Rapid Opioid Detoxification Research Articles

Managing Subarachnoid Hemorrhage Precipitated by Anesthesia-assisted Rapid Opioid Detoxification: A Case Report.

IntroductionAnesthesia-assisted rapid opioid detoxification (AAROD) is a controversial method of treating opioid dependence that involves sedating patients during a period of provoked withdrawal. Reported adverse outcomes of the procedure demonstrate the importance of recognizing the potential complications of AAROD.Case PresentationWe present a case of a 41-year-old male presenting with a subarachnoid hemorrhage following an AAROD procedure.ConclusionThis case report and discussion reviews the pathophysiology of opioid withdrawal syndrome, potential complications following AAROD, and important management considerations.

Opioid-dependent error processing

To evaluate error processing in contrasting opioid treatment samples by finding the relative risk of fatal dosing errors leading to opioid overdose in a controlled cohort of detoxified patients with opioid dependence. Data linkage was performed between the Western Australian deaths register and recorded admissions to the Perth Naltrexone Clinic and community-based methadone program. Death register and corresponding data of coronial findings for all the patients who were treated with rapid opioid detoxification under sedation and oral naltrexone were compared with corresponding data for all the patients who were prescribed methadone over a 2-year period. Data for naltrexone-treated patients (n = 1,097) and community-based methadone-treated patients (n = 2,520) showed mortality rates to be 2.6 percent per year for naltrexone treatment when compared with O.7 percent for methadone treatment (p < 0.001). This was due to 4.3 times the relative risk of death from opioid toxicity for naltrexone-treated patients (p < 0.001). Naltrexone increases vulnerability to overdose as enhanced opioid effects following neuroanatomical blockade can reverse behavioral tolerance and lead to greater fatal dosing errors on reinstatement of opioid dependence.

The Stress Respond, Related To the Opioid Abstinence And Detoxification: literature review

Materials and Methods. Published articles on the opioid abuse and methods of opioid detoxification were identified by searching medical databases, using corresponding literature and were also searched manually for applicable papers. The search was limited to articles published from 1985 through 2014. Results. Opioid dependence determine pathophysiologic changes in the dopaminergic pathways of the organism, as well as the alterations in the stress-responsive hypothalamic-pituitary-adrenal axis. The usage of opioid antagonists in the early stages of withdrawal, can lead the effectiveness of opioid detoxification to 100%. Rapid opioid detoxification do not remove all the symptoms of abstinence. Negative aspects, concerning the procedure, while using prevention, can be reduced to the minimum risk. Rapid opioid detoxification, comparing it with Ultrarapid opioid detoxification procedure, diverges as less financial resources and a lower risk containing technique. Conclusions. Use of antagonists may reduce the duration of withdrawal, thus reducing the overall severity of withdrawal and increasing the chances of successful completion. This technique facilitates commencement of naltrexone treatment. Dosing regimens used in clinical trials vary. Subsequent results do not correlate with the methods of detoxification.

OR10-2 * STRESS CAN BE AVOIDABLE IN OPIOID DETOXIFICATION

Introduction. Opioid detoxification is related to unavoidable stress response. Subjective and Objective Opiate Withdrawal Scales provide an indirect quantitative evaluation, whereas cortisol and adrenocorticotropic hormone (ACTH) have been used in some studies as direct markers of stress response. Statistically significant increase of both markers have been reported in studies of opioid detoxification under general anaesthesia and conscious sedation. Method. Randomised double-blind study comparing stress response to Naltrexone induction during rapid opioid detoxification under conscious sedation. Control group received a single 12,5 mg dose, intervention group received an gradual increase from 50 microg to a total of 12,5 mg according to a predefined protocol. Serum concentrations of stress hormones were measured before Naltrexone induction and every 2, 4, and 24 hours after the induction and compared in both control and intervention groups. Result. We report interim results (n = 32). Following Naltrexone induction, levels of both stress hormones incresed significantly in control group and decreased in intervention group - cortisol 850 and 571 nmol/L (p < 0.001), ACTH 34.7 and 19.7 pg/mL (p < 0.05). Conclusions. Gradual increase of Naltrexone dose may significantly reduce stress response to opioid detoxification procedure.

