Medical Policy



Subject: Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification
Document #: BEH.00001 Current Effective Date:    03/29/2017
Status: Reviewed Last Review Date:    02/02/2017

Description/Scope

This document addresses the use of relatively high doses of opioid antagonists, such as naltrexone or naloxone, under deep sedation with benzodiazepine or general anesthesia. This strategy has been referred to as "ultra-rapid," "anesthesia-assisted" or "one-day" detoxification.

Position Statement

Investigational and Not Medically Necessary:

Administration of opioid antagonists under heavy sedation or general anesthesia, as a technique of opioid detoxification, is considered investigational and not medically necessary.

Rationale

Evaluation of the safety and effectiveness of ultra-rapid treatment of opioid withdrawal using sedation or general anesthesia involves consideration of a variety of outcomes. For example, one might consider the number of dependent individuals enrolling in detoxification programs. Many opioid addicts may be fearful of prolonged detoxification programs and thus may only seek treatment in an accelerated detoxification program. Advocates of ultra-rapid detoxification point out that an increasing enrollment in detoxification programs is an important outcome (Bovill, 2000; Gooberman, 1998). In addition, proponents suggest that the procedure is a rapid and painless method of detoxification. Therefore, an important outcome is the comparison of the duration and severity of withdrawal symptoms associated with ultra-rapid detoxification and other detoxification strategies.

The completion rate of a detoxification program is another possible outcome. As noted by Scherbaum, up to 30% of individuals may drop out of traditional inpatient detoxification programs (Scherbaum, 1998). Using sedation or anesthesia, one is assured of 100% completion of detoxification. However, as is commonly pointed out, detoxification is only the first step in treating opiate addiction and ultra-rapid detoxification programs may offer different types of long-term follow-up care, based on ongoing psychosocial support with or without additional medication, such as naltrexone. Therefore, the rate of abstinence during both the short-term 6-month period of protracted withdrawal symptoms and longer-term abstinence are also important outcomes. For example, traditional methods of withdrawal (i.e., tapering doses of methadone or buprenorphine) require the individual to be in a therapeutic environment for a prolonged period of time, potentially reducing the risk of long-term relapse.

In addition, the success of any detoxification program must be evaluated according to the populations requiring treatment. For example, individuals addicted to heroin may respond differently than those addicted to oxycodone and response may vary according to duration of addiction or prior attempts at traditional detoxification. Also, ultra-fast detoxification may be offered to individuals on methadone maintenance, in an effort to render these individuals drug free. Methadone withdrawal after abrupt drug discontinuation tends to be prolonged compared to ultra-rapid detoxification and withdrawal from other opioids. However, methadone maintenance can be an important element in diminishing the risk of illicit opioid use as well as support other desirable outcomes. Switching to buprenorphine and naloxone or a slow methadone taper are widely employed alternatives to ultra-rapid detoxification from methadone.

The major safety considerations regarding ultra-rapid detoxification are the risks associated with general anesthesia in combination with opioid antagonists. While participants are generally intubated and ventilated, eliminating the risk of choking, intravenous naloxone has been associated with cardiovascular complications such as cardiac arrest and pulmonary edema. These potential safety issues are particularly important, since opioid withdrawal itself is not associated with life-threatening complications. Advocates of ultra-rapid detoxification point out, however, that detoxification is a painful procedure, and that the risk of anesthesia has generally been considered acceptable when used to relieve pain (Brewer, 1998).

Given the above considerations, assessment of ultra-rapid 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 subjects, based on type and duration of addiction. Efficacy outcomes are balanced against the safety considerations of deep sedation or general anesthesia in conjunction with naloxone.

A search of the peer-reviewed literature did not identify any studies that directly compared the outcomes of ultra-rapid detoxification with other methods of detoxification. As also noted by two published reviews, the majority of the published literature consists of single institution case series including heterogeneous populations and a variety of protocols, varying in the opioid antagonist used, the dose and mode of administration, the anesthetic agent, duration of anesthesia, and adjunct medications used (Gowing, 2010; O'Connor, 1998). Two randomized studies were identified; however, these studies focused on treatment regimens that varied only in the level of sedation used and did not include a conventionally treated control group (Kienbaum, 2000; Seoane, 1997).

