Anesthesia Length in Ultra Rapid Opioid Detoxification
Subgroup: Volume 12, Issue 2
Date: March 2010
Type: Letter to Editor
Start Page: 200
End Page: 201
- K Nasseri Department of Anesthesia and Intensive Care, Kurdistan University of Medical Sciences, Sanandaj, Iran
- Sh Shami Faculty of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran
City, Province: Sanandaj,
Ultra rapid opioid detoxification (UROD) has received more attention during the past three decades due to the challenges in treating opioid-dependent patients and is heralded as a humane, effective way to rapidly accomplish detoxification while avoiding the physical symptoms of withdrawal.1 UROD has been shown to be as effective as intensive inpatient detoxification.2,3 However, this procedure can be dangerous due to the prolonged anesthesia (or deep sedation) period. This danger can be mitigated with proper shortening of anesthesia time. This study aims to compare the effects of different anesthesia duration time in UROD procedure on severity of withdrawal symptoms in opioid dependent patients.
After obtaining approval from the Ethics Committee and written informed consent, 72 patients with diagnosis of opiate addiction according to DSM classification,4 were enrolled and randomly assigned to three treatment groups.
Premedication and anesthesia protocol were identical for three groups. Detoxification was carried out with the administration of 4 mg bolus naloxone and perfusion of other 12 mg for two (2 hours anesthesia duration group), Four (four hours anesthesia duration group) and six (six hours anesthesia duration group) hours. High-dose and/or rapidly infused naloxone may cause catecholamine release and consequently pulmonary edema and cardiac arrhythmias. These risks warrant the adequate monitoring of the cardiopulmonary status of the patient after naloxone administration,4 so the patients were monitored cautiously.
Clinical signs of withdrawal were evaluated by rating the signs and symptoms of withdrawal according to the criteria proposed by Wang et al. modifying scale adapted to the conditions of general anesthesia.5 The signs and symptoms were rated as present or absent and were scored. The total score represented the cumulative rating for the signs and symptoms and was recorded after starting the infusion of naloxone and then hourly during anesthesia, at the first 2, 12 and 24 hours since induction of the anesthesia. Patients were kept in the hospital for 24 hours, and then discharged, when 50 mg daily naltroxone were administered for six months and 2 mg nightly clonazepame for insomnia if needed . Morphine test (using urine sample) was performed at the end of 10th day and after one and six months.
Base line characteristics were comparable in three groups. The most common opioid used was opium (82%) and the most common rout of consumption was orally (60%). No statistically differences were observed between all groups in relation to withdrawal intensity. We did not find any correlation between withdrawal intensity and age (p=0.7) and drug addiction time (p=0.2). There was a statistically significant correlation between withdrawal intensity and opioid type. The sign’s and symptom’s of withdrawal were very intense in opium than heroin (p=0.02) and oral consumption method than intravenous (p=0.04) and smoking (p=0.02) too. The important complications were 3 delirium cases (2 in 2H group, and one of the 6H group patients), that treated with IV diazepam, and a case of pulmonary edema that developed 24 hours after termination of anesthesia with history of COPD who needed intubation and mechanical ventilation for an additional 6 hours. Eleven of 60 patients did not come back to follow up tests. After ten days, one and six months, 3, 10 and 15 of 49 remainder patients had relapse respectively, Recurrence of addiction was similar in 3 groups.
The intensity of withdrawal signs and symptoms were more in the beginning of naloxone infusion and two hours after termination the anesthetic infusion in all groups. These results are not compatible with the results of other studies, 6-8 that concluded the highest peak in the beginning of naloxone infusion and a lower peak the day after detoxification. It may be due to the highest level of sedation in the patient of our study and use of muscle relaxants during the anesthesia that covered the symptoms of withdrawal appearing in the recovery awakening time.
