CAM 30102

Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification

Category:Mental Health   Last Reviewed:April 2019
Department(s):Medical Affairs   Next Review:April 2999
Original Date:October 2002    

Description:
The use of relatively high doses of opioid antagonists under deep sedation or general anesthesia is a technique for opioid detoxification and is known as ultrarapid detoxification. It is a potential alternative to standard detoxification that allows patients to avoid the acute symptoms associated with initial detoxification. Ultrarapid detoxification is used in conjunction with maintenance treatments, e.g., oral opioid antagonists and psychosocial support.

The paucity of controlled trials and lack of a standardized approach to ultrarapid detoxification does not permit scientific conclusions regarding the safety or efficacy of ultrarapid detoxification compared with other approaches that do not involve deep sedation or general anesthesia. Moreover, there are concerns about adverse effects, including life-threatening or potentially life-threatening events. Thus, this technology is considered investigational.

Background
The traditional treatment of opioid addiction involves substituting the opiate (i.e., heroin) with an equivalent dose of a longer-acting opioid antagonist, i.e., methadone, followed by tapering to a maintenance dose. Methadone maintenance therapy does not resolve opioid addiction but has been shown to result in improved general health, retention of patients in treatment and a decrease in the risk of transmitting HIV or hepatitis. However, critics of methadone maintenance point out that this strategy substitutes one drug of dependence for the indefinite use of another. Detoxification followed by abstinence is another treatment option, which can be used as the initial treatment of opioid addiction or offered as a final treatment strategy for patients on methadone maintenance. Detoxification is associated with acute symptoms followed by a longer period of protracted symptoms (i.e., six months) of withdrawal. Although typically not life-threatening, acute detoxification symptoms include irritability, anxiety, apprehension, muscular and abdominal pains, chills, nausea, diarrhea, yawning, lacrimation, sweating, sneezing, rhinorrhea, general weakness and insomnia. Protracted withdrawal symptoms include a general feeling of reduced well-being and drug craving. Relapse is common during this period.

Detoxification may be initiated with tapering doses of methadone or buprenorphine (an opioid agonistantagonist), treatment with a combination of buprenorphine and naloxone (an opioid antagonist) or discontinuation of opioids and administration of oral clonidine and other medications to relieve acute symptoms. However, no matter what type of patient support and oral medications are offered, detoxification is associated with patient discomfort, and many patients may be unwilling to attempt detoxification. In addition, detoxification is only the first stage of treatment. Without ongoing medication and psychosocial support after detoxification, the probability is low that any detoxification procedure alone will result in lasting abstinence. Opioid antagonists, such as naltrexone, may also be used as maintenance therapy to reduce drug craving and, thus, reduce the risk of relapse.

Dissatisfaction with current approaches to detoxification has led to interest in using relatively high doses of opioid antagonists, such as naltrexone, naloxone or nalmefene under deep sedation with benzodiazepine or general anesthesia. This strategy has been referred to as "ultrarapid," "anesthesia-assisted" or "one-day" detoxification. The use of opioid antagonists accelerates the acute phase of detoxification, which can be completed within 24 to 48 hours. Because the patient is under anesthesia, he or she has no discomfort or memory of the symptoms of acute withdrawal. Various other drugs are also administered to control acute withdrawal symptoms, such as clonidine (to attenuate sympathetic and hemodynamic effects of withdrawal), ondansetron (to control nausea and vomiting) and somatostatin (to control diarrhea). Hospital admission is required if general anesthesia is used. If heavy sedation is used, the program can potentially be offered on an outpatient basis. Initial detoxification is then followed by ongoing support for the protracted symptoms of withdrawal. In addition, naltrexone may be continued to discourage relapse.

Ultrarapid detoxification may be offered by specialized facilities. Neuraad Treatment Centers, Nutmeg Intensive Rehabilitation and Center for Research and Treatment of Addiction (CITA) are examples. These programs typically consist of three phases: a comprehensive evaluation, inpatient detoxification under anesthesia and, finally, mandatory postdetoxification care and follow-up. The program may be offered to patients addicted to opioid or narcotic drugs such as opium, heroin, methadone, morphine, meperidine, hydromorphone, fentanyl, oxycodone, hydrocodone or butorphanol. Once acute detoxification is complete, the opioid antagonist naltrexone is often continued to decrease drug craving, with the hope of reducing the incidence of relapse.

Regulatory Status
In October 2002, Reckitt Benckiser received U.S. Food and Drug Administration (FDA) approval to market a buprenorphine monotherapy product, Subutex®, and a buprenorphine/naloxone combination product, Suboxone®, for use in opioid addiction treatment.

Policy:
Opioid antagonists under heavy sedation or anesthesia is considered INVESTIGATIONAL as a technique for opioid detoxification (i.e., ultra-rapid detoxification).

Benefit Application
BlueCard®/National Account Issues
Opioid dependence is considered a mental disorder; thus, claims for ultra-rapid detoxification may be adjudicated under the mental health benefits.

