Ultra-Rapid Opiate Detoxification Followed by Nine Months of Naltrexone Maintenance Therapy in Iran

Abstract

Introduction: The aim of this retrospective study was to assess ultra-rapid opiate detoxification (UROD) and to estimate the retention rate in naltrexone maintenance treatment.

Methods: 45 opiate-addicted male patients (DSM-IV 304.00; opiate per oral or per inhalation n=40, heroin intravenous n=5; concomitant cannabis abuse n=6) were detoxified by 6 h of naloxone infusion under general anesthesia with midazolam, propofol, clonidine and atracurium. Withdrawal signs were evaluated by the objective opiate withdrawal scale (OOWS, range 0–13) up to 24 h after awakening. After UROD, naltrexone 50 mg/day was prescribed for 9 months with assessments in 4-week intervals.

Results: Adverse events after UROD were prolonged unconsciousness (n=1), transient confusion (n=8) and depressive mood (n=6). The total sample showed a median OOWS score of 2 (mild withdrawal syndrome). The only two extreme outliers were found only in the subgroups “intravenous” (score 8) and “cannabis” (score 11). 96% (43/45) of the patients could be discharged the day after UROD. Thirty-six patients (80%) continued naltrexone therapy for the entire 9-month observation period.

Discussion: UROD and subsequently induction of naltrexone maintenance therapy can be regarded as safe and effective in patients with pure opiate addiction. Owing to cultural and economical factors our Iranian results may not correspond to European and American treatment modalities.