The relapse rate in our study was about 55% with no significant difference between the groups. This was similar to Albanese study that reported 55% of patients with relapse free status at the six months follow up interval.5In our study after six months, only 7% of heroin users versus 56% of opium addicts remained abstinent. This difference was statistically significant. Most studies have shown high relapse rates to heroin use.8,9 In our study, relapse rate was 15% in the10th day, 72% after one month and 92% after six months among 14 heroin users. A report on 15 heroin users in Sydney estimated that relapse rate was 42% after one month, 77% after two months and 83% after three months.10Another study reported only 5% of 43 patients at retention for six months.11 In contrast with our results, Rabinowitz et al. reported much lower rates of relapse after naltroxone treatment reporting that 60% of patients were free of heroin use six month after detoxification.7
A reliable method in assessing the adequacy of detoxification is the IV reinjection of high dose naloxone (20–30 mg). If the patient does not show exacerbation of the signs of withdrawal, detoxification is considered adequate. Alan et al. believed that absence of response to naloxone challenge may require six hours of general anesthesia with injection of high dose naloxone at repeated intervals.12
We can conclude that the intensity of withdrawal signs in UROD procedure under general anesthesia has no correlation with anesthesia length and duration but the duration can be shortened up to two hours.
Conflict of interest: None declared.
- Plunkett A, Fahlgren M, McLean B, Mundey D. Opioid-free balanced anesthesia for cervical ganglionectomy subsequent to recent ultra rapid opioid detoxification. Pain Med 2009;10:767-70.  [doi:10.1111/j.1526-4637.2009.00610.x]
- Singh J, Basu D. Ultra-rapid opioid detoxification: Current status and controversies. J Postgrad Med 2004;50:227-32. 
- Kaye AD, Banister RE, Hoover JM, Baluch AR, Jacobs S, Shah RV. Chronic pain and ultrarapid opioid detoxification. Pain Pract 2005;5:33-42.  [doi:10.1111/j.1533-2500.2005.05105.x]
- van Dorp EL, Yassen A, Dahan A. Naloxone treatment in opioid addiction: the risks and benefits. Expert Opin Drug Saf 2007;6:125-32.  [doi:10.1517/147403188.8.131.52]
- Albanese AP, Gevirtz C, Oppenheim B, Field JM, Abels I, Eustace JC. Outcome and six month follow up of patients after Ultra Rapid Opiate Detoxification (UROD). J Addict Dis 2000;19:11-28.  [doi:10.1300/J069v19n02_02]
- Broers B, Giner F, Dumont P, Mino A. Inpatient opiate detoxification in Geneva: follow-up at 1 and 6 months. Drug Alcohol Depend 2000;58:85-92.  [doi:10.1016/S0376-8716(99)00063-0]
- Rabinowitz J, Cohen H, Atias S. Outcomes of naltrexone maintenance following ultra rapid opiate detoxification versus intensive inpatient detoxification. Am J Addict 2002;11:52-6.  [doi:10.1080/10550490252801639]
- Lorenzi P, Marsili M, Boncinelli S, Fabbri LP, Fontanari P, Zorn AM, Mannaioni PF, Masini E. Searching for a general anaesthesia protocol for rapid detoxification from opioids. Eur J Anaesthesiol 1999;16:719-27. 
- Bell JR, Young MR, Masterman SC, Morris A, Mattick RP, Bammer G. A pilot study of naltrexone-accelerated detoxification in opioid dependence. Med J Aust 1999;171:26-30. 
- Foy A, Sadler C, Taylor A. An open trial of naltrexone for opiate dependence. Drug Alcohol Rev 1998;17:167-74.  [doi:10.1080/09595239800186971]
- Rabinowitz J, Cohen H, Tarrasch R, Kotler M. Compliance to naltrexone treatment after ultra-rapid opiate detoxification: an open label naturalistic study. Drug Alcohol Depend 1997;47:77-86.  [doi:10.1016/S0376-8716(97)00073-2]
- Kaye AD, Gevirtz C, Bosscher HA, Duke JB, Frost EA, Richards TA, Fields AM. Ultrarapid opiate detoxification: a review. Can J Anaesth 2003;50:663-71.  [doi:10.1007/BF03018708]