Heroin dependence remains a significant public health problem in the United States, according to background information in the article. Most of the approximately 1 million heroin-dependent individuals in the United States are not in treatment. Their main initial contact with the treatment system is often detoxification. Medically supervised heroin withdrawal remains plagued by patient discomfort and high dropout rates. Many patients fear the physical discomfort of withdrawal and either avoid treatment or leave it prematurely.
Even those who complete the detoxification process have high relapse rates, partly due to the absence of continuing treatment. These problems have given rise, in the past 15 years, to ultra-rapid, or anesthesia-assisted opioid detoxification, which involves administering an opioid antagonist drug to neutralize the effects of heroin while the patient is unconscious from general anesthesia. This has been publicized as a fast, painless way to withdraw from heroin. However, this treatment is expensive (as much as $15,000 in 2005), not covered by insurance, and lacks good evidence to support efficacy. There are also significant concerns about health risks. The detoxification procedure is usually followed by longer term treatment with an antagonist drug such as naltrexone to block the effects of any subsequent heroin use.
Eric D. Collins, M.D., of Columbia University, New York, and colleagues conducted a randomized controlled trial between 2000 and 2003 to evaluate the safety, tolerability, and efficacy of anesthesia-assisted rapid opioid detoxification compared with two other inpatient withdrawal and naltrexone treatment procedures. The study included 106 treatment-seeking heroin-dependent patients, aged 21 through 50 years, who were randomly assigned to 1 of 3 inpatient withdrawal treatments over 72 hours followed by 12 weeks of outpatient naltrexone maintenance with relapse prevention psychotherapy. Patients received either anesthesia-assisted rapid opioid detoxification (for 4 to 6 hours) with naltrexone induction, rapid opioid detoxification with buprenorphine (an opioid substitute) followed by naltrexone induction, or treatment with clonidine (an antihypertensive drug that decreases withdrawal symptoms) followed by delayed naltrexone induction.
The researchers found that average withdrawal severities were comparable across the 3 treatments. Compared with clonidine-assisted detoxification, the anesthesia- and buprenorphine-assisted detoxification interventions had significantly greater rates of naltrexone induction (94 percent for anesthesia, 97 percent for buprenorphine, and 21 percent for clonidine), but the groups did not differ in rates of completion of inpatient detoxification. Treatment retention over 12 weeks was low and not significantly different among the three groups. Overall, only 11 percent of patients continued in treatment for 12 weeks and had less than two opioid-positive urine tests, indicating a high rate of relapse to heroin use. The anesthesia procedure was associated with 3 potentially life-threatening adverse events: severe pulmonary edema and aspiration pneumonia; diabetic ketoacidosis, and a bipolar mixed state requiring hospitalization.
"In summary, this randomized trial of general anesthesia for opioid withdrawal and naltrexone induction demonstrates no benefit of anesthesia over a safer, cheaper, and potentially outpatient alternative using buprenorphine as a bridge to naltrexone treatment. Taken together with the results of earlier studies, our findings suggest that general anesthesia for rapid antagonist induction does not currently have a meaningful role to play in the treatment of opioid dependence," the authors conclude.
(JAMA. 2005; 294:903-913. Available pre-embargo to the media at www.jamamedia.org.)
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Editorial: Methods of Detoxification and Their Role in Treating Patients With Opioid Dependence
In an accompanying editorial, Patrick G. O'Connor, M.D., M.P.H., of the Yale University School of Medicine, New Haven, Conn., comments on the study and the broader issue of the role of detoxification in treating opioid dependence.
"The study by Collins et al in this issue of JAMA contributes significantly to the growing body of evidence concerning effective and safe treatment for opioid dependence by further documenting that anesthesia-assisted opioid detoxification is no more effective than opioid detoxification without anesthesia and that it can be unsafe. Thus, anesthesia-assisted detoxification should have no significant role in the treatment of opioid dependence. When detoxification is provided to patients, other approaches using clonidine, methadone, or buprenorphine are likely to be at least as effective as anesthesia-assisted detoxification and also are safer and far less costly."
"In the larger context of treating opioid dependence, the major implication of the overall results of this study and other studies is that regardless of the protocol used, detoxification-based treatment of opioid dependence has a low likelihood of long-term success for most opioid-dependent patients. Further research on detoxification-based treatment should focus on how to provide effective relapse prevention treatment. In the meantime, for the majority of individuals with chronic relapsing opioid dependence, opioid maintenance using methadone or buprenorphine is much more effective than detoxification in terms of decreasing drug use, supporting treatment retention, improving health outcomes, and improving social functioning. Thus, maintenance therapy should be considered first-line treatment for such patients," Dr. O'Connor writes.
(JAMA. 2005; 294:961-963. Available pre-embargo to the media at www.jamamedia.org.)