Rapid Detox

for treatment as they do not have to fear to experience the withdrawal and rapid detox hazard. It is also let the patient  to start recovery sooner.

Rapid detox: New ways of treatment for the addicted persons.

TOPIC. Despite substantive advances in understanding of genetic and biochemical basis of substance abuse and addiction in the last decade, little information has been translated into alternative treatment models for the addicted patient. Rapid detox, an alternative form of detox treatment, is gaining in both acceptance and popularity.

PURPOSE. To increase readers' understanding of the neurobiology of addiction and the mode of action of new detox approaches for patients addicted to opiate drugs.

SOURCES. A review of the current literature pertaining to rapid detox.

CONCLUSIONS. Rapid detox is a viable alternative for selected patients attempting to detox from opiate agents of abuse. Increasing knowledge of new treatment approaches allows nurses working to assist addicted patients in planning and receiving treatment based on new awareness of the neurobiology of addiction.

Detox, neurobiology of addiction, opiate, rapid detox.

Substance abuse and dependency persist as major health concerns in the whole world. While the economic costs to our society are huge, the human cost is harder to quantify and remains far more damaging. Enormous healthcare resources have been devoted to reducing substance abuse and dependency (Scott, 1996), with the number of drug and alcohol treatment facilities almost doubling between 1980 and 1994 (Substance Abuse & Mental Health Services Administration [SAMHSA], 1996), and with national and state expenditures doubling during the same period (Huber, Pope, & Dayhoff, 1994).

Current drug abuse treatment approaches, developed primarily during the 1960s and 1970s, have changed very little since their inception (Metzger, McKay, Durell, Alterman, & O'Brien, 1996). The changes that have occurred in treatment in the last decade have been primarily structural and have been propelled by the tide of managed care reforms rather than the emergence of new treatment models. Managed care and cost-containment policies have affected substance abuse treatment by decreasing the type and intensity of services; shifting treatment from inpatient and residential care to outpatient settings, with 87% of patients now treated in outpatient programs (SAMI-ISA, 1996); and in the blurring of public and private programs (D'Aunno & Vaughn, 1995). While these structural changes have altered the landscape in which treatment occurs, the nature of treatment has remained constant.

The Development of New Models of Treatment

Substantive advances have occurred in our understanding of the genetic and biochemical basis of substance abuse and addiction in the last decade, yet little of this information has been translated into alternative treatment models for the addicted patient. Abstinence remains the goal of traditional addiction treatment. Abstinence, and the concomitant sudden cessation of drug use in addicted individuals, causes a predictable cascade of symptoms collectively referred to as withdrawal syndrome.

Medically supervised detox treatment has traditionally been seen as the gold standard and as the logical starting point of treatment. Traditional detox has involved treatment with prescription medications, which produce similar physiological responses, less psychoactivation, and which can be more precisely regulated and tapered as the patient's metabolism readjusts to functioning without the addictive drug (McLellan, Arndt, Metzger, Woody, & O'Brien, 1993). Taking an average of 3 to 15 days, depending on the abused drug, medical detox controls but does not eliminate subjectively uncomfortable withdrawal symptoms (Delfs, Zhu, Druhan, & Aston-Jones, 2000).

Universally accepted addiction treatment approaches are beginning to be challenged by the emergence of innovative treatment approaches based on new understanding of the neurochemistry of addiction. One such approach, rapid detox, has emerged as an alternative that is gaining in both acceptance and popularity, evidenced by its recent showcasing in television episodes of both "E.R." and "General Hospital."

Rapid detox is an umbrella term that has come to represent a new treatment approach specifically designed to detox patients addicted to natural and synthetic opiate drugs within hours, rather than the traditional days, and to almost completely eliminate the subjective discomfort of withdrawal symptoms. Started in Europe in the late 1980s and brought to the United States in late 1996 (Biddle, 1998), rapid detox programs have grown quickly in this country. Understanding rapid detox has been made difficult by the lack of consistency for the terms and names given to the various models of rapid detox, which are provided under a myriad of copyrighted and patented names.

Understanding Opiate Addiction is the first step to rapid detox.

Opium has been used by humans since 4000 B.C. (Simon, 1992), with opiates most often referred to as narcotics. In its purest sense, the term opiate refers to compounds derived from the opium or poppy plant. In a broader sense, opiate refers to both naturally occurring opiate compounds as well as synthetically derived, molecularly similar compounds.