References

• 1 Abnet C-C, Saadatian-Elahi M, Pourshams A. et al . Reliability and Validity of opiate use self-report in a population at high risk for esophageal cancer in Golestan, Iran.  Cancer Epidemiol Biomarkers Prev. 2004;  13 1068-1070
• 2 Adi Y, Juarez-Garcia A, Wang D. et al . Oral naltrexone as a treatment for relapse prevention in formerly opioid-dependent drug users: A systematic review and economic evaluation.  Health Technol Assess. 2007;  11 1-85
• 3 Ahmadi J, Motamed F. Treatment success rate among Iranian opioid dependents.  Substance use and misuse. 2003;  38 151-163
• 4 Albanese A-P, Gevirtz C, Oppenheim B. et al . Outcome and six month follow up of patients after Ultra Rapid Opiate Detoxification (UROD).  J Addict Dis. 2000;  19 11-28
• 5 Amato L, Davoli M, Minozzi S. et al . Methadone at tapered doses for the management of opioid withdrawal.  Cochrane Database Syst Rev. 2005;  20 CD003409
• 6 Ambrosio E, Martin S, Garcia-Lecumberri C. et al . The neurobiology of cannabinoid dependence: Sex differences and potential interactions between cannabinoid and opioid systems.  Life Sci. 1999;  65 687-694
• 7 American Psychiatric Association. .Diagnostic and Statistical Manual of Mental Disorders 4^th ed. Washington, DC: American Psychiatric Press 1994
• 8 Ashton C-H. Adverse effects of cannabis and cannabinoids.  Br J Anaesth. 1999;  83 637-649
• 9 Broers B, Giner F, Dumont P. et al . Inpatient opiate detoxification in Geneva: Follow-up at 1 and 6 months.  Drug and Alcohol dependence. 2000;  58 85-92
• 10 Collins E-D, Kleber H-D, Whittington R-A. et al . Anesthesia-assisted vs. buprenorphine- or clonidine-assisted heroin detoxification and naltrexone induction: a randomized trial.  JAMA. 2005;  294 903-913
• 11 Day E, Ison J, Strang J. Inpatient versus other settings for detoxification for opioid dependence.  Cochrane Database Syst Rev. 2005;  18 CD004580
• 12 Favrat B, Zimmermann G, Zullino D. et al . Opioid antagonist detoxification under anaesthesia versus traditional clonidine detoxification combined with an additional week of psychosocial support: A randomised clinical trial.  Drug Alcohol Depend. 2006;  81 109-116
• 13 Foster J, Brewer C, Steele T. Naltrexone implants can completely prevent early (1-month) relapse after opiate detoxification: a pilot study of two cohorts totalling 101 patients with a note on naltrexone blood levels.  Addict Biol. 2003;  8 211-217
• 14 Gonzalez J-P, Brogden R-N. Naltrexone: A review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy in the management of opioid dependence.  Drugs. 1988;  35 192-213
• 15 Gossop M, Green L, Phillips G. et al . Lapse, relapse and survival among opiate addicts after treatment. A prospective follow-up study.  Br J Psychiatry. 1989;  154 348-353
• 16 Gowing L, Farrell M, Ali R. et al . Alpha2 adrenergic agonists for the management of opioid withdrawal.  Cochrane Database Syst Rev. 2004;  18 ((4)) CD002024
• 17 Gowing L, Ali R, White J. Buprenorphine for the management of opioid withdrawal.  Cochrane Database Syst Rev. 2006a;  19 ((2)) CD002025
• 18 Gowing L, Ali R, White J. Opioid antagonists with minimal sedation for opioid withdrawal.  Cochrane Database Syst Rev. 2006b;  25 ((1)) CD002021
• 19 Gowing L, Ali R, White J. Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal.  Cochrane Database Syst Rev. 2006c;  19 ((2)) CD002022
• 20 Handelsman L, Cochrane K-J, Aronson M-J. et al . Two new rating scales for opiate withdrawal.  Am J Drug Alcohol Abuse. 1987;  13 293-308
• 21 Hensel M, Kox W-J. Safety, efficacy, and long-term results of a modified version of rapid opiate detoxification under general anaesthesia: A prospective study in methadone, heroin, codeine and morphine addicts.  Acta Anaesthesiol Scand. 2000;  44 326-333
• 22 Herman B-H, Czechowicz D. NIDA scientific report of ultra rapid detoxification with anesthesia (UROD): Opinion of the consultants and criteria relating to evaluating the safety and efficacy of UROD.  American National Institute on Drug Abuse (NIDA) Report. 1996;  23 1-8
• 23 Javier Alvarez F, Carmen del Rio M. Ultrarapid opiate detoxification: a look at what is happening in Spain.  Addiction. 1999;  94 1239-1240
• 24 Karbakhsh M, Salehian Zandi N. Acute opiate overdose in Tehran: The forgotten role of opium.  Addictive Behaviors. 2007;  32 1835-1342
• 25 Kaye A-D, Gevirtz C, Bosscher H-A. et al . Ultrarapid opiate detoxification:a review.  Can J Anaesth. 2003;  50 663-671
• 26 Kienbaum P, Thürauf N, Michel M-C. et al . Profound increase in epinephrine concentration in plasma and cardiovascular stimulation after mu-opioid receptor blockade in opioid-addicted patients during barbiturate-induced anesthesia for acute detoxification.  Anesthesiology. 1998;  88 1154-1161
• 27 Kirchmayer U, Davoli M, Verster A. Naltrexone maintenance treatment for opioid dependence.  Cochrane Database Syst Rev. 2000;  4 CD001333
• 28 Kirchmayer U, Davoli M, Verster A-D. et al . A systematic review on the efficacy of naltrexone maintenance treatment in opioid dependence.  Addiction. 2002;  97 1241-1249
• 29 Kornor H, Waal H. From opioid maintenance to abstinence: a literature review.  Drug Alcohol. 2005;  24 267-274
• 30 Krabbe P-F, Koning J-P, Heinen N. et al . Rapid detoxification from opioid dependence under general anaesthesia versus standard methadone tapering: abstinence rates and withdrawal distress experiences.  Addict Biol. 2003;  8 351-358
• 31 Loimer N, Schmid R-W, Presslich O. et al . Continuous naloxone administration suppresses opiate withdrawal symptoms in human opiate addicts during detoxification treatment.  J Psychiat Res. 1989;  23 81-86
• 32 Lorenzi P, Marsili M, Boncinelli S. et al . Searching for a general anaesthesia protocol from opioids.  Eur J Anaesthesiol. 1999;  16 719-727
• 33 Madoz-Gúrpide A, Barbudo del Cura E, Leira Sanmartín M. et al . Addiction characteristics as prognostic factors in opiate dependence treated with naltrexone.  Actas Esp Psiquiatr. 2004;  32 199-210
• 34 McGregor C, Ali R, White J-M. et al . A comparison of antagonist-precipitated withdrawal under anesthesia to standard inpatient withdrawal as a precursor to maintenance naltrexone treatment in heroin users: outcomes at 6 and 12 months.  Drug Alcohol Depend. 2002;  68 5-14
• 35 McLellan A-T, Kushner H, Metzger D. et al . The fifth edition of the Addiction Severity Index.  J Subst Abuse Treat. 1992;  9 199-213
• 36 Minozzi S, Amato L, Vecchi S. et al . Oral naltrexone maintenance treatment for opioid dependence.  Cochrane Database of Systematic Reviews. 2006;  Issue 1. Art. No.: CD001333. DOI: 10.1002/14651858.CD001333 
• 37 Presslich O, Loimer N, Lenz K. et al . Opiate detoxification under general anesthesia by large doses of naloxone.  J Toxicol Clin Toxicol. 1989;  27 263-270
• 38 Rabinowitz J, Cohen H, Kotler M. Outcome of ultrarapid opiate detoxification combined with naltrexone maintenance and counseling.  Psychiatr Serv. 1998;  49 831-833
• 39 Rabinowitz J, Cohen H, Atias S. Outcomes of naltrexone maintenance following ultra rapid opiate detoxification versus intensive inpatient detoxification.  Am J Addict. 2002;  11 52-56
• 40 Satel S-L, Kosten T-R, Schuckit M-A. et al . Should protracted withdrawal from drugs be included in DSM-IV?.  Am J Psychiatry. 1993;  150 695-704
• 41 Singh J, Basu D. Ultra-rapid opioid detoxification: current status and controversies.  J Postgrad Med. 2004;  50 227-232
• 42 Sullivan M-A, Garawi F, Bisaga A. et al . Management of relapse in naltrexone maintenance for heroin dependence.  Drug Alcohol Depend. 2007;  91 289-292
• 43 Teplin D, Raz B, Daiter J. et al . Measurement of symptom withdrawal severity in a 24-hour period after the anesthesia-assisted rapid opiate detoxification procedure.  Am J Drug Alcohol Abuse. 2005;  31 327-335
• 44 Van den Brink W, Haasen C. Evidenced-based treatment of opioid-dependent patients.  Can J Psychiatry. 2006;  51 635-646
• 45 Van Dorp EL, Yassen A, Dahan A. Naloxone treatment in opioid addiction: the risks and benefits.  Expert Opin Drug Saf. 2007;  6 125-132
• 46 Wang WS, Chiou TJ, Hsieh RK. et al . Lethal acute pulmonary edema following intravenous naloxone in a patient received unrelated bone marrow transplantation.  Zhonghua Yi Xue Za Zhi (Taipei). 1997;  60 219-223
• 47 Yamaguchi T, Hagiwara Y, Tanaka H. et al . Endogenous cannabinoid 2-arachidonoylglycerol, attenuates naloxone-precipitated withdrawal signs in morphine-dependent mice.  Brain Res. 2001;  909 121-126

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