Immediate and lasting improvements in depression following rapid opioid detoxification

Patients with chronic pain often suffer a habitual cycle of physical pain, decreased functioning, and emotional distress. While opioid medications commonly prescribed to treat the pain may initially be effective, long-term use is associated with dependence, loss of analgesic effectiveness, and potentially greater depressive symptomatology. We examined the effect of rapid opioid detoxification on depressive symptoms. Our sample comprised 16 patients with chronic pain, admitted to the Stanford Comprehensive Interdisciplinary Pain Program.

Use of Ultra Rapid Opioid Detoxification in the Treatment of US Military Burn Casualties

The purpose of this case series was to review the management of burn patients who requested ultrarapid opioid detoxification under anesthesia after extended duration of narcotic use for chronic pain related to burn injury. The treatment plan of six opioid-dependent burn patients was analyzed to assess the effectiveness of our detoxification practice to date. Demographic and clinical information was used to characterize the patient population served: age, burn size, injury severity, duration of narcotic use before detoxification intervention, and length of hospitalization stay. Daily narcotic consumption, in morphine equivalent units, was noted both before and after detoxification. Six burn patients (average age, 31 years) underwent detoxification at the Burn Center during a hospitalization lasting between 1 day and 2 days. Average burn size was 38% total body surface area (range, 17-65); average Injury Severity Score was 30 (range, 25-38). Mean duration of narcotic use was 672 days (range, 239-1,156 days); average use of narcotics at time of detoxification was >200 units daily. Mean outpatient consumption for opioids after the intervention was minimal (<25 units/d). No complications were noted during any procedures. The results of ultrarapid opioid detoxification under anesthesia suggests that it is safe and effective for treating opioid addiction in military burn casualties when a coordinated, multidisciplinary approach is used. Safety and effectiveness to date validate current practice and supports incorporation into clinical practice guidelines. Further clinical research is warranted to identify those patients who may benefit most from detoxification and to determine the timing of such treatment.

Opioid-Free Balanced Anesthesia for Cervical Ganglionectomy Subsequent to Recent Ultra Rapid Opioid Detoxification

To perform an opioid-free, balanced anesthetic for an Active Duty soldier undergoing cervical ganglionectomy for intractable occipital neuralgia 7 days after ultra rapid opioid detoxification (UROD) under general anesthesia. Opioids have been a mainstay for both intraoperative and postoperative analgesia. With the emergence of newer non-opioid analgesics and the practice of the multimodal analgesia, opioid therapy will be complimented and, in some cases, replaced by these newer agents. The increasing knowledge in the literature of both pain mechanisms and chronic pain treatment can present anesthesiologists with a challenge when faced with opioid-tolerant patients in the acute perioperative setting. With an increased focus on adequate pain control among health care regulatory agencies, we may expect to see a growing number of patients who desire weaning from chronic opioid therapy. There have been many weaning protocols proposed in the literature, with UROD under general anesthesia being one of them. We report a case of successful non-opioid analgesia in a patient that presented for a cervical ganglionectomy 7 days after UROD. This patient successfully completed a perioperative and postoperative course using ketamine and dexmedetomidine infusions, in addition to other non-opioid adjuncts. The patient returned to her Active Duty station, with increased functional capacity and remains opioid-free.

Opioid-Induced Hyperalgesia and Rapid Opioid Detoxification After Tacrolimus Administration

Opioids can induce central sensitization and hyperalgesia, referred to as "opioid-induced hyperalgesia." Our report describes a patient who underwent intestinal transplant followed by immunosuppressant-related neuropathic pain. Her pain was treated with limited success over the course of 3 yr with different therapies, including i.v. morphine. She developed opioid-induced hyperalgesia, which was successfully treated with rapid detoxification under general anesthesia. Detoxification improved her quality of life, including the ability to resume physiotherapy. Six months after treatment, she remained opioid free. Our experience suggests that rapid detoxification under general anesthesia may be an effective treatment for opioid-induced hyperalgesia and merits comparison to traditional detoxification methods.

CLINICAL STUDY: Does naltrexone affect craving in abstinent opioid‐dependent patients?