Opiates are frequently prescribed analgesic medications, as well as commonly abused drugs. With almost 2 million Americans estimated to have experimented with heroin (Boyd & Nihart, 1998) and national trends indicating yearly increased use and prescription of opiate narcotic analgesics (Joranson, Ryan, Gilson, & Dahl, 2000), the prevalence of opiate addiction is estimated at 2% of the U.S. adult population (American Society of Addiction Medicine, 2000). Common opiate drugs of abuse and the opiate addictions may be treated through rapid detox procedures.

Exogenous opiate drugs act on opiate receptors in the brain. Researchers theorize that these opiate receptors exist in order to facilitate the action of the body's endogenous opiatelike substances known as endorphin and enkephalin. Referred to as natural morphine (Stahl, 1996), these endogenous substances are naturally occurring analgesics, the role of which is just beginning to be understood. Exogenous opiate drugs function as an agonist to the brain's opiate receptors, turning on the natural analgesic pathway in the brain and producing the characteristic analgesia and euphoria sensation that in susceptible individuals reinforces drug use and propels the addiction. Habitual opiate use, while turning on the pain-suppression pathway, causes the normal endogenous opiate system to decrease production of endorphin and enkephalin. This diminishing of the normal pain-suppression system leaves the person with substantially reduced pain regulation and little tolerance of discomfort, increasing the compulsion to continue opiate use in order to decrease subjective discomfort.

Repetitive use of exogenous opiates also produces adaptation of the opiate receptors, rendering them less sensitive to agonist actions (Schulteis, Heyser, & Koob, 1997). This "down regulation" of the receptor requires larger amounts of the drug to produce similar effects, a phenomenon known as tolerance, and produces withdrawal symptoms when the receptors are not under agonist effect (Stahl, 1996).

While not considered life threatening, the withdrawal symptoms characteristic of opiate dependency are notorious for how subjectively distressful they can be, producing dramatic and desperate attempts of the user to avoid withdrawal (Delfs et al., 2000). Ranging from agonizing chills, nausea and vomiting, excruciating stomach cramps, fever, insomnia, irritability, dysphoria, crawling skin sensation, and piloerection ("goose bumps," which led to the term cold turkey), the symptoms of opiate withdrawal are among the most feared and subjectively distressful syndromes, that means rapid detox is a difficult task. (Boyd & Nihart, 1998).

The compelling and distressful nature of withdrawal is one of the largest barriers to successful rapid detox treatment from opiate dependency. Treatment of opiate addiction entails either controlled cold-turkey detox, with adjunctive drugs such as antiemetics used to mediate withdrawal discomfort, or attempts at detox using a traditional pharmacological-substitution approach, where a drug with similar pharmacologic effects but with less subjective euphoric "rush" is used instead. In the case of opiate dependency, methadone is the substitute drug of choice. Methadone, an opiate, is potentially psychologically addicting but does not produce the subjective euphoric state characteristic of other opiate drugs, making it easier for a patient to adapt lifestyles and to adjust to a less cognitively impaired state (Boyd & Nihart, 1998). Once these lifestyle changes occur, the patient still faces eventual detox off methadone, a process that often takes months to years to accomplish.
The discomfort of opiate withdrawal, which can last up to 14 days with heroin, has led to many addicts avoiding rapid detox treatment in order to avoid the extreme subjective discomfort. Until recently, avoidance of withdrawal left patients with only two options: continue to use, or substitute with methadone. Acknowledgment of this reality led researchers to attempt to accelerate the rapid detox process and decrease the discomfort, using new understanding of the opiate receptor regulation system by treating the addiction at the neuroreceptor level.

Rapid detox procedures, the outgrowth of these attempts, employs two novel approaches. First, general anesthesia is administered to ensure no subjective distress is felt, which allows the second approach: the use of large dosages of opiate antagonists in order to rapidly and completely remove the exogenous opiate drugs from the opiate receptors in the brain. Because the patient feels no subjective distress from withdrawal, detox can be accomplished rapidly, usually within 4 to 6 hours, rather than 5 to 15 days with traditional detox procedures.

While rapid detox is the most common and most generic of labels used to describe this new approach to opiate dependency treatment, a few authors (Albanese et al., 2000; Legarda, 1998; O'Connor & Kosten, 1998) make a distinction between rapid detox and ultra-rapid detox:

Rapid detox: Similar to traditional detox programs, but the patient receives more sedation than usually used during withdrawal. This sedation is most commonly accomplished through the use of benzodiazepines and can decrease the time for withdrawal by a day or two. The sedation is done to minimize the subjective distress of withdrawal symptoms, allowing detox to progress more rapidly.

