Rapid Detox

[coprolalia]

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With all this talk of drug addiction and withdrawal, I thought this might be an intereting topic to revive.

There was a thread on this back in 2006:
http://forums.studentdoctor.net/showthread.php?t=249358

Is anyone still doing this?

I ask because I think that you can do rapid detox without intubating the patient. Hear me out.

The key here is Precedex. It has an indication for sedation without need for airway manipulation. Plus, with it's alpha-2 properties, you can probably mitigate a lot of the sympathetic outflow associated with withdrawal from opiates.

I think a reasonable protocol would consist of placing the patient on Precedex, a beta-blocker (like esmolol), and some benzodiazepine for sedation. I don't think you'd need a midazolam drip, but (for example) a rapidly de-escalating diazepam regimen. You could also add a decremental dose of a short acting opiate, like remifentanil, to augment and manage the full opiate-withdrawal side effects.

I just wonder if anyone doing rapid detox has incorporated dexmedetomidine into their practice. Seems like a logical choice in this scenario. Obviously, this would require continuous monitoring of the patient and wouldn't get at the underlying reason why they became addicted to opiates in the first place. But, I think it would work. And, I've had good success (albeit anecdotal) treating alcoholics with Precedex and a similar regimen.

Any thoughts?

-copro

 

[jetproppilot]

Funny how you posted this as I was thinking about the same thing yesterday, Cop.

Problem I came up with is the frequent, incessant vomiting that occurs with opiate withdrawal and the (what seems) high risk of aspiration if the patient is sedated but not intubated.

That was my thought process but my knowledge is limited on this subject.

 

[coprolalia]

Funny how you posted this as I was thinking about the same thing yesterday, Cop.

Problem I came up with is the frequent, incessant vomiting that occurs with opiate withdrawal and the (what seems) high risk of aspiration if the patient is sedated but not intubated.

That was my thought process but my knowledge is limited on this subject.

Is there effective anti-emetic treatment for these? Perhaps you can augment with ondansetron and promethazine prophylactically. Also, I would assume that we would still require strict NPO during the pre-anesthetic (which is still what this is) and could plan to intubate if the patient developed uncontrolled nausea.

I'm trying to think of a "less invasive" way to do this procedure. Again, I've had good success with doing this in the ICU with ethanol withdrawal. Haven't yet had any pukers, and have done a similar Precedex/Valium detox with good effect.

-copro

 

[Planktonmd]

Dex is definitely an attractive choice here with or without intubation.
There is no literature on using it for drug withdrawal and little literature on it's use for ETOH withdrawal but it makes perfect sense.
It could be a great subject for a study.

 

[OB1🤙]

I think it's a damn fine idea.

I have given serious thought to opening a cash-only celebrity-oriented boutique inpatient detox center here in LA.

Like, serious thought.

And they can afford the dex...

 

[dhb]

We don't have dex here but clonidine is used daily in the icu for all types of withdrawal etoh, drugs etc...
could you get someone deep enough on dex + benzo to cover opiate withdrawal with a secure airway? i guess you'd have to try it.

 

[Monty Python]

Funny how you posted this as I was thinking about the same thing yesterday, Cop.

Problem I came up with is the frequent, incessant vomiting that occurs with opiate withdrawal and the (what seems) high risk of aspiration if the patient is sedated but not intubated.

That was my thought process but my knowledge is limited on this subject.

One of JPP's hombres:

http://www.kayerapiddetox.com/0bios1.html

I used to work with Dr. Kaye at LSU/Kenner, primarily in the pain management block suite but on rare occasion with a detox case. Those were in the ICU, intubated.

http://www.kayerapiddetox.com/0ultrarapid.html

 

[lobelsteve]

I thought rapid detox was a bad idea. Not covered by insurance for a reason.

http://www.cigna.com/customer_care/...sitioncriteria_ultra_rapid_detoxification.pdf

http://blue.regence.com/trgmedpol/mentalHealth/mh14.html

Cochrane reviews says: The authors reported that due to the increased risk of clinically significant adverse events associated with withdrawal under heavy sedation or anesthesia, the value of anesthesia-assisted antagonist-induced withdrawal is questionable.

