September 13, 2012

Ultra-rapid Opiate Detox

Ultra-rapid Opiate Detox
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Background

Historically, both opiate addicted patients and the public have tended to confuse and equate withdrawal from opiates with longer term abstinence. In the search for some method that would deal with the frustrating relapse rate post-detoxification, attention is often focused on ways to improve / speed up withdrawal with the hope that this will improve the success rate of long term outcome. An approach to this is ultra-rapid opiate detoxification (UROD).

Withdrawal is precipitated by opiate antagonists, usually naltrexone in a rapid (4-5 hour) time frame. The resultant discomfort is medicated by a variety of agents under general anesthesia or heavy benzodiazepine sedation that permits the procedure to take place without patient awareness of discomfort.

Variants of this ultra-rapid approach have been introduced recently with differences as to cost ($3,000-$7,500), setting (hospital, outpatient), and provision of post-detoxification care (vouchers for 16 outpatient visits vs. referral to other programs, or no follow-up). This procedure emerged from work pioneered in the 1980s at Yale, in which naltrexone was used to precipitate withdrawal and clonidine (plus other medications) used to ameliorate the resultant signs/symptoms.

Opiate withdrawal could be completed in 2-3 days on an outpatient basis at relatively low cost (<$500), high completion rate (80-95%), and about 75 percent of patients still on naltrexone 30 days later. The new ultra-rapid approach makes a shorter completion time possible with the addition of the anesthesia or heavy sedation. However, such an approach also raises issues of safety and cost compared to long term efficacy. The goal of detoxification is to withdraw the patient safely, and with minimal discomfort while preparing him / her for the longer term treatment usually necessary for sustained abstinence.

Problems with the Ultra-Rapid Opiate Detoxification Approach
  • Anesthesia increases the risk of morbidity / mortality of opioid withdrawal which usually has no associated mortality.
  • The key issue in treatment of opioid addiction is not withdrawal, but remaining in treatment post withdrawal.
  • At present, there is inadequate evidence of any long term benefit from the more rapid detoxification techniques.
  • Given the lack of documented long term benefit, there appears to be inadequate demonstration of an appropriate risk/benefit ratio.
  • Further, the substantial initial cost involved at a time of fiscal constraint could lead to inadequate funds being available for the critical ongoing treatment.

 

Research in 2005 by Collins and Kleber in JAMA (JAMA.2005; 294:903-913) further supports the Panel's opinion that there is little data which shows a benefit of the use of general anesthesia for opiate detoxification.

Position Statement: The NYS OASAS Medical Advisory Panel does not support ultra-rapid opiate detoxification as a safe and effective modality for the treatment of opiate dependence.

Position Statement of the OASAS Medical Advisory Panel

Final Adoption - October, 1997

Updated - September 13, 2012

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