Advocacy

Rapid and Ultra Rapid Opioid Detoxification

Adoption Date:
April 1, 2000; rev. April1, 2005

Public Policy Statement on Rapid and Ultra Rapid Opioid Detoxification
(Formerly Public Policy Statement on Opioid Antagonist Agent Detoxification under Sedation or Anesthesia (OADUSA))

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Background

Opioid addiction is a complex disease involving physiological, psychological, genetic, behavioral and environmental factors. It shares features of other drug dependencies but often requires unique treatment strategies. No single treatment approach is effective in all cases. In carefully chosen patient populations, both abstinence-based treatment and opioid agonist maintenance treatment are effective, safe and accepted modalities. (See ASAM Public Policy Statements on Methadone and Buprenorphine.)

The withdrawal syndrome from opioids--including those that have been therapeutically administered in an opioid maintenance treatment program--can be protracted and intensely symptomatic, albeit virtually without risk of mortality. There is no single "right way" to detoxify all opioid addicted patients. Traditional methods include tapering with methadone or buprenorphine or discontinuing opioids and administering oral clonidine to ameliorate symptoms of withdrawal. Even when pharmacologic agents are utilized in the management of opioid withdrawal, there is often a significant amount of patient discomfort. Patients who are unable to tolerate this discomfort often terminate the detoxification process and many return to illicit opioid use. Other opioid-dependent patients--both those engaged in active illicit drug use and those stabilized in an opioid agonist maintenance program--will not even attempt opioid withdrawal because of their fears of the discomforts of the process. Whereas mortality from opioid withdrawal is negligible, the mortality rate for persons who resume opioid use is significant. This is due not only to the mortality inherent in active opioid addiction but also to the increased risk of fatal overdose which results from the loss of opioid tolerance associated with even a short period of abstinence, as occurs in most detoxification attempts.

Clinicians have developed various accelerated methods of opioid detoxification that rapidly induce withdrawal through the monitored therapeutic administration of opioid antagonist agents, while concurrently diminishing the patient’s discomfort by inducing various degrees of sedation through the use of sedative hypnotic agents or general anesthetics. More commonly used terminology refers to rapid opioid detoxification (ROD), in which oral opioid antagonists (naltrexone) are administered along with moderate sedation orally or ‘conscious sedation’ intravenously; and ultra rapid opioid detoxification (UROD), in which intravenous opioid antagonists (naltrexone) are administered along with general anesthesia.

The topic of antagonist-assisted acute detoxification accompanied by heavy sedation or anesthesia has been the subject of two Cochrane Database Reviews, most recently updated in 2004. In these reviews, the available literature was surveyed and described in detail. The reviewers conclude that there is insufficient evidence to support the clinical use of antagonist-assisted detoxification with heavy sedation or anesthesia in the management of opioid addiction (UROD). In the case of the use of antagonist-assisted detoxification with minimal sedation (ROD), the reviewers conclude that adjunctive use of minimal sedation with an opioid antagonist and an alpha-2 adrenergic agonist may increase the likelihood of entry into longer-term naltrexone treatment, compared to withdrawal managed with an opioid antagonist and an adrenergic agonist without the assistance of minimal sedation. A high level of monitoring and support (for several hours following administration of opioid antagonists) is recommended because of the possibility of vomiting, diarrhea and delirium.

The goal of addiction treatment is to have patients functioning optimally in their families and communities; abstinence alone does not assure optimum functioning, and detoxification does not in itself address the chronic dysfunctions of addiction. Ongoing engagement in addiction treatment is an important variable in how effective treatment will be. It is unclear how any specific method of detoxification relates to retention in addiction treatment. Further research could give information on the safety and effectiveness of antagonist-induced acute detoxification regimes, as well as of the variables influencing the severity of withdrawal, the prevalence and severity of adverse effects, the most effective antagonist-based detoxification regimens, and approaches that might increase retention in subsequent treatment and/or opioid or naltrexone maintenance programs for persons receiving opioid detoxification services. As stated so succinctly by authors of a 1998 article in the Journal of the American Medical Association, “the existing literature on Rapid Opiate Detox is limited in terms of the number of subjects evaluated, the variation in protocols studied, lack of randomized design…and the short term nature of the outcomes reported. Further research is indicated and needed using more rigorous research methods, longer term outcomes, and comparison with other methods of treatment for opiate dependence.” Almost a decade since the appearance of this article, the same conclusions are justified.

Policy Recommendations

1. Opioid detoxification alone is not a treatment of opioid addiction. ASAM does not support the initiation of acute opioid detoxification interventions unless they are part of an integrated continuum of services that promote ongoing recovery from addiction.

2. Ultra-Rapid Opioid Detoxification (UROD) is a procedure with uncertain risks and benefits, and its use in clinical settings is not supportable until a clearly positive risk-benefit relationship can be demonstrated. Further research on UROD should be conducted.

3. Although there is medical literature describing various techniques of Rapid Opioid Detoxification (ROD), further research into the physiology and consequences of ROD should be supported so that patients may be directed to the most effective treatment methods and practices.

4. Prior to participation in any particular modality of opioid detoxification, a patient should be provided with sufficient information by which to provide informed consent, including information about the risks of termination of a treatment plan of prescribed agonist medications such as methadone or buprenorphine, as well as the need to comply with medical monitoring of their clinical status for a defined period of time following the procedure to ensure a safe outcome. Patients should also be informed of the risks, benefits and costs of alternative methods of treatment available.