Ultra-rapid detox: An approach using general anesthesia to induce complete unconsciousness, thus ensuring complete comfort during detox.

Ultra-Rapid Opiate Detox is seen as an outgrowth and logical extension of rapid detox procedures, and has become a patent-protected treatment name (UROD). This has led to rapid detox becoming an inclusive and interchangeable term with ultra-rapid detox, with rapid detox being the term most frequently appearing in the literature. "Rapid detox" as used in this article refers to this broader use, when opiate detoxification is attempted with the use of general anesthesia.

Rapid detox programs vary in aspects of their protocol, but all share basic similarities. Some require overnight monitoring, while some are 1-day programs where the individual checks in early in the morning and leaves late on the same day. All programs require some form of pre-evaluation that generally entails a detailed drug history, psychological evaluation, medical history review, and current health status evaluation. After patients have been certified as stable for the procedure, an IV is started and general anesthesia induced.

Most programs offering rapid detox require an anesthesiologist be present to monitor the anesthesia and perform the procedure in a location (e.g., the hospital) where emergency services are quickly available should complications arise. The failure of a few programs to use an anesthesiologist or to have appropriate and complete emergency equipment and personnel available have given rise to one aspect of criticism and debate regarding the procedure (D'Ambra, 1998).

Once general anesthesia has been induced and no subjective withdrawal discomfort is felt by the patient, opiate receptor blockade is accomplished with the use of opiate antagonist agents. Three common opiate antagonists exist: naltrexone, naloxone, and nalmefene (see Table 3 for a comparison of the drugs). All three drugs are fairly safe, have few significant side effects, and have no abuse potential. Naltrexone is by far the most commonly used opiate antagonist during rapid detox. The opiate antagonists create a blockade of the opiate receptors, preventing effects of exogenous opiates from being felt (Schatzberg, Cole, & DeBattista, 1997).

The opiate antagonists have competitive binding at the opiate receptor level, washing out any exogenous opiates and assisting the receptors to begin to reestablish normal sensitivity (O'Connor & Kosten, 1998). The amount of opiate antagonist required and, therefore, the length of time anesthesia must be maintained, depends on patients' weights and the duration and intensity of their addiction. The procedure averages 4 to 6 hours in most patients. When anesthesia is reversed and patients awaken, they are physically detoxed.

A short recovery period from rapid detox should be anticipated, with some mild discomfort that includes grogginess, mild nausea, and diarrhea. The patient is continued on the opiate antagonist agent, usually naltrexone, as a once-a-day oral dose, a treatment that will continue for 6 to 12 months post-detox. One of the advantages of the rapid detox is the patient's ability to start the opiate antagonist as soon as detox is completed. With traditional, nonrapid detox, withdrawal symptoms usually preclude the patient's ability to tolerate a drug such as naltrexone for at least 7 to 10 days post-detox. Naltrexone functions at this point in treatment to prevent relapse by providing continuous opiate receptor blockade and by decreasing cravings (Dean, 1999).

It should be emphasized that rapid detox represents a new approach to the detoxification of a patient off opiate drugs, but by no means is it a complete treatment protocol. Intensive follow-up counseling is required after the rapid detox to address needed lifestyle changes, psychological factors, and continued abstinence.

Advantages and Disadvantages of Rapid Detox

The advantages of rapid detox seem evident. The single biggest advantage is seen to be its humanistic approach to minimize the very clinically significant, subjectively distressing, withdrawal symptoms of opiate addiction. The removal of the subjective distress allows rapid detoxification to occur at the neuroreceptor level and affords the patient an opportunity to start intensive follow-up care immediately, while feeling physically capable to engage in ongoing treatment. Patients can return to work one day after rapid detox. Anonymity and confidentiality can be facilitated when patients do not require protracted hospitalization, making treatment more acceptable for some. Continuous use of opiate antagonists post-detox affords the patient a measure of protection against relapse and decreases cravings, increasing the likelihood of successful treatment.

The largest risk identified in rapid detox relates to the use of general anesthesia. While the risk of death associated with general anesthesia is low, estimated at 1 in 250,000, the risk of adverse events rises to 1 in 10,000 (D'Ambra, 1998). Some critics have expressed a concern that this risk level is unacceptable and that anesthesia should be reserved for surgical needs, given the ability to detox opiate-dependent patients using older methods (Biddle, 1998; Kirsner & Biddle, 1999). Habitual opiate use has been linked with a risk for alteration in normal thyroid functioning, increasing the likelihood of an adverse anesthesia event. For this reason, most rapid detox programs require patients to have euthyroid lab values to minimize adverse events.