Naltrexone blocks the opioid receptors that modulate the release of dopamine in the brain reward system and therefore blocks the rewarding effects of heroin and alcohol. It is generally assumed that naltrexone leads to reduction of craving, but few studies have been performed to prove this. The purpose of the present study was to examine the effect of the administration of naltrexone on craving level after rapid opioid detoxification induced by naltrexone. A naturalistic study was carried out in which patients were followed during 10 months after rapid detoxification. Data about abstinence, relapse, and naltrexone use were collected by means of urine specimens. Craving was measured by the visual analogue scale craving, the Obsessive Compulsive Drug Use Scale, and the Desires for Drug Questionnaire. Results showed that patients who relapsed in opioid use experienced obviously more craving than abstinent people. Patients who took naltrexone did not experience significant less craving than those who did not. These results suggest that the use of opioids is associated with increased craving and that abstinence for opioids is associated with less craving, independent of the use of naltrexone. This is in contrast to the general opinion. Because of the naturalistic design of the study, no firm conclusions can be drawn, but the results grounded the needs of an experimental study.

A Comparison of Mental Health Hospital Admissions in a Cohort of Heroin Users Prior to and After Rapid Opiate Detoxification and Oral Naltrexone Maintenance

Mental health (MH) hospital admissions were investigated in a cohort (N = 1184) of heroin dependent persons using linked health records. All MH in-patient admissions were extracted 36 months before to 36 months after commencing rapid opioid detoxification (ROD) and oral naltrexone. Results show that the incidence rate ratio (IRR) of drug-related and other MH admissions peaked in the 3 months immediately prior to treatment. All categories subsequently declined to baseline levels by 36 months following treatment. The authors conclude that treatment for heroin dependence reduces risk of MH admissions.

S(+)-Ketamine Attenuates Increase in Electroencephalograph Activity and Amplitude Height of Sensory-Evoked Potentials During Rapid Opioid Detoxification

Anesthesia-assisted opioid detoxification offers an opportunity for patients who have undergone unsuccessful conventional detoxifications. Little is known of excitatory effects taking place in the central nervous system during this procedure. Because acute withdrawal is accompanied by N-methyl-d-aspartic acid (NMDA)-receptor activation we tested whether the administration of the nonspecific N-methyl-d-aspartic acid antagonist S(+)-ketamine results in a reduction of hyperactivity in the central nervous system. Thirty-one patients with a long history of opioid abuse were acutely withdrawn with naltrexone during propofol/clonidine anesthesia and mechanical ventilation. Electroencephalogram (EEG) power spectra as well as median nerve-evoked somatosensory potentials (SSEP) were determined at the following times: evening before detoxification (control), steady-state propofol/clonidine-anesthesia, 30 min after naltrexone administration, and 5 min and 60 min after additional S(+)-ketamine (1.5 mg/kg). Compared to steady-state anesthesia, naltrexone induced a decrease by 270% in the low delta (0.5-3 Hz) and an increase by 110% in the fast beta (13-30 Hz) domain of the EEG with only minor changes in the theta-(3-7 Hz) and alpha-(7-13 Hz) band. Simultaneously, mean amplitude of the late N(100) peak of the SSEP increased from 3.3 muV to 10.5 muV. The changes could be attenuated by the additional administration of S(+)-ketamine, 5 min and 60 min after injection. Cardiovascular changes were not a reliable index for monitoring acute withdrawal symptoms and determining termination of rapid opioid detoxification. In this regard, EEG power spectra and SSEP were more consistent and clinically useful variables. S(+)-ketamine is a valuable adjunct in the anesthetic regimen, since it attenuates hyperactivity of the central nervous system during rapid opioid detoxification.

Anesthesia-Assisted vs Buprenorphine- or Clonidine-Assisted Heroin Detoxification and Naltrexone Induction

