Anesthesia for Rapid Heroin Detox Called Dangerous and Ineffective
By Michael Smith , MedPage Today Staff Writer. Reviewed by Rubeen K. Israni, M.D., Fellow, Renal-Electrolyte and Hypertension Division, University of Pennsylvania School of Medicine. Source News Article: Boston Globe, LA Times (Registration Req.), USA Today
Review: NEW YORK, Aug. 24-So-called rapid opioid detox using general anesthesia is more expensive than other methods, no more effective, and has potentially life-threatening consequences, researchers here said today.
In the past 15 years, anesthesia-assisted opioid withdrawal has been publicized as a fast, painless solution to heroin addiction, said Eric Collins, M.D., of Columbia division on substance abuse. Yet there's no good evidence that it works, and it costs as much as $15,000.
Dr. Collins and colleagues randomized 106 heroin addicts who were seeking treatment to detoxification with either general anesthesia, buprenorphine (an opioid partial antagonist), or clonidine (an alpha-2-adrenergic agonist that is the standard of care for treating withdrawal symptoms). The investigators reported in the Aug. 24 issue of the Journal of the American Medical Association.
In all three arms, the detoxification was followed by treatment with the opioid antagonist naltrexone to prevent recurrent heroin abuse. Naltrexone was given on day 1 after anesthesia in the anesthesia group, was given on day 2 and 3 in the buprenorphine group, and was given on day 7 in the clonidine group.
The severity of withdrawal symptoms -- assessed using several common scales -- was similar in all three arms, the researchers found.
The study also found:
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94% of the anesthesia participants and 97% of those taking buprenorphine were given naltrexone, compared with 21% for those on clonidine.
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There was no difference in how many patients in each arm completed in-patient treatment.
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There was a high rate of relapse to heroin. Only 11% of patients completed the 12-week treatment period and had fewer than two positive urine tests.
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Patients who stayed in the study long enough to receive natltrexone induction at the full 50 mg maintenance dose were at lower risk of dropping out (OR 0.28; 95% CI 0.15-0.51).
There were three potentially life-threatening adverse events among the anesthesia participants -- one case of severe pulmonary edema and aspiration pneumonia, one of diabetic ketoacidosis, and a bipolar mixed state requiring hospitalization.
The study "yields convincing evidence that this (anesthesia) procedure is neither effective nor safe," commented Patrick O'Connor, M.D., of the Yale University School of Medicine in New Haven.
"Anesthesia-assisted detoxification should have no significant role in the treatment of opioid dependence," Dr. O'Connor argued in an editorial accompanying the Columbia study.
In the larger context, however, Dr. O'Connor argued that the study provides additional evidence that detoxification of heroin addicts -- or those addicted to other opioids -- is not likely to work "regardless of the protocol used."
Instead, he said, maintenance therapy, using methadone or buprenorphine, "should be considered first-line treatment."
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