Rapid detox accomplishes medical detox, or removal of the physiological effects of the opiate. It does little to affect the psychological withdrawal syndrome, and substantial psychosocial support and counseling are required for the patient to maintain a drug-free lifestyle. Almost all rapid detox programs have intensive followup programs, and patients must be committed to this as an essential element in treatment success (Brewer, Catalano, Haggerty, Gainey, & Fleming, 1998). The commitment to follow-up care not only is essential to treatment success, but also is critical in minimizing a known risk of rapid detox. The detox process, using opiate antagonists drugs, is intended to remove all effects of opiates and to assist the body to reset the sensitivity of the opiate receptors. The receptor down regulation that occurs with habitual drug use, clinically expressed as tolerance, is rapidly reversed. A high degree of the patient's tolerance is lost following the rapid detox procedure. Resumption of opiate abuse at a patient's past use levels leads easily to potential overdose and death because of the loss of tolerance (Legarda, 1998).

The cost of rapid detox is a consideration. Programs charge anywhere from $3,550 to $7,000 for rapid detox. Most often this cost reflects 6 to 12 months of aftercare, but not in all cases. This cost is two to three times that of traditional methadone treatment using a similar time frame. Supporters of the rapid procedure reply to the cost concern by pointing out the average patient detoxing with methadone can stay on methadone for years, at an average cost of $300 per month, making rapid detox a cost-effective option (Laheij, Krabbe, & Jong, 2000). Because rapid detox is considered experimental, insurance companies do not cover the cost. The lack of insurance coverage has been cited as the single biggest barrier to more widespread use of this procedure.

Perhaps the greatest single disadvantage to the rapid detox procedure is lack of reliable and valid empirical studies regarding the efficacy of the treatment. Significant anecdotal evidence and testimonies of success cases can be found, most commonly in the advertising brochures of companies offering rapid detox. But almost no research has been conducted and little scientific evidence can be found comparing long-term success rates of rapid detox to traditional detox success rates. Some studies with small sample sizes or inconclusive findings do exist.

Most of these support the immediate efficacy of rapid detox (Albanese et al., 2000; Scherbaum et al., 1998), but contribute little to evaluating the longterm benefits. Current studies help identify which patients may represent the best candidates for this method of treatment. Individuals with past histories of traditional detox treatment failure, especially related to subjective intolerance of withdrawal symptoms, appear to do better than patients with no history of withdrawal attempts (Hensel & Kox, 2000). Table 4 identifies the probable indications and contraindications for rapid detox based on the limited available empirical studies (Kirsner & Biddle, 1999; Laheij et al., 2000; Marinelli, DeRisio, Pozzi, Janiri, & DeGiacomo, 1999). This lack of empirical testing has contributed to very slow acceptance of the rapid detox procedure by mainstream health professionals.

Nursing Considerations

Rapid detox exists as an alternative treatment approach for opiate dependency. While popularized by TV heroes such as Dr. Doug Ross on "E.R." and Dr. Alan Quartermaine on "General Hospital," little knowledge of this treatment can be found in the professional nursing literature. This leaves professional nurses in a quandary as to how to advise patients regarding this new treatment approach. The available empirical data support that rapid detox appears to accomplish physical detoxification quickly and humanely. While some risks exist, especially related to the use of general anesthesia, this risk can be minimized through appropriate selection of candidates for this form of treatment.

Few long-term empirical data exist to assist nurse or patient in judging the benefits of this form of detox over traditional approaches. There is evidence to support the very critical role of aftercare for patients using rapid detox. While physical detoxification can be rapidly accomplished, significant commitment of time and effort on the part of the patient will be required to maintain a drug-free life. Rapid detox does not replace the need for effective therapy.

Conclusion

Rapid detox suggests the future of substance abuse treatment. It is a new and different approach to substance abuse that reflects new knowledge regarding the etiology and pathophysiology of addictions. Researchers anticipate that new and innovative treatments that address addictions at the neuroreceptor level will be available in the next few years. Nurses working with individuals with addictions will face new challenges in understanding, teaching, and advocating for patients in their struggles with addictions. This effort will require nurses to stay abreast of innovations and new understanding of brain neurochemistry, a daunting but rewarding challenge. Author contact: mccabes@etsu.edu, with a copy to the Editor: mary77@concentric.net

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