Wired and Tired

Wired Magazine joins a long list of major media organizations – from "20/20" to "48 Hours" to the Orlando Sentinel – to be drawn in by the unproven promises of "rapid opioid detox." While the magazine did note that there are serious concerns about proponents' claims to withdraw heroin and other prescription opioid addicts safely and more effectively than other methods, it missed the fact that rapid detox promoters can't even prove their main contention: better relief of withdrawal pain.

Instead, Wired called rapid detox "a useful treatment that can seem like a miracle cure," saying, "for addicts who cannot make it through withdrawal any other way, the $15,000 procedure may be their only hope." It quoted an addiction doctor who "claims [that rapid detox] is one of the most innovative developments in the field since the advent of the 12 step program in the 1930s."

Rapid detox proponents say that they can put an opioid addict to sleep with anesthesia, pump him full of opioid-blocking drugs, and when he awakes, he will suffer no withdrawal symptoms.

But Wired should have been far more skeptical about this notion, given the inflated claims it documented the programs making in other areas. For one, though promoters claim a 65 percent recovery rate after one year (compared to 30-40 percent for other treatments), controlled research doesn't support this. The largest NIDA-funded study found that after three months, those who underwent rapid detox were clean in no greater numbers than those who kicked by other methods.

Claims of safety are also problematic: ordinary detox methods kill no one (withdrawal from opioids itself, while unpleasant, is not deadly) but about a dozen deaths are known to be associated with complications from this procedure. As the Wired article notes, seven of these were caused by one New Jersey doctor – still practicing! – alone. While these deaths appear to be related to lack of proper monitoring of patients under anesthesia and immediately following it (the known deaths followed outpatient, not hospital-based, treatment), there's another risk associated with the procedure that Wired failed to even mention.

Rapid detox involves giving large doses of opioid-blocking drugs, including a follow-up prescription for one called naltrexone to be taken for several months afterwards. This will prevent any new use of opioids from producing a high – and is supposed to reduce craving.

But Australian researchers have found increased overdose death rates amongst heroin addicts who ended naltrexone treatment, compared to those who quit treatment with methadone or buprenorphine. Naltrexone drug reduces patients' tolerances for opioids, so that when they stop taking it, they are at far greater risk of death from doses they used to take without problem if they relapse.

In the Australian study of over 1,200 patients, the overdose rate was eight times higher amongst former naltrexone patients, compared to former methadone or buprenorphine patients. The Wired article didn't include this information.

The magazine did note, however, that many rapid detox programs simply provide the detox, a few follow-up phone calls and a naltrexone prescription: exactly the situation in which such overdoses are likely to go unprevented and undetected.

In terms of comfort, rapid detox proponents claim that because opioid-blockers are administered in high doses while the patient is sedated, the withdrawal period is shortened because the receptors are stripped of opioids, then blocked.

However, there is little evidence to support the idea that simply stripping and blocking these receptors makes the brain return to normal faster. And there are many rapid detox patients who claim that after waking from anesthesia, they actually suffered more intense and difficult withdrawal periods than they had when they used other detox methods. Without controlled research, it's impossible to know if comfort or extra pain is more common – and for whom.

Some rapid detox programs implant naltrexone under the skin to ensure that addicts won't skip doses – but some addicts find this so unpleasant that they've literally cut the implants out themselves rather than continue the treatment. Naltrexone can also cause extreme anxiety in certain patients.

While studies find naltrexone to be well-tolerated and effective for treating alcohol problems, it seems far less helpful to opioid addicts. A 2002 study, for example, found that only 19 percent of heroin addicts completed a six-month course of naltrexone treatment, which had been especially designed to encourage them to take the medicine faithfully. This does not suggest that most opioid addicts find the drug helpful – nor that a procedure involving taking it orally with no support would be particularly effective.

Without further research, and as presently conducted, the media should not be using words like "miracle" in association with rapid detox. If it could be proven more comfortable for addicts – even if it had added safety risks and no added advantage in efficacy – that would be a reason to offer it. It could draw people in then, people who might otherwise die on the street. But if the programs can't even prove they are more comfortable than other detoxes, why add the risks and the high cost?

Sadly, I have to close this article with the same cautionary quote I used when I wrote about rapid detox for Newsday in 1996 – because research still hasn't answered the key questions and the media still doesn't get that claims about extra comfort are as suspect as other claims made for the treatment.

Herbert Kleber, director of the division of substance abuse at Columbia University School of Medicine, is also a former deputy drug czar. It was his work that showed that rapid detox didn't actually improve long-term outcomes. He wrote this back in 1982, and just like in 1996, it's just as true today:

The history of the treatment of narcotic withdrawal is a long and dishonorable one. The trail is strewn with cures enthusiastically received and then quietly discarded when they turned out to be relatively ineffective or even worse, productive of greater morbidity and mortality ... Any claim for a new method should be put forward modestly and viewed with skepticism until amply documented by careful experimental procedures.
We're still waiting for the rapid detox data, and Wired should have known that if a program's claims of safety and efficacy are exaggerated, the same might be true about its claims of comfort.
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