And: An updated search of the literature through March 25, 2008 returned three new randomized clinical trials. (19, 20, 22) All studies found that rapid detoxification with general anesthesia did not improve treatment retention, overall recidivism, or significantly improve severity of withdrawal symptoms compared to standard detoxification procedures without general anesthesia.



Just does not seem right.

 

[BADMD]

You could also add a decremental dose of a short acting opiate, like remifentanil, to augment and manage the full opiate-withdrawal side effects.

This part doesn't make any sense. For anesthesia facilitated detox, most systems give escalating doses of an opioid antagonist. Giving an opioid basically negates the idea of what you are doing.

I don't think you'd need a midazolam drip, but (for example) a rapidly de-escalating diazepam regimen.

For what are generally 6 hour(ish) procedures, it is tough to rapidly de-escalate diazepam. The kinetics and metabolites are not particularly conducive to it. I happen to love diazepam for this purpose, but you are probably making it too tough. Get 'em loaded with diazepam and the stuff practically auto-tapers.

and wouldn't get at the underlying reason why they became addicted to opiates in the first place.

And there in lies the answer. All of these systems treat the withdrawal aspect, but not the craving, habituation, and conditioning associated with drug abuse. Properly treating withdrawal isn't that hard, it just takes some attention to the patient. Treating the other stuff is the tough part. Most systems end up relying on implanted Naltrexone to prevent re-enforcement of the limbic reward pathways. Likely this is why Ultra rapid detox and anesthesia facilitated detox haven't been more successful.

 

[coprolalia]

Reviving this thread...

Who does rapid detox?

I'm thinking of opening a "home-based" treatment facility where someone can go discretely and get detoxed. I think that you could do this with a protocol that would get someone detoxed in 72 hours.

Recipe:

-Precedex infusion
-Long-acting benzo (e.g., chlordiazepoxide)
-De-escalating remifentanil infusion
-Cardiovascular support with appropriate adjuncts (beta-blockers such as esmolol infusion, etc.)
-Full cardiovascular monitoring
-Enteral feeding during the treatment period

It would be a cash-on-the-barrel-head type of practice. I think you could charge $3500-$4500 for this procedure. Then, you would put the person on Suboxone or Naltrexone when they walk out the door with pyschiatric follow-up.

Not sure about insurance or DOH accreditation, though. Likewise, I'm not sure how you could get the drugs to do it in such a setting. Insurance and "back-up plan" would also be issues. Would (obviously) want to keep this legal.

Thoughts?

-copro

 

[coprolalia]

Properly treating withdrawal isn't that hard, it just takes some attention to the patient. Treating the other stuff is the tough part.

Not my problem. 🙂

Offering a quick solution to getting the patient through the "crash" of cold-turkey would be my area of expertise.

I think you could do this in a 2:1 patient-to-detoxer ratio pretty safely.

-copro

 

[jetproppilot]

It would be a cash-on-the-barrel-head type of practice. I think you could charge $3500-$4500 for this procedure.


-copro

You could charge THREE TIMES that.

 

[2win]

With all this talk of drug addiction and withdrawal, I thought this might be an intereting topic to revive.

There was a thread on this back in 2006:
http://forums.studentdoctor.net/showthread.php?t=249358

Is anyone still doing this?

I ask because I think that you can do rapid detox without intubating the patient. Hear me out.

The key here is Precedex. It has an indication for sedation without need for airway manipulation. Plus, with it's alpha-2 properties, you can probably mitigate a lot of the sympathetic outflow associated with withdrawal from opiates.

I think a reasonable protocol would consist of placing the patient on Precedex, a beta-blocker (like esmolol), and some benzodiazepine for sedation. I don't think you'd need a midazolam drip, but (for example) a rapidly de-escalating diazepam regimen. You could also add a decremental dose of a short acting opiate, like remifentanil, to augment and manage the full opiate-withdrawal side effects.

