September 6, 2005

Opiate addicts endure a grueling withdrawal process when they decide to go clean. The pain is intense, the suffering significant.

A handful of doctors promise patients they can speed up these agonizing steps via rapid detox, a catch-all term indicating a swift withdrawal process via the use of opioid-antagonist agents typically done while the patient is lightly anesthetized. The program is meant to wean addicts off of opiates found in drugs such as heroin, methadone, Vicodin and Oxycontin. Not so fast, say many physicians as well as a new study funded by the National Institute on Drug Abuse. Last month's study of 106 patients, co-authored by Dr. Herbert Kleber of Columbia University Medical Center in New York showed patients' withdrawal pain via rapid detox was comparable to those of addicts undergoing other detox methods, according to Associated Press. The study also said these methods can be life-threatening. The method's detractors say pushing the body through opiate withdrawal risks developing either brain or lung edemas, potentially life-threatening conditions.

The American Society of Addiction Medicine released a policy statement earlier this year saying the method has "uncertain risks and benefits." The decision is a reversal from its previous statement, which said if the process is done it should be paired with counseling services and performed only by professionals with emergency medical equipment. Now, ASAM contends rapid detox measures shouldn't be done without being paired with a post-withdrawal addiction program. ASAM says opioid withdrawal is an intense procedure, but it is "virtually without risk of mortality."

Dr. George Kolodner, associate professor of psychiatry at Georgetown University Hospital, says rapid detox misses the crucial component for addicts hoping to go clean."The problem is keeping people off [drugs], not getting them off them," Dr. Kolodner says. Some of Dr. Kolodner's patients are receptive, generally, to the idea of a quicker detox process, but he tries to talk them out of it. "I've been approached about doing it. There's no question it's a lucrative thing to do," he says.

Those dreading the pain associated withdrawal may not mind the cost, which can run into the tens of thousands of dollars. Dr. Daniel Lieberman, associate professor of psychiatry and behavioral sciences with George Washington University, says the chemicals used to induce withdrawal in rapid detox lead to a state of decreased withdrawal pain. These opiate receptors involved with pain relief affected by the chemical addition also control blood flow in capillaries, Dr. Lieberman says."With rapid detox, you can lead to abnormalities with blood flow that can have serious consequences," he says. "You can have fluid leakages into the lungs, or pulmonary edema."

"The risk of death is uncommon but not rare," he says. Performing rapid detox procedures outside a hospital setting increases the risks dramatically. If conducted within a hospital, "one can identify and treat a problem if something goes wrong," he says. Dr. Lieberman won't sugarcoat what a traditional withdrawal process feels like for a patient. "It's an awful experience to go through," he says. "With ultra rapid detox, you're essentially unconscious." That said, he doesn't see modern medicine moving toward the rapid detox as a potential solution. "We all want proactive medicine in which the risks and benefits have been delineated through good scientific research," he says. So far, doctors aren't publishing results of any such research involving rapid detox, to his knowledge. "We don't see a body of scientific literature developing," he says.

Dr. Clifford A. Bernstein of the Waismann Institute in Beverly Hills says his office has been performing rapid detox procedures since the early 1990s. "We treat opiate dependency as the medical problem it is," says Dr. Bernstein, who calls his work a "humane way" of treating addiction patients. His procedures are conducted in an intensive care unit and last up to three days. "I've treated 2,200 patients. I wouldn't dare not do it in a hospital," says Dr. Bernstein, who charges $15,000 for the entire process. "The traditional rehab community has really just let you wait it out," Dr. Bernstein continues. "You have to go through this withdrawal and transfer yourself to a 12-step program. The goal should not be to make people suffer."

Dr. Bernstein says worries about patients developing edemas are only legitimate if the procedure is performed improperly, but he argues that can be said of many medical practices. He adds it's never happened to any of his patients. One area Dr. Bernstein finds common ground with the method's detractors is in the area of research, adding he takes some responsibility for not conducting his own studies. He adds it's difficult to bring some patients back for follow-ups or to submit urine samples for further testing. "Patients want to forget about the whole thing. They're not obliged to get back to me," he says.

Counseling for some patients may not be necessary once clean of chemicals, he says."You cannot address the psychological aspects until you get them off the drugs," Dr. Bernstein says. "A lot of these people don't need psychological intervention."

Dr. Herbert Kleber, a professor of psychiatry at Columbia University who co-authored last month's study, says the findings represent one of the first controlled studies on the subject. A number of researchers previously examined rapid detox, but the studies often lacked scientific controls, adequate follow-up research and failed to monitor persistent withdrawal symptoms, Dr. Kleber says. The study showed that substance detoxification isn't "nearly as important as what happens afterward, what kind of therapy goes on," Dr. Kleber says.

The findings also showed researchers that the agony associated with withdrawal may be exaggerated.
"The current methods of detox aren't horribly painful," he says. "The horrors of opiate withdrawal tend to be [for people who quit] cold turkey."

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