7 comments

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  1. ASAM Sep 15, 2014 - 08:42 AM

    Shane and others seeking treatment services,

    Please contact the ASAM state chapter in your area for a referral to a treatment provider in your area.  They will be able to recommend the best course of treatment and can answer any questions about cost, etc.

    Here is a link to the listing of ASAM state chapter presidents: http://www.asam.org/membership/state-chapters/chapter-presidents-and-executives

    Thank you for your question and don't hesitate to contact us again with any further.

    ASAM

  2. Ralph delcore Sep 11, 2014 - 05:29 PM

    Please send me info on how affective this process is , where is it done how much does it cost as well

    I've been on suboxone for 3 years n can't get off b. it hurts too much us I can't miss months of work please help

  3. Shane Farrington Sep 07, 2014 - 06:18 PM

    I am interested in the rapid heroin detox. Could you please send me some more info eg. Where you are based, how much it costs etc etc. Thank you.

  4. Michael H. Lowenstein, M.D. Apr 20, 2014 - 06:52 PM

    I have been at the forefront of rapid opiate detox under anesthesia/sedation performing the Waismann Method since 1999 and have safely, humanely and effectively treated thousands of patients. During this time, I have also attempted to set the standard for safety. In all cases, patients need to undergo appropriate medical screening to determine if they are a candidate for rapid detox both from a physical and psychological perspective. I feel very strongly that  rapid detox procedures should only be performed as an inpatient in a fully accredited hospital ICU where the patient is kept overnight and their vitals signs are monitored by qualified professionals and their fluids and electrolytes are measured and replaced if necessary.  This should not be performed on an outpatient basis where the responsibility for post procedure care is placed upon a family member or friend in a hotel setting.

     

    Rapid detox does not treat addiction. It does however treat opiate dependency in a very short time. At the end of the rapid treatment all patients are opiate free and on an opiate antagonist which helps to block craving and starts the clock on the physical and psychological recovery. Patients are ready to start the process of identifying and treating their underlying psychological and social issues much sooner.

    I fully agree with the ASAM policy statement that "no single treatment approach is effective in all cases." Rapid opiate detox under sedation is a safe, humane and effective alternative if performed by trained professionals in the appropriate setting. There is obviously a demand for rapid detox based on the number of programs nationwide. Rather than marginalizing the programs who are attempting to provide a safe and effective alternative to patients who want rapid detox, I strongly encourage organizations like ASAM, of which I am a member, to engage the physicians providing these services in an effort to document the efficacy of rapid detox and to establish safety standards.

  5. Ellen Joy Sep 28, 2013 - 02:56 PM

    Rapid detox for opiate addiction can be a life saving procedure when done correctly and when following safety protocols. A lot of cheaper rapid detox programs exist that cut corners to save money, but at the risk of the patient. Waismann Method is one the professional and reputable programs out there that safely provide rapid opiate detoxification. Here is a link that goes over safety protocols that each rapid detox for opiate treatment should follow. https://www.rapiddetox.com/2013/09/rapid-detox-difference-safety-first/

  6. Mike Sep 16, 2013 - 11:04 PM

    14 months ago, I was shocked to find my 21 year old son was addicted to opiates.  I did research on every type of recovery program that I could find.  As angry as I was, my foremost concern was his safety.  He had already exposed himself to considerable risk, and my job as  a parent was to ensure his safety and wellbeing as best I could.  In my internet search, I came across rapid detox numerous times and did considerable research regarding the safety and success of this treatment.  In my research, I learned that not all "Rapid Detox" programs are alike.  Some offer one day of treatment, followed by a stay in a hotel room which greatly concerned me.  I called two hotels that accepted patients after treatment, only to hear actual horror stories that I had previously read from blogs on the net.  At this point, I almost gave up on rapid detox, but took one last stab by consulting with my primary physician.  He told me about Dr. Lowenstein in California, director of the Waismann Method.  After speaking with Dr. Lowenstein, I realized that the doctor that performs the procedure, where it is performed, and the center's experience would determine the safety of my son.
    I scheduled rapid detox for my son, and watched as he was admitted a full day in advance of treatment. The next day, he was treated by Dr. Lowenstein in the ICU where I was not able to visit, but received a call from their medical staff as soon as the procedure was completed. I was permitted to visit the following day in the hospital and was surprised to see he was in good spirits.  I spent a couple of hours with him, and spoke with the doctor before he was taken to their aftercare facility where professionals monitored his health and progress for a few more days.

    During that time, we were consulted by their therapist for an aftercare plan that would best for him.  I understand the temptation of the overnight less expensive rapid detox procedures available, but I cannot fathom having gone that route now that its all said and done.  Although it was not said to me on the onset, I realize now that Waismann would not have taken my son if I was the driving force for treatment and he resisted, as the willingness and desire of the patient is extremely important for a long term successful outcome.  As a result of rapid detox, I have back my healthy and sober son today. 

  7. Michael Jun 16, 2013 - 09:35 PM

    I was the office and clinical administrator in 1997 in Mount Sinai hospital in Miami, Florida. I personally (to date) still speak to the patients that went through the program. 2 out of 5 patients are still clean and have a life today and I am grateful for that. It truly works as long as the MOST important part of the treatment is followed up on AFTERCARE! I've found that drugs are NOT an issue, It's the end result of all in the other issues in there life.

    It's a shame the hospital did away with the program after 1 year, a great % of success, due to bureaucratic issues with the hospitals image. Having addicts in the hospital. 

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