I just wonder if anyone doing rapid detox has incorporated dexmedetomidine into their practice. Seems like a logical choice in this scenario. Obviously, this would require continuous monitoring of the patient and wouldn't get at the underlying reason why they became addicted to opiates in the first place. But, I think it would work. And, I've had good success (albeit anecdotal) treating alcoholics with Precedex and a similar regimen.

Any thoughts?

-copro

I tried it few years ago...If you have the population (AND I MEAN CASH ONLY) is a fine idea. Of course in your business you need a psychologist, social worker and a definite plan for follow up.

 

[PainRN]

Reviving this thread...

Who does rapid detox?

I'm thinking of opening a "home-based" treatment facility where someone can go discretely and get detoxed. I think that you could do this with a protocol that would get someone detoxed in 72 hours.

Recipe:

-Precedex infusion
-Long-acting benzo (e.g., chlordiazepoxide)
-De-escalating remifentanil infusion
-Cardiovascular support with appropriate adjuncts (beta-blockers such as esmolol infusion, etc.)
-Full cardiovascular monitoring
-Enteral feeding during the treatment period

It would be a cash-on-the-barrel-head type of practice. I think you could charge $3500-$4500 for this procedure. Then, you would put the person on Suboxone or Naltrexone when they walk out the door with pyschiatric follow-up.

Not sure about insurance or DOH accreditation, though. Likewise, I'm not sure how you could get the drugs to do it in such a setting. Insurance and "back-up plan" would also be issues. Would (obviously) want to keep this legal.

Thoughts?

-copro

Sounds like a great idea!! Do you need a nurse to work with you on this since you probably won't be able to stay awake and monitor the patient completely by yourself for the whole 72 hours. Plus there's all that other routine "nursing" stuff that would need to be done for the patient as well.

One thing you might want to substitute/add in your "protocol" is ondansetron either as an infusion or in regularly scheduled doses ATC plus a taper for a several days afterward based on the work they are doing at Stamford.

From mouse to man: the 5-HT3 receptor modulates physical dependence on opioid narcotics
Chu, Larry F.; Liang, De-Yong; Li, Xiangqi; Sahbaie, Peyman; D'Arcy, Nicole; Liao, Guochun; Peltz, Gary; David Clark, J.
Pharmacogenetics and Genomics. 19(3):193-205, March 2009.
doi: 10.1097/FPC.0b013e328322e73d

PDF (400 KB)


Abstract:

Objectives: Addiction to opioid narcotics represents a major public health challenge. Animal models of one component of addiction, physical dependence, show this trait to be highly heritable. The analysis of opioid dependence using contemporary in-silico techniques offers an approach to discover novel treatments for dependence and addiction.
Methods: In these experiments, opioid withdrawal behavior in 18 inbred strains of mice was assessed. Mice were treated for 4 days with escalating doses of morphine before the administration of naloxone allowing the quantification of opioid dependence. After haplotypic analysis, experiments were designed to evaluate the top gene candidate as a modulator of physical dependence. Behavioral studies as well as measurements of gene expression on the mRNA and protein levels were completed. Finally, a human model of opioid dependence was used to quantify the effects of the 5-HT3 antagonist ondansetron on signs and symptoms of withdrawal.

Results: The Htr3a gene corresponding to the 5-HT3 receptor emerged as the leading candidate. Pharmacological studies using the selective 5-HT3 antagonist ondansetron supported the link in mice. Morphine strongly regulated the expression of the Htr3a gene in various central nervous system regions including the amygdala, dorsal raphe, and periaqueductal gray nuclei, which have been linked to opioid dependence in previous studies. Using an acute morphine administration model, the role of 5-HT3 in controlling the objective signs of withdrawal in humans was confirmed.

Conclusion: These studies show the power of in-silico genetic mapping, and reveal a novel target for treating an important component of opioid addiction.
(C) 2009 Lippincott Williams & Wilkins, Inc.

 

[coprolalia]

Absolutely! How much of a cut do you want? 😀

-copro