Regarding severity and duration of withdrawal symptoms, Gowing's review (2010) suggests that most individuals experienced moderate withdrawal symptoms lasting a few days post-anesthesia or sedation, including nausea, vomiting, diarrhea, and sleep disturbances. In addition, withdrawal severity may also be related to the anesthetic used. However, without a controlled trial, no conclusion can be made regarding the duration or severity of withdrawal symptoms compared to other techniques of detoxification.

Most of the studies did not report short- or long-term follow-up of abstinence and those studies that did include follow-up have reported conflicting results. For example, Seoane and colleagues (1997) reported that 279 of the 300 participants treated were abstinent after 1 month, while in Cucchia's study of 20 participants, 16 reported some resumption of heroin in the 6 months following detoxification, with 60% considered to have relapsed (Cucchia, 1998). Albanese assessed relapse at 6 months in 120 participants. Relapse data was available for 111 participants; 55% were relapse free (Albanese, 2000). Again, without controlled studies in similar populations of subjects, no conclusions can be drawn about the relative long-term efficacy of ultra-rapid detoxification compared with other treatment strategies.

A variety of adverse events have been reported in small numbers of participants, including vomiting while under anesthesia or sedation, various cardiac rhythmic disturbances, pulmonary dysfunction, and renal insufficiency (Gowing, 2010). 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 afterward have been reported (Bearn, 1999; Dyer, 1998; Gold, 1999; Solomont, 1997). In addition, deaths subsequent to ultra-rapid detoxifications have been reported (Brewer, 1998). Of particular concern is the fact that the use of opioid antagonists results in loss of tolerance to opioids, rendering the individuals susceptible to overdose if the individual returns to his/her pre-detoxification dosage of illicit drugs (O'Connor, 1998).

In a trial by Collins and colleagues (2005), 106 heroin addicts were randomized to undergo detoxification with an anesthesia-assisted rapid opioid detoxification, buprenorphine-assisted rapid opioid detoxification, or clonidine-assisted opioid detoxification. All participants received an additional 12 weeks of outpatient naltrexone maintenance. Mean withdrawal severities were similar among the 3 groups, and treatment retention in the 12-week follow-up period was similar. However, the anesthesia procedure was associated with three potentially significant life-threatening adverse events. The authors concluded that the data did not support the use of general anesthesia for heroin detoxification. A randomized trial from a European center reported that the initial improvement in the rate of opiate detoxification and abstinence (3 months) with anesthesia was not maintained with long-term follow-up; both groups (36 participants treated with anesthesia and 34 with classical clonidine detoxification) showed less than 5% abstinence after 12 months (Favrat, 2006). In addition, a Cochrane review on heavy sedation or anesthesia for opioid withdrawal concluded that:

Heavy sedation compared to light sedation does not confer additional benefits in terms of less severe withdrawal or increased rates of commencement on naltrexone maintenance treatment. Given that the adverse events are potentially life-threatening; the value of antagonist-induced withdrawal under heavy sedation or anesthesia is not supported (Gowing, 2010).

In April, 2000 The American Society of Addiction Medicine (ASAM) released a Policy Statement titled "Rapid and Ultra Rapid Opioid Detoxification." In this document their policy recommendations include:

  1. 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.
  2. 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.
  3. 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.

This document was last reviewed in April of 2005, probably reflecting the lack of scientific progress regarding the safety and efficacy of various rapid opioid detoxification techniques. This document still stands as an active position of the ASAM.

Forozeshfard et al. (2014), evaluated 1-month relapse outcomes of 64 subjects who underwent ultra-rapid opiate detoxification. The relapse rate observed was very high: 75% (n=48) of subjects reported relapse, with 4 subjects in the non-relapsed group reporting at least one episode of opiate use.

In summary, additional controlled trials and standardized approach to ultra-rapid detoxification are required to permit scientific conclusions regarding the safety or efficacy of ultra-rapid detoxification compared to other approaches that do not involve deep sedation or general anesthesia.

Background/Overview

The traditional treatment of opioid addiction involves substituting for the opiate (that is, heroin) 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 individuals in treatment, and a decrease in the risk of transmitting HIV or hepatitis. However, critics of methadone maintenance point out that this strategy is a substitution of 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 an individual on methadone maintenance. Detoxification is associated with acute symptoms followed by a longer period of protracted symptoms. 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 agonist-antagonist), 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 individual support and oral medications are offered, detoxification is associated with an individual's discomfort, and many dependent individuals 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.