Rapid opioid detoxification with opioid antagonist induction using general anesthesia has emerged as an expensive, potentially dangerous, unproven approach to treat opioid dependence. To determine how anesthesia-assisted detoxification with rapid antagonist induction for heroin dependence compared with 2 alternative detoxification and antagonist induction methods. A total of 106 treatment-seeking heroin-dependent patients, aged 21 through 50 years, 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. This randomized trial was conducted between 2000 and 2003 at Columbia University Medical Center's Clinical Research Center. Outpatient treatment occurred at the Columbia University research service for substance use disorders. Patients were included if they had an American Society of Anesthesiologists physical status of I or II, were without major comorbid psychiatric illness, and were not dependent on other drugs or alcohol. Anesthesia-assisted rapid opioid detoxification with naltrexone induction, buprenorphine-assisted rapid opioid detoxification with naltrexone induction, and clonidine-assisted opioid detoxification with delayed naltrexone induction. Withdrawal severity scores on objective and subjective scales; proportions of patients receiving naltrexone, completing inpatient detoxification, and retained in treatment; proportion of opioid-positive urine specimens. Mean 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% anesthesia, 97% buprenorphine, and 21% clonidine), but the groups did not differ in rates of completion of inpatient detoxification. Treatment retention over 12 weeks was not significantly different among groups with 7 of 35 (20%) retained in the anesthesia-assisted group, 9 of 37 (24%) in the buprenorphine-assisted group, and 3 of 34 (9%) in the clonidine-assisted group. Induction with 50 mg of naltrexone significantly reduced the risk of dropping out (odds ratio, 0.28; 95% confidence interval, 0.15-0.51). There were no significant group differences in proportions of opioid-positive urine specimens. The anesthesia procedure was associated with 3 potentially life-threatening adverse events. These data do not support the use of general anesthesia for heroin detoxification and rapid opioid antagonist induction.

A cost-effectiveness analysis of heroin detoxification methods in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD)

This economic evaluation was part of the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD) project. Data from four trials of heroin detoxification methods, involving 365 participants, were pooled to enable a comprehensive comparison of the cost-effectiveness of five inpatient and outpatient detoxification methods. This study took the perspective of the treatment provider in assessing resource use and costs. Two short-term outcome measures were used—achievement of an initial 7-day period of abstinence, and entry into ongoing post-detoxification treatment. The mean costs of the various detoxification methods ranged widely, from AUD $491 (buprenorphine-based outpatient); to AUD $605 for conventional outpatient; AUD $1404 for conventional inpatient; AUD $1990 for rapid detoxification under sedation; and to AUD $2689 for anaesthesia per episode. An incremental cost-effectiveness analysis was carried out using conventional outpatient detoxification as the base comparator. The buprenorphine-based outpatient detoxification method was found to be the most cost-effective method overall, and rapid opioid detoxification under sedation was the most cost-effective inpatient method.

A comparison of rapid (opioid) detoxification with clonidine-assisted detoxification for heroin-dependent persons

This study compares two methods of detoxification available to heroin users in Western Australia: clonidine-assisted detoxification (CD) or clonidine-naloxone precipitated withdrawal under sedation (rapid opioid detoxification [ROD]). Oral naltrexone was made available to all participants following detoxification. Eighty heroin-dependent persons were randomly assigned to either ROD or CD. Most undertaking ROD commenced and completed this treatment. Less than one-third undertaking CD completed this treatment. There was no significant difference in those treated by CD or ROD in subjective assessment of degree or duration of pain, severity of withdrawal and craving, nor was there an increase in the withdrawal sequelae after treatment. Induction of oral naltrexone following ROD was greater, but oral naltrexone compliance levels and abstinence from heroin four weeks following detoxification were similar between ROD and CD groups. The level of patient satisfaction between the two treatments was also similar. The authors discuss why ROD is considered more effective than CD.

Increase in delta- and beta-wave activity of the EEG during rapid opiate detoxification (ROD)-reversal by administration of the non-specific NMDA-antagonist S(+) ketamine-

Little is known on effects taking place in the CNS during rapid opioid detoxification (ROD) while the patient is under anesthesia. We therefore measured EEG-power spectra in the β, α, Θ, and δ-band in 36 patients undergoing ROD. Measurements were taken before, during steady-state anesthesia and following administration of the antagonist naltrexone. In addition, the non-specific NMDA-antagonist S(+) ketamine was given for reduction of CNS-hyperexcitation, while the efficacy of this adjunct was determined using EEG power spectra analysis. Compared to steady-state anesthesia, EEG power spectra were characterized by a marked decrease of power by 251% in the delta (0.5–3 Hz) and an increase by 209% in the beta- (13–30 Hz) domain when withdrawal was induced with naltrexone. Subsequent administration of S(+)-ketamine induced a reversal of acute abstinence-related EEG power changes: compared to anesthesia with naltrexone on board, power in the EEG increased by 65% in the delta- and decreased by 723% in the beta-band. While sympathetically induced hemodynamic alterations in anesthesia-assisted opioid detoxification can be attenuated by the α 2-agonist clonidine and sedation, central nervous sensory activation can be attenuated by the administration of S(+)-ketamine (1.5 mg/kg). Since EEG alterations during acute withdrawal with naltrexone can be controlled by the non-specific NMDA-antagonist S(+)-ketamine, this latter presents a useful adjunct during ROD management.

