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Buprenorphine opiate detox beats anesthesia: safety concerns.

SAN FRANCISCO -- Opiate detoxification by the rapid buprenorphine method offers clear advantages over the trendy--but far riskier--anesthesia rapid opiate detox method, Dr. Herbert D. Kleber reported at the annual meeting of the American Psychiatric Association.

"You get much more potential for serious adverse events with the anesthesia detox. There are a couple dozen deaths reported worldwide. We find that even with very careful patient selection, it's still quite risky--and it's no different in terms of long-term outcome than the buprenorphine. So my preference in terms of detoxification is if you need to do it rapidly, do the rapid buprenorphine detox," said Dr. Kleber, professor of psychiatry and director of the division on substance abuse at Columbia University and the New York State Psychiatric Institute, New York.

He and his colleagues are just wrapping up a randomized clinical trial comparing anesthesia rapid opiate detox (AROD) with buprenorphine rapid detox and with detoxification using clonidine.

The data analyses aren't completed yet, but Dr. Kleber was able to form a strong early clinical impression of the results because the study was unblinded. He was particularly impressed by the fact that, despite meticulous oversight, there was one case of pulmonary edema and one case of diabetic ketoacidosis in the AROD group. And yet there was no payoff in terms of better efficacy.

"We found AROD produces comparable or worse withdrawal symptoms over the [first] 48 hours after patients awake than buprenorphine or clonidine," he said.

The AROD technique involves endotracheal intubation followed by about 6 hours under general anesthesia, then a few more hours in the recovery room. The hope has been that this approach would result in less discomfort and therefore higher completion rates than other detox methods, but that has not been borne out.

Buprenorphine is approved by the Food and Drug Administration for opiate detoxification, as well as for maintenance therapy. The drug can be prescribed by office--based physicians and picked up by patients at their local pharmacy, and the detoxification can be performed in the physician's office. However, all of this can occur only if the physician has applied for and received a special license waiver from the Drug Enforcement Administration.

Clonidine has been used off label since the 1970s for detoxification from heroin and other opiates. The withdrawal is much shorter with clonidine than with methadone and, unlike with methadone, there are no rebound withdrawal symptoms upon stopping clonidine.

Buprenorphine rapid detox works like this:

** Day 1. The patient takes heroin.

** Day 2. The patient doesn't take heroin and is given 8 mg of sublingual buprenorphine.

** Day 3. The patient takes nothing.

** Day 4. In the morning, the physician gives clonidine, waits 2 hours, and then gives either 12.5 mg or 25 mg of naltrexone. Later, the patient receives more clonidine, as well as benzodiazepines as needed for withdrawal symptoms.

** Day 5. The patient receives double the dose of naltrexone given the day before.

Buprenorphine enjoys much greater patient acceptance and has better efficacy for detox than clonidine. In addition, buprenorphine is easier to use and has fewer side effects.

The patient's withdrawal symptoms--particularly anxiety, insomnia, and craving--are profoundly reduced with buprenorphine.

A patient going through clonidine detox needs to be observed throughout the whole first day; a patient undergoing buprenorphine detox can leave the office after an hour or two.
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Title Annotation:Addiction Psychiatry
Author:Jancin, Bruce
Publication:Clinical Psychiatry News
Date:Oct 1, 2003
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