Anesthesia-Assisted Opioid Detoxification

What is Anesthesia-Assisted Opioid Detoxification?

Anesthesia-assisted rapid opioid detoxification (AAROD) is a method of rapid opioid detoxification (ROD) where the patient is given doses of an opioid antagonist (e.g naltrexone) to precipitate withdrawal while under heavy sedation. It is usually performed under the clinical supervision of an anesthesiologist and nurses. During the treatment, the patient is put under deep sedation for several hours with general anesthesia. Once the patient awakens, they are usually started on an antagonist such as oral naltrexone. Any other withdrawal symptoms that persist are then treated symptomatically.

As the patient must continue taking doses of oral naltrexone for several weeks, noncompliance can be an issue. A different approach that tries to solve the problem of noncompliance involves implanting a pellet of naltrexone in subcutaneous tissue. The pellet releases naltrexone slowly over the course of many months, providing a continuous dose while eliminating the need to take a daily oral dose.

AAROD appeals to patients who are seeking a quick treatment for their addiction and want to avoid the painful symptoms of opioid withdrawal. Treatment providers marketing AAROD often play into their patient's unrealistic expectations. Although anesthesia may prevent a person undergoing precipitated withdrawal from being conscious of the most intense withdrawal symptoms, patients often experience severe symptoms for several days after the procedure.

History of Anesthesia-Assisted Opioid Detoxification

Rapid opioid detoxification (ROD) was developed by Dr. Hebert Kleber^[1][2] and colleagues in the 1980s as a way to reduce the length of hospitalization for patients detoxifying from opioids. Rapid opioid detoxification did not involve anesthesia. Patients received graduated doses of naltrexone (an opioid antagonist) to precipitate withdrawal, while they were simultaneously given clonidine and other symptomatic treatments. Rapid opioid detoxification without anesthesia is more gradual and less risky than anesthesia-assisted rapid opioid detoxification (AAROD). Though the procedure of rapid opioid detoxification without anesthesia has been developed and researched, it has not received wide acceptance by addiction medicine practitioners or their patients.

Anesthesia-assisted rapid opioid detoxification, sometimes called ultra rapid opioid detoxification (UROD), aimed to improve on the technique of rapid opioid detoxification by performing the treatment while the patient is heavily sedated under anesthesia. The clinicians who developed this treatment hoped that it would lessen the discomfort of withdrawal. Anesthesia-assisted rapid opioid detoxification is not a standardized procedure. There are several different variables including the anesthetic agents used, the antagonist(s) used, the duration of the procedure, the level of sedation and respiratory support, and medications used after the acute procedure. The many variables can all have an affect on the safety and effectiveness of the treatment.

Recent Studies on Anesthesia-Assisted Opioid Detoxification

A 2005 study in the Journal of the American Medical Association compared buprenorphine-assisted or clonidine-assisted opioid detoxification with anesthesia-assisted detoxification in heroin addicts.^[3] The study reported that patients who underwent anesthesia-assisted detoxification commonly experienced withdrawal when they awoke from the procedure and had a similar study dropout rate as the patients who underwent buprenorphine or clonidine-assisted detoxification (approximately 80%). In addition, some anesthesia patients also experienced severe medical complications.

Another 2005 study compared clonidine-assisted detoxification to anesthesia-assisted rapid opioid detoxification using naloxone to precipitate withdrawal.^[4] The study reported no significant differences in degree or duration of pain, withdrawal severity, or drug craving between those treated with clonidine and those who underwent AAROD. As part of the study, patients were given continuing doses of oral naltrexone following the acute detoxification. The study reported that both oral naltrexone compliance levels and abstinence from heroin four weeks following detoxification were similar between the two groups of patients.

The results of these studies suggest that AAROD is not the withdrawal-free miracle cure for opioid addiction that many providers of AAROD claim it to be. AAROD is an expensive treatment that is unregulated and has not been proven to be safe. There have been several cases of negative reactions to AAROD, particularly in patients with other underlying health issues such as diabetes.^[3] A 2002 study looked six cases where complications resulted from ultra-rapid opioid detoxification performed under anesthesia and utilizing an implanted naltrexone pellet. Some of the severe complications that were reported included prolonged withdrawal, drug toxicity, and death.^[5]

Is AAROD Recommended?

AAROD has not been proven to be effective and the procedure carries with it several potential risks. In particular, precipitated withdrawal and anesthesia are two components of the procedure that are known to have risks that are not present in other more commonly used detoxification and withdrawal treatment methods. Any benefits of the procedure have not yet been shown to be worth these added risks.

There are poor long-term outcomes for patients, with similar relapse rates to other forms of opioid detoxification (40-60% relapse by 6 months, approaching 90% by 12 months). There exist other treatments for opioid addiction, such as methadone-assisted treatment, that are safe, effective, and well-studied. A treatment such as methadone maintenance has a high patient retention rate and allows addicts time to stabilize and improve their quality of life. These excellent outcomes of methadone maintenance compared to the poor outcomes of opioid detoxification call into question the role of detoxification in the treatment of opioid addiction.

Until AAROD is proven to be safe and effective, the procedure has been standardized, and these other issues have been addressed, it is hard to give the procedure any kind of favorable recommendation for treating opioid-addicted patients.

1. ^ Vining E, Kosten TR, Kleber HD. Clinical Utility of rapid clonidine-naltrexone detoxification for opioid abusers. British Journal of Addiction 1988; 83(5):567-75. [PubMed]
2. ^ Riordan CE, Kleber HD. Rapid Opiate Detoxification with Clonidine and Naloxone. The Lancet 1980; 8177(1):1079-80. [PubMed]
3. ^ Collins ED, Kleber HD, Whittington RA, Heitler NE. Anesthesia-assisted vs buprenorphine- or clonidine-assisted heroin detoxification and naltrexone induction: a randomized trial. JAMA 2005 Aug; 294(8):903–13. [PubMed] [PDF]
4. ^ Arnold-Reed DE, Hulse GK. A comparison of rapid (opioid) detoxification with clonidine-assisted detoxification for heroin-dependent persons. Journal of Opioid Management 2005 Mar-Apr; 1(1):17-23. [PubMed]
5. ^ Hamilton RJ, Olmedo RE, Shah S, Hung OL, Howland MA, Perrone J, Nelson LS, Lewin NL, Hoffman RS. Complications of Ultrarapid Opioid Detoxification with Subcutaneous Naltrexone Pellets. Academic Emergency Medicine 2002 Jan; 9(1):63-8. [PubMed] [PDF]

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