to detoxification. Treatment regimes for the studies considered for this review varied in the opioid antagonist used, the dose and mode of administration, the anaesthetic agent, duration of anaesthesia and adjunct medications employed. More detailed monitoring of withdrawal is required before any conclusions can be drawn as to what comprises a typical pattern of withdrawal and what factors might influence the pattern. There is only very limited information on referral to ongoing treatment, and relapse to opioid use. Together with the lack of adequate comparisons, this makes it impossible to draw any conclusions about the long-term effectiveness, or the cost-effectiveness, of withdrawal induced by opioid antagonists under heavy sedation or anaesthesia.

REVIEWER'S CONCLUSIONS

Considerably more research evidence will be needed before any conclusions can be drawn regarding the effectiveness of managing withdrawal by administration of opioid antagonists under heavy sedation or anaesthesia. The risk of vomiting during sedation, respiratory depression and cardiac irregularities point to the approach being limited to facilities equipped for intubation, assisted ventilation and a high level of monitoring, and with the capacity to respond to adverse events that might occur. The approach must be regarded as experimental with both risks and benefits remaining uncertain.

The impact of naloxone/lofexidine combination treatment on the opiate withdrawal syndrome

Clinical studies in opiate-dependent patients suggest that detoxification treatment with opiate antagonists may accelerate the resolution of the opiate withdrawal syndrome, permitting early induction onto naltrexone maintenance treatment. The present open study compared the clinical efficacy of daily naloxone injections in conjunction with lofexidine, with conventional lofexidine monotherapy, in 49 polysubstance-misusing opiate-dependent patients. Overall, the addition of naloxone did not confer substantial benefit over lofexidine monotherapy, although area-under-the-curve analysis showed that withdrawal severity in the naloxone/lofexidine combination group was significantly less than in the lofexidine monotherapy group, who experienced more severe withdrawal symptoms on days 4, 7, 9 and 13 of treatment. There were no significant differences in rates of completion of detoxification. Blood pressure remained within normal limits in both groups. Naltrexone maintenance treatment acceptability was low; only four patients continued with treatment for 5 or more days. The modest benefit of adding naloxone to lofexidine compared to the findings of previous opiate antagonist detoxification treatment studies is discussed in the context of the hypothesis that a critical level of opiate receptor occupancy is required to accelerate resolution of opiate withdrawal; the neurochemical mechanisms which may promote this are discussed.

Combining median electroencephalography frequency and sympathetic activity in an index to evaluate opioid detoxification in patients

During rapid opioid detoxification, increased sympathetic activity and a greater median frequency (MF) of activity on electroencephalography (EEG) have been reported. The purpose of this study was to evaluate a new index for detoxification that combines sympathetic activity and MF data. After informed consent was obtained, eight patients were sedated with propofol. The MF of EEG activity derived from frontal electrodes was determined. Heart rate variability was evaluated in 256-second segments by power spectral analysis, and sympathetic activity was determined by the low frequency component. The Hoffman Index for narcotic detoxification was weighted 70% to sympathetic activity and 30% to MF to normalize the difference in scales and to provide adequate weight to the sympathetic component. Opioid detoxification was produced by infusion of 25 mg naloxone for 30 minutes, followed by a 24-hour infusion of 1 mg per hour. The MF showed a rapid increase during high-dose infusion of naloxone, but the peak response occurred 1 to 2 hours later. Sympathetic activation and the Hoffman Index increased more slowly after the start of naloxone infusion, but peak increases in all components occurred at approximately the same time. The peak increases in Hoffman Index (110% of baseline), MF (260%), and sympathetic activity (304%) during administration of naloxone were significant and correlated with respect to time (r = 0.89-0.94). The Hoffman Index showed an early increase related to MF and a well-defined peak response indicative of sympathetic and MF activity. The behavior of the Hoffman Index in relation to the MF and sympathetic activity more clearly indicated the onset of opioid detoxification and the maximum response to opioid reversal than did MF or sympathetic activity alone.

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.

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.

Electrocardiographic abnormalities during recovery from ultra-short opiate detoxification

The aim of this study was to detect electrocardiographic abnormalities during recovery from ultra-short opiate detoxification, using a retrospective study design conducted at a university hospital. Twenty-two consecutive patients (mean±SD, age 30.0±6.3 years) receiving daily oral methadone underwent ultrashort opiate detoxification under general anaesthesia. In the post-anaesthetic stages they received oral clonidine and naltrexone, and in some cases trimipramine was dispensed. Heart rate, rate-corrected QT interval (msec) and repolarization abnormalities of 12-lead electrocardiographic recordings before and after detoxification were examined. The serum electrolyte concentrations (mmol/l) including Na⁺, K⁺ and Ca2⁺ were assessed. Eighty-one ECGs were evaluated in total. Compared to the initial values, heart rate was significantly lowered in the first two tracings after detoxification (median values 60.0/min. vs. 52,5/min; p=0.0006). The lowest heart rate measured after detoxification was 44/min. The cQT interval was significantly lengthened (median value 420 msec vs. 453 msec after detoxification). In 16 tracings (20%) taken from 10 patients (45%) cQT rose above 460 msec and in two tracings (2%) it topped 500 msec. Modest hypokalaemia (2.9-3.5 mmol/l) was linked to cQT prolongation (460 msec) in 10 ECG tracings. Spearman's correlation coefficient indicated that prolonged cQT intervals correlated with decreased potassium values. Twelve tracings (15%) taken from 10 patients (45%) after detoxification showed T-wave inversion and in two cases sinus rhythm was turned into a rhythm arising from the atrioventricular node. Serum potassium was significantly lowered (median values 4.3 v.s 3.8 mmol/l, p=0.0001). The Ca2⁺ concentration fell significantly (2.4 vs. 2.2 mmol/l, p=0.0001) but not below the normal range. It was concluded that ultra-short opiate detoxification carries the risk of QT prolongation and bradycardia. These side effects are reversible and can be explained by hypokalaemia and clonidine medication, the effects of which might reinforce each other. To avoid arrhythmic complications, ECG tracings should be carried out regularly during recovery, i.e. at least daily, for a span of 3 days after discharge from the intensive care unit.

Opiate detoxification under anesthesia: no apparent benefit but suppression of thyroid hormones and risk of pulmonary and renal failure

INTRODUCTION

The new technique for opiate detoxification using anesthesia and high, repetitive doses of opiate-antagonists claims to detoxify addicts without withdrawal symptoms within 24-48 hours. We studied the method with 12 opiate addicts (5 L-polamidone, 4 dihydrocodeine, 3 heroin), using general anesthesia and the antagonists naloxone 0.5 mg/kg and naltrexone > 150 mg. Objective and subjective withdrawal symptoms were measured until urine was free of drugs and patients had no withdrawal symptoms. Thyroid hormones were measured before, during, and after the anesthesia period.

RESULTS

All patients had moderate to severe opiate withdrawal symptoms. No detoxification was finished within 48 hours. The dihydrocodeine subjects were compared with conventionally detoxified controls; no difference was seen. The method suppressed thyroid hormones TT3, TT4, and TSH. The study was terminated because of side effects: 1 pulmonary failure and 2 renal failures. All patients survived without sequelae.

CONCLUSION

There is no obvious benefit from this method, whereas the risks are high.