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May 1998
Rapid and Ultrarapid Opioid Detoxification Techniques
O'Connor PG and Kosten TR;JAMA1998;279:229-234.
[ see abstract below ]
Opioid addiction and dependence is characterized by a withdrawal syndrome that is so unpleasant that many addicted individuals avoid detoxifying their bodies, even though they desperately want to do so. Traditional management utilizes a methadone taper to ease the withdrawal from drugs such as heroin. In point of fact, due to the unpleasant effects of withdrawing methadone support, many people stay on methadone for extended periods of time, never truly losing their opioid dependence. Given the rise of heroin use in the United States, and the fact that treatment costs less than punishment for non-violent drug addicts, there is a great need for a better way to manage opioid withdrawal.
The anesthesia community is beginning to embrace ultra-rapid detoxification (URD) - acute withdrawal under general anesthesia induced by opioid antagonists (like naloxone). The basic idea is that the hemodynamic consequences of withdrawal are managed under anesthesia, the physical manifestations of withdrawal are bypassed while under general anesthesia, and the patient wakes up no longer physically addicted after about 6 hours. There is little actual science available on this subject, despite the recent portrayal on the TV show "Chicago Hope" that this was a proven and effective therapy. This JAMA review looks at all articles on the subject from 1966-1997. Before we embrace ultra- rapid detoxification, it is important to know what we are getting into. It is a lucrative business, which makes it even more important that we don't convince ourselves of URD's efficacy if it doesn't exist.
O'Connor and Kosten considered only peer reviewed articles with specified pharmacologic protocols (i.e. only real science, not anecdotal evidence). Only 9 studies of URD were found, enrolling a total of 424 inpatients. Seven of the studies had fewer than 20 patients. Only 2 were randomized, and only two reported outcomes beyond 2 days. Seven of the nine studies came from one group (Loimer et al.) and the other two from abroad. Usually, naloxone initiated withdrawal, and naltrexone was used to sustain the effect.
Only one study in the entire world compared patients undergoing URD with the traditional method of a methadone taper (15 vs. 29 patients). A single large controlled study of 300 patients compared light vs. deep sedation. This 1997 study by Seoane et al. essentially compared URD to itself. This would have been an appropriate study once the studies were done that proved URD more efficacious than traditional therapy. However, the real questions still remain as to which protocols work, how effective they are in the long term, and how they compare to traditional protocols using methadone, including cost, and patient satisfaction. Seoane et al did note that 279 of 300 patients remained abstinent after 1 month (a very good rate), but how this was assessed was not noted.
It is my belief that, hands down, patients would prefer going through withdrawal under anesthesia. Pain and agony are no man's friend. The only question then, is, does URD work? Despite a review of the literature, we are still left with that question. The variability in patient selection, small studies, varied protocols, and the confounding effects of drugs like benzodiazepines in these studies, all make generalizing about efficacy difficult.
Finally, relapse rates without follow up are extremely high, so the true benefits will only be achieved in conjunction with an ongoing outpatient evaluation of the opioid dependent patient. There are some who believe that the ease of withdrawal with this technique will not promote the psychological commitment that many feel is necessary to sustain abstinence. Having gone through withdrawal and having experienced immense discomfort can be a sobering thought when considering using drugs again. If URD bypasses this psychological support mechanism, we may not be helping patients in the long run as much as we would like.
One company , UniQual (www.uniqual.com) out of Boston, is attempting to market their detoxification services by providing protocols based on scientific research. In conjunction with that company, one of our researchers, Dr. Peter Glass, will be leading a program at Duke University to do further clinical studies. Not all companies are as thorough; be careful whose treatment plans you use. As physicians who are beginning one of the first uses of general anesthesia as a therapy, we want to make sure we are actually helping people.
Return to the Current Literature Review Front Page, or read the abstract:
ABSTRACT
OBJECTIVE: To review the scientific literature on the effectiveness of rapid opioid detoxification (RD) (opioid withdrawalprecipitated by naloxone hydrochloride or naltrexone) and ultrarapid opioid detoxification (URD) (opioid withdrawal precipitated by naloxone or naltrexone under anesthesia or heavy sedation) techniques.
DATA SOURCES: The MEDLINE database was searched from 1966 through 1997 using the indexing terms naloxone, naltrexone, substance dependence, and substance withdrawal syndrome. Additional data sources included bibliographies of papers identified on MEDLINE and bibliographies in textbooks on substance abuse.
STUDY SELECTION: Inclusion criteria were studies of RD or URD, pharmacologic protocols specified, and clinical outcomes specified and reported. Exclusion criteria were unpublished data, data not in peer-reviewed Journals, abstract-only publications, and review articles.
DATA EXTRACTION: The methodologic characteristics of studies were extracted by the authors and summarized according to key components of research design concerning subject characteristics, therapy allocation, and outcomes assessed.
DATA SYNTHESIS: A qualitative analysis was performed on the 12 studies of RD and the 9 studies of URD identified in our search. The RD studies enrolled 641 subJects (range for individual studies, 1-162): 7 were inpatient studies' and the protocols varied considerably, as did the outcomes assessed. Three RD studies included a control group, 2 used a randomized design, and 3 reported outcomes beyond 12 days. The URD studies enrolled 424 subJects (range for individual studies, 6-300): all were inpatient studies, the detoxification and anesthesia protocols varied, 3 included a control group, 2 used a randomized design, and 2 reported outcomes for URD beyond 7 days.
CONCLUSIONS: The existing literature on RD and URD is limited in terms of the number of subJects evaluated, the variation in protocols studied, lack of randomized design and use of control groups, and the short-term nature of the outcomes reported. Further research is needed using more rigorous research methods, longer-term outcomes, and comparisons with other methods of treatment for opioid dependence.
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