Unexpected Delirium During Rapid Opioid Detoxification (ROD)

Rapid Opioid Detoxification (ROD), using a combination of the long acting opioid antagonist, Naltrexone and the alpha 2 agonist Clonidine, is a method to detoxify patients who are opioid dependent. The daily administration of Naltrexone in increasing dosages decreases the duration of the withdrawal syndrome associated with opioids, especially longer acting drugs such as Methadone. This study is intended to report the frequency of delirium, as defined in DSMIV, during the ROD of Methadone maintained patients. A chart review was conducted of twenty consecutive patients who received in-patient ROD from Methadone maintenance from January 1999 to December 1999. Methadone was tapered and discontinued prior to ROD and Naltrexone was administered in increasing daily doses. Five individuals developed delirium and discontinued the procedure on the first day, fourteen patients completed the protocol, and one dropped out prior to completion. A significant incidence of delirium resulted from the ROD procedure.

Use Of Remifentanil For Reverse Opioid Blockade In A Patient

Naltrexone is a pure competitive antagonist at opioid receptors used in the maintenance of abstinence from opioids, alcohol and in rapid opioid detoxification under anaesthesia. Patients on naltrexone therapy may present a challenge in emergency anesthesia and pain management because of very high opioid requirements with several side effects. We report a case where remifentanil was used successfully and uneventfully to overcome this competitive blockade during the anaesthetic management using high doses without accumulation and prolonged recuperation.

Emergency management of inadvertent accelerated opiate withdrawal in dependent opiate users.

Six opiate-dependent drug users presented to the local emergency department within a 10-day period with symptoms of severe opioid withdrawal immediately following intravenous use of recently acquired street 'heroin'. The withdrawal picture was similar to that described in patients undergoing rapid opioid detoxification, suggesting that the substance injected was contaminated with an opiate antagonist. A number of potential compounds are discussed, including naltrexone and buprenorphine, and recommendations for the medical management of severe opiate withdrawal within an emergency setting are outlined. [Lubman DI, Koutsogiannis Z, Kronborg I. Emergency management of inadvertent accelerated opiate withdrawal in dependent opiate users.

Neuroendocrine and behavioural responses to opioid receptor-antagonist during heroin detoxification: relationship with personality traits

The present study investigated clinical, cardiovascular and neuroendocrine consequences of rapid opioid detoxification (ROD) in heroin-dependent individuals, affected, or not, by comorbid antisocial personality disorder (ASPD). Thirty-two patients underwent ROD and subsequent treatment with daily naltrexone: 3 days detoxification procedures were performed utilizing clonidine, baclofen, oxazepam and ketoprofene, without anaesthesia. Withdrawal symptoms, mood changes, cardiovascular indexes (heart rate, blood pressure), norepinephrine (NE), epinephrine (EPI), adrenocorticotropic hormone (ACTH) and cortisol (CORT) were evaluated during naloxone–naltrexone administration on the second day of detoxification treatment. The patients were divided into two groups following DSM-IV criteria for ASPD. Group A comprised 14 ASPD patients and group B comprised 18 patients without ASPD. Slight and transient withdrawal symptoms and mood changes were demonstrated on the second day in the whole sample of patients, in association with a significant, but moderate, elevation of heart rate, blood pressure, NE (two-fold), EPI (five-fold), ACTH (two-fold) and CORT (two-fold) plasma levels, in response to opioid receptor-antagonist administration. When evaluated separately in ASPD (group A) and non-ASPD patients (group B), significantly higher withdrawal symptoms and mood changes, heart rate, blood pressure, NE, ACTH and cortisol levels were observed in ASPD subjects. By contrast, no differences were found in EPI responses to naloxone–naltrexone administration between group A and B patients. The significant differences demonstrated in clinical and neuroendocrine responses to opioid receptor-antagonist administration, in relation to personality traits, could be due to reduced alpha-adrenergic receptor sensitivity, which was previously reported in ASPD, with a possible impairment of clonidine action. Our study suggests that a detailed diagnostic assessment before detoxification procedure may help to predict treatment outcome.

Rapid Opioid Detoxification in Australia

Rapid Opioid Detoxification in Australia