Rationale
This policy was originally created in 2002 and was updated regularly with searches of the MEDLINE database. The most recent literature review was performed through Nov. 5, 2014. Following is a summary of the key literature to date.

This assessment of ultrarapid opioid detoxification focuses on data reporting the severity and duration of withdrawal symptoms and the short- and long-term outcomes of maintenance of abstinence in distinct populations of patients, based on type and duration of addiction. Efficacy outcomes will be balanced against the safety considerations of deep sedation or general anesthesia in conjunction with naloxone.

In 2010, Gowing et al. published a Cochrane review on opioid antagonists under heavy sedation or anesthesia for opioid withdrawal.1 A total of nine studies including 1,109 participants were eligible for inclusion; there were eight randomized controlled trials (RCTs) and one non-RCT. Four studies compared the intervention to conventional approaches of withdrawal, and five compared different regimens of antagonist-induced withdrawal. In five of the studies, all participants were withdrawing from heroin or other short-acting opioids. In three studies, they were using heroin and/or methadone and, in one study, all participants were withdrawing from methadone.

Due to differences in study designs (e.g., antagonist and anesthesia or sedation regimens, comparison interventions, outcome variables), few pooled analyses could be conducted. Findings from three trials (total N=240) comparing antagonist-induced and conventional withdrawal were pooled for several outcome variables. The number of participants completing maintenance treatment was significantly higher in the antagonist-induced group than in the conventional treatment group (relative risk [RR], 4.28; 95 percent confidence interval [CI], 2.91 to 6.30). The number of participants who continued maintenance treatment or were abstinent at 12 months also favored the antagonist-induced group (RR=2.77; 95 percent CI, 1.37 to 5.61). Safety data from these three studies were not pooled. One of the studies reported no adverse events (AEs) and one only reported AEs in patients who received octreotide (a somatostatin analog) during the anesthetic procedure; seven of these 11 patients (64 percent) experienced vomiting and/or diarrhea. The third study reported three serious AEs, all of which occurred in the anesthesia group. There were no pooled analyses of the results of studies that evaluated the efficacy of differing opioid antagonist withdrawal regimens. One meta-analysis of safety data from two studies (total N=572) found a statistically significantly higher rate of AEs with heavy sedation compared with light sedation (RR=3.21; 95 percent CI, 1.13 to 9.12). Other AEs included high rates of vomiting in several studies and, in one study, episodes of irregularities in respiratory patterns during withdrawal.

The authors of the Cochrane review commented that, due to variability among the trials, “it is not possible to identify ‘standard’ treatment regimens for antagonist-induced withdrawal in conjunction with heavy sedation or anesthesia.” They concluded that “the increased risk of clinically significant adverse events associated with withdrawal under heavy sedation or anesthesia make the value of anesthesia-assisted antagonist-induced withdrawal questionable.” 

A representative RCT included in the Cochrane review was a 2005 trial by Collins et al.2  In this study, 106 persons addicted to heroin were randomly assigned to undergo detoxification with an anesthesia-assisted rapid opioid detoxification, buprenorphine-assisted rapid opioid detoxification or clonidine-assisted opioid detoxification. All study participants received an additional 12 weeks of outpatient naltrexone maintenance. Mean withdrawal severities were similar among the three groups, and treatment retention in the 12-week follow-up period was also similar. However, the anesthesia procedure was associated with three potentially significant life-threatening AEs. The authors concluded that the data did not support the use of general anesthesia for heroin detoxification. 

Among the AEs reported in the Cochrane review, vomiting under sedation is particularly worrisome due to the threat of aspiration. Techniques reported to minimize this risk include intubation, use of prophylactic antibiotics and the use of medication to diminish the volume of gastric secretions. Several deaths occurring either during anesthesia or immediately thereafter have been reported.3-6 Also, deaths subsequent to ultrarapid detoxification have been reported.7 Of particular concern is the fact that the use of opioid antagonists results in loss of tolerance to opioids, rendering patients susceptible to overdose if they return to predetoxification dosage of illicit drugs.8 

Relapse after ultrarapid detoxification was examined in a 2014 study by Salimi et al.9 A total of 424 patients with self-reported opioid use entered a treatment program at a single institution in Iran. Treatment consisted of rapid detoxification under general anesthesia and naltrexone maintenance therapy. Four hundred of the 424 patients (94 percent) completed two years of follow-up. Among completers, 97 patients (24 percent) experienced at least one incident of relapse. Patients who relapsed had significantly lower rates of long-term compliance with naltrexone therapy, and all of the patients who relapsed had discontinued naltrexone use prior to relapse. Mild AEs were common and did not differentiate between patients with successful abstinence versus relapse. For example, 52 percent of those with treatment success and 56 percent who relapsed (p>0.05) experienced mild muscle pain in the first three months after withdrawal. This study was uncontrolled and does not provide data on the relative efficacy of detoxification methods. 

