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Sleeping Through Withdrawal --
Anesthesia-Assisted Rapid Opioid Detox


By Dr. Gerard M. DiLeo, MD, CLCP
Source:
Addictions.com

Until there are developed inexpensive, effective painkillers that aren’t addictive and don’t cause dependence or promote tolerance, we’re stuck with the opioids.

While opioids are quite effective and affordable, they do promote tolerance (requiring stronger doses to get the same relief), and you can easily become dependent or addicted to opioids. The race is on for pharmaceutical companies to find the ideal painkiller, but because the entire pain process is so complex, this has proved elusive.

The Nature of the Beast

There are two major concerns with opioids and narcotics in general:

1. Tolerance, dependence, and addiction.
2. Withdrawal.

These concerns cover the majority of problems, but from them also spring societal problems such as overdose deaths, drug abuse, and criminal behavior. While the benefits of opioids are there, most doctors and patients alike are justifiably fearful of them, and the social cost is significant.

It is still not completely understood why tolerance, dependence, and addiction develop, although it probably has something to do with the powerful effects of the “reward” neurotransmitter, dopamine, which is a major player in opioid exposure. Likewise, this probably plays a major impact in the discomfort of going without opioids once the dopamine system is firmly entrenched in the expectation of continued opioid use. In fact, addiction, withdrawal, and their associated tragedies have been referred to as “Reward Deficiency Syndrome.”

Sleeping with the Enemy

The withdrawal from opioids is well-known to be particularly severe. It is the fear of the symptoms that often maintains one’s addiction—even those who would like to detox. If anesthesia and sedation are used for other unpleasant procedures, such as surgery or dentistry, it follows that these methods can be applied to detox and for avoidance of the entire withdrawal ordeal.

There are three ways this is being explored:

Ultra-rapid Opiate Detox (UROD): this uses general anesthesia for a duration of less than 6 hours.

Rapid-opiate Detox (ROD): this uses deep sedation for a duration between 6 and 72 hours.

Compressed Opiate Detox (COD) and Naltrexone-compressed Opiate Detox (NCOD): this uses UROD or ROD followed by naltrexone sedation. While the FDA has approved drugs like naltrexone, it is a narcotic itself, so is not a final solution.

Using these protocols, under anesthesiology supervision, the peak of withdrawal symptoms can be over by the time a patient recovers from the anesthesia/sedation. If this sounds too good to be true, read on.

Not So Fast!

Before signing up for a get-clear-fast scheme, you must realize that anesthesia is not a benign procedure. One way of looking at it is to consider it the administration of poison in a controlled environment. As such, it has all of the complications any general anesthetic or deep sedation has. This is why there is medical literature which seems to condemn this approach, concluding the risk outweighs the benefit.

In the journal, Science-Based Medicine, a publication dedicated to “exploring issues and controversies in the relationship between science and medicine,” it cites “the overwhelming evidence against AAROD”:

“…many addiction experts say that until claims of superior relapse rates for the ultrarapid detoxification methods are proven and concerns about the potential risks are allayed, the procedure should be considered experimental.”

Also,

“Two components of this procedure, precipitated withdrawal and anesthesia, are known to have risks that are not present in the more commonly used detoxification and withdrawal treatments. Any benefits of the procedure have not yet been shown to be worth these added risks.”

Further, in a 14-year-old study reported in JAMA, it was concluded that their data did “not support the use of general anesthesia for heroin detoxification and rapid opioid antagonist [naltrexone] induction.”

Who’s Right?

Deciphering risk vs benefit is tricky, because risk is in the mind of the beholder (the person at risk). Sure, you need to listen to the healthcare professional who tells you what could happen, but only a true perspective on likelihood can allow any patient to make the determination of where the division lies between risk and benefit.

For example, if you need your ruptured appendix removed—and quick—you will readily agree to the risks of anesthesia, because the other two alternatives (undergoing surgery you feel or death) are unacceptable. Looking at it like that, the decision is easy. But does trying to avoid detox symptoms qualify on the same level as life-threatening peritonitis? No, agreed. But what about a non-life-threatening hernia that requires general anesthesia? What about cosmetic surgery that requires it?

Let’s face it, you don’t need general anesthesia if you need an amputation, but it really helps. Otherwise, we might as well be practicing Civil War medicine. Why is detox considered unworthy when other elective surgeries aren’t? Is it possibly because of a bias against those who are addicted? This would not be the first bias they have ever encountered.

Those who oppose this will explain that there is added risk for a person who has both opioid addiction AND general anesthesia—that the risk is greater than the sum of the parts. While this is true, so does a heart surgery patient undergoing anesthesia. Or an obese patient having a gastric bypass procedure.

For those who say the relapse rate may not be improved, shouldn’t that apply to persons undergoing multiple anesthetic for recurrent pre-cancerous polyps. The patient experiencing withdrawal is not doing it to improve his or her life in general, but just mask an unnecessary unpleasantness. And that may be the only thing standing in the way of detoxing at all.

Exercising Rights

The individualized and special relationship between the doctor and patient is what determines who is right. All medical procedures are considered to have the potential for harm. But so does withdrawal. While typically no one dies from narcotic withdrawal, there is still a huge potential for psychological harm that comes from the negative impact of suffering. (Ask a PTSD patient.)

As has been medically established, a patient has the right to consider a non-FDA-approved indication for an otherwise FDA-approved procedure or medication.

 

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