An increasingly common method of heroin detoxification under general anesthesia is ineffective and unsafe, according to a study by psychiatrists at Columbia University Medical Center and the New York State Psychiatric Institute at Columbia.
The study, published in the August 24 Journal of the American Medical Association (JAMA), is the first rigorously controlled trial to monitor all of the critical outcomes associated with the procedure, including comfort, treatment retention, abstinence rates and the ability to receive the full and effective dose of naltrexone, a drug that blocks activation on the receptor sites in the brain where the opioids attach.
Heroin addiction is notoriously difficult to overcome. The nervous system of heroin users adapts over time to accommodate to chronic exposure to the opioid, and its sudden absence during detoxification results in excruciating withdrawal symptoms, including nausea, diarrhea, abdominal pain, insomnia and irritability. Despite improvements in recent decades, medically supervised heroin withdrawal remains plagued by patient discomfort and high dropout rates. This has led to the growth of ultra-rapid, anesthesia-assisted opioid withdrawal procedures, which have been publicized as a fast, painless way to withdraw from opioids.
Results of the JAMA study, however, found that the procedure can lead to risk of death, psychosis and increased stress. Other studies have found other risks including delirium, attempted suicide, abnormal heart rhythm and acute renal failure. The anesthesia method is also prohibitively expensive, with most centers charging between $5,000 and $15,000 for the procedure.
“Our research illustrated that rapid heroin detoxification under anesthesia does not work well enough to justify the significant risk and expense,” said Eric D. Collins, M.D., assistant professor of clinical psychiatry at Columbia University Medical Center and the New York State Psychiatric Institute, and the project director and first author on the study.
The study compared detoxification under anesthesia to two other alternative methods. Detoxification with a single dose of the drug buprenorphine was slower than anesthesia, but more effective and significantly less expensive. The third option, using the drug clonidine, was the slowest method and the least effective.
“Quitting heroin use can be an extremely painful process and we continue to strive to identify more comfortable and rapid methods of helping patients reach that goal,” said Herbert D. Kleber, M.D., professor of psychiatry at Columbia University Medical Center, director of the substance abuse division at the New York State Psychiatric Institute and principal investigator on the study. “Unfortunately the anesthesia method is not the answer.”
Dr. Kleber believes that regardless of the detoxification method used, the treatment received after detoxification is the most important factor in determining the ultimate success in remaining off heroin, as Patrick G. O’Connor, M.D., of the Yale University School of Medicine argued in his accompanying JAMA editorial.
Most of the approximately one million heroin-dependent Americans are not in treatment, and their main initial contact with the treatments system is often detoxification. Throughout the 20th century, many methods of opioid detoxification have been proposed – including insulin-induced seizures, artificial hibernation and electroconvulsive therapy. But these approaches often produced greater morbidity and mortality than untreated withdrawal.
From Columbia University