Summary of Evidence
Ultrarapid detoxification is an opioid detoxification technique that uses relatively high doses of opioid antagonists under deep sedation or general anesthesia. The paucity of controlled trials and lack of a standardized approach to ultrarapid detoxification does not permit scientific conclusions regarding the safety or efficacy of ultrarapid detoxification compared with other approaches that do not involve deep sedation or general anesthesia. Moreover, there are concerns about adverse effects, including life-threatening or potentially life-threatening events. Thus, this technology is considered investigational.

Practice Guidelines and Position Statements
In 2007, the National Institute for Health and Clinical Excellence issued clinical practice guidelines on “drug misuse, opioid detoxification.”10 The guidelines include the following statement regarding ultrarapid detoxification: “Ultra-rapid detoxification under general anesthesia or heavy sedation (where the airway needs to be supported) must not be offered. This is because of the risk of serious adverse events, including death.”

In 2007, the American Psychiatric Association Work Group on Substance Use Disorders released a practice guideline for the treatment of patients with substance use disorders.11 The practice guideline included the following recommendation: “Anesthesia-assisted rapid opioid detoxification is not recommended because of lack of proven efficacy and adverse risk-benefit ratios.” 

In 2005, the American Society of Addiction Medicine (ASAM) published a public policy statement regarding opiate detoxification under sedation or anesthesia.12 It included the following position statements: 

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. 

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. 

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. 

U.S. Preventive Services Task Force Recommendations
No U.S. Preventive Services Task Force recommendations for opioid detoxification under heavy sedation or general anesthesia have been identified. 

References:

  1. Gowing L, Ali R, White J. Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal. Cochrane Database Syst Rev. 2010(1):CD002022.
  2. Collins ED, Kleber HD, Whittington RA, et al. Anesthesia-assisted vs buprenorphine- or clonidine-assisted heroin detoxification and naltrexone induction: a randomized trial. JAMA. 2005;294(8):903-913.
  3. Bearn J, Gossop M, Strang J. Rapid opiate detoxification treatments. Drug Alcohol Rev. 1999;18(1):75-81.
  4. Dyer C. Addict died after rapid opiate detoxification. Bmj. 1998;316(7126):170.
  5. Gold CG, Cullen DJ, Gonzales S, et al. Rapid opioid detoxification during general anesthesia: a review of 20 patients. Anesthesiology. 1999;91(6):1639-1647.
  6. Solomont JH. Opiate detoxification under anesthesia. JAMA. 1997;278(16):1318-1319. PMID
  7. Brewer C, Laban M, Schmulian C, et al. Rapid opiate detoxification and naltrexone induction under general anaesthesia and assisted ventilation: experience with 510 patients in four different centres. Acta Psychiatr Belg 1998;98:181-189.
  8. American Society of Addiction Medicine. Public Policy Statement on Opioid Antagonist Agent Detoxification Under Sedation Or Anesthesia (OADUSA). J Addict Dis. 2000;19(4):109-112.
  9. Salimi A, Safari F, Mohajerani SA, et al. Long-term relapse of ultra-rapid opioid detoxification. J Addict Dis. 2014;33(1):33-40. PMID 24471478
  10. National Institute for Health and Clinical Evidence. Drug misuse, opioid detoxification. NICE Clinical Guideline 52. http://www.nice.org.uk/Guidance/CG52. Accessed October, 2014.
  11. Kleber HD, Weiss RD, Anton RF, et al. Work Group on Substance Use Disorders. Treatment of patients with substance use disorders. American Psychiatric Association. Am J Psychiatry. 2006;163(8 suppl):5-82.
  12. American Society of Addiction Medicine. Public Policy Statement on Rapid and Ultra Rapid Opioid Detoxification. http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policystatements/ 2011/12/15/rapid-and-ultra-rapid-opioid-detoxification. Accessed October, 2014.
  13. Centers for Medicaid and Medicare Services. Medicare Policy 35-22.2. http://www.cms.gov/manuals/downloads/Pub06_PART_35.pdf Accessed October, 2014.

Coding Section

Codes  Number  Description 
CPT    No specific CPT code 
ICD-9 Diagnosis 304.0  Opioid type dependence 
ICD-10-CM (effective 10/01/15)   F11.10-F11.99  Opioid related disorders code range 
ICD-10-PCS (effective 10/01/15)    ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for this procedure 
   HZ2ZZZZ Substance abuse treatment, detoxification 
 Type of Service

Mental Health/Prescription Drug 

 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

04/17/2018 

Annual review, no change to policy intent. 

04/05/2017 

Annual review, no change to policy intent. 

04/06/2016 

Annual review, no change to policy intent. 

04/14/2015 

Annual review, no change to policy intent. Updated background, description, rationale and references. Added coding.

04/02/2014

Annual review.  Added benefit application. No change to policy intent. Policy reviewed by Dr. Castriotta for appropriateness.


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