Ultra-rapid and rapid detoxification are approaches for detoxifying opioid-dependent individuals using opioid antagonists, such as naltrexone used typically under general anesthesia or heavy sedation. The aim is to flood the brain with an opioid antagonist to remove all agonists very rapidly while the anesthesia or sedation minimizes the discomfort. The individual is then maintained on naltrexone, which has been referred to as rapid antagonist induction. Since the individual is under anesthesia during the procedure, he/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 octreotide acetate (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.

Ultra-rapid detoxification may be offered by specialized facilities with programs typically consisting of three phases: a comprehensive evaluation, inpatient detoxification under anesthesia, and mandatory post-detoxification care and follow-up. The program may be offered to individuals addicted to opioid or narcotic drugs such as opium, heroin, methadone, morphine, demerol, dilaudid, fentanyl, oxycodone, hydrocodone, or butorphanol. Once acute detoxification is complete, the opioid antagonist naltrexone is often continued to decrease drug craving, thus reducing the incidence of relapse.

Definitions

Buprenorphine: A partial opioid agonist and potent antagonist and analgesic that can be administered once a day to block withdrawal symptoms.

Detoxification: A short-term approach designed to help selected individuals achieve a drug-free state.

Naltrexone: A derivative of naloxone, approved by the FDA in 1984, an opioid antagonist used for maintenance treatment of opioid dependence.

Opioids: Meaning opiate like, derivatives of opium; all opioids can produce euphoria, can be used as analgesics, and are the most powerful known pain relievers.

Opioids can be classified as the following:

Opioid antagonists: Agents which block opioid effects, thereby eliminating opioid-induced euphoria, diminishing the reinforcing effects of heroin, and potentially extinguishing the association between conditioned stimuli and opioid use; opioid antagonists offer the advantage of treatment with medications that have no addictive potential or tolerance.

Opioid maintenance agonists: Long-acting noneuphorigenic opioids with relative steady-state pharmacokinetics are used to replace heroin, a short-acting, euphorigenic opioid is characterized by rapidly changing serum levels.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When Services are Investigational and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

CPT  
  No specific code for rapid or ultra-rapid opioid detoxification procedure under anesthesia
   
HCPCS  
H0047 Alcohol and/or other drug abuse services, not otherwise specified [when describing rapid or ultra-rapid opioid detoxification under anesthesia]
   
ICD-10 Procedure  
HZ2ZZZZ Detoxification services for substance abuse treatment [when specified as rapid or ultra-rapid opioid detoxification under anesthesia]
   
ICD-10 Diagnosis  
F11.10-F11.99 Opioid related disorders, dependence, use unspecified
   
References

Peer Reviewed Publications:

  1. Albanese AP, Gevirtz C, Oppenheim B, et al. Outcome and six months follow up of patients after ultra rapid opiate detoxification (UROD). J Addict Dis. 2000; 19(2):11-28.
  2. Bearn J, Gossop M, Strang J. Rapid opiate detoxification treatments. Drug Alcohol Rev. 1999; 18(1):75-81.
  3. Bovill JG. Opioid detoxification under anesthesia. Eur J Anaesthesiol. 2000; 17(11):657-661.
  4. Brewer C, Laban M, Schmulian, 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.
  5. Brewer C. Opiate detoxification under anesthesia. BMJ. 1998; 316(7149):1983-1984.
  6. Collins ED, Kleber HD, Whittington RA, Heitler NE. Anesthesia-assisted vs buprenorphine- or clonidine-assisted heroin detoxification and naltrexone induction: a randomized trial. JAMA. 2005; 294(8):903-913.
  7. Cucchia AT, Monnat M, Spagnoli J, et al. Ultra-rapid opiate detoxification using deep sedation with oral midazolam: short and long-term results. Drug Alcohol Depend. 1998; 52(3):243-250.
  8. Day E, Ison J, Strang J. Inpatient versus other settings for detoxification for opioid dependence. Cochrane Database Syst Rev. 2005;(2):CD004580.
  9. Favrat B, Zimmerman G, Zullino D, et al. Opioid antagonist detoxification under anaesthesia versus traditional clonidine detoxification combined with an additional week of psychosocial support: a randomized clinical trial. Drug Alcohol Depend. 2