"Rapid detox" using general anesthesia and high-dose naltrexone
to treat individuals addicted to heroin is not more effective, and may be more
dangerous, than alternative withdrawal strategies using buprenorphine or
clonidine with naltrexone.
In what appears to be the most rigorous randomized trial yet of rapid
detoxification for heroin addiction, researchers at Columbia University
Medical Center found that the use of general anesthesia and high-dose
naltrexone induction was not significantly better in terms of treatment
retention or withdrawal symptoms than buprenorphine-assisted detox with
naltrexone or clonidine-assisted detox with delayed naltrexone induction.
In addition, the rapid-detox strategy was associated with three potentially
life-threatening adverse events, according to the report, which appeared in
the August 24/31 Journal of the American Medical Association.
"In general, the data do not support using general anesthesia during
detoxification," said Herbert Kleber, M.D., vice chair of APA's Council
on Addiction Psychiatry and a coauthor of the report. "The critical
thing is not what happens during detox, but what happens after, and we found
no difference between the groups. In addition, there were serious
life-threatening adverse effects in the anesthesia group."
Medically supervised heroin withdrawal is hindered by patient discomfort
and high dropout rates. This has given rise to "rapid-detox"
strategies in which very high doses of the opioid-antagonist naltrexone are
given to patients under general anesthesia. Costing as much as $1,500, the
strategy has been advertised as a fast, painless way to ease withdrawal from
"I have heard of people making significant financial sacrifices to
have a son or a husband undergo this procedure in the hopes it will end the
person's heroin addiction," Kleber said. "But I see no evidence
that they are using their financial resources with any better
In the study, 106 treatment-seeking, heroin-dependent patients aged 21
through 50 years were randomly assigned to one of three withdrawal treatments
over 72 hours, followed by 12 weeks of outpatient naltrexone maintenance with
relapse prevention psychotherapy.
The treatments consisted of anesthesia-assisted rapid opioid detox with
naltrexone induction, buprenorphine-assisted opioid detoxification with
naltrexone induction, or clonidine-assisted opioid detox with delayed
The primary outcome measures were opioid withdrawal severity during the
fourday inpatient phase of the trial, the proportion of patients completing
inpatient detoxification, the proportion of patients receiving naltrexone
induction (at any dose and at 50 mg), and the number of weeks completed in
Rates of naltrexone induction differed significantly across the groups: 33
of the 35 patients in the anesthesia group received the full 50-mg maintenance
dose of naltrexone, compared with 27 out of 37 in the buprenorphine group, and
six out of 34 in the clonidine group.
Treatment retention over the course of the study did not differ
significantly across intervention groups. By week three more than 50 percent
of patients had dropped out of each treatment arm. Among those who remained in
treatment for 12 weeks, seven of the group's original 35 patients were in the
anesthesia group, nine of 37 were in the buprenorphine group, and three of 34
were in the clonidine group.
Three patients in the anesthesia group experienced serious adverse events
requiring hospitalization. One developed severe pulmonary edema and aspiration
pneumonia approximately 14 hours after extubation. The second patient had
concealed a history of bipolar illness during the screening process and about
five days after anesthesia developed a mixed bipolar state with suicidal
ideation. The third patient developed diabetic ketoacidosis two days after
"Anesthesia-assisted detoxification should have no significant role
in the treatment of opioid dependence," wrote Patrick G. O'Connor, M.D.,
M.P.H., in an editorial accompanying the JAMA report. "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
An abstract of "Anesthesia-Assisted vs. Buprenorphine- or
Clonidine-Assisted Heroin Detoxification and Naltrexone Induction: A
Randomized Trial" is posted at<http://jama.ama-assn.org/cgi/content/abstract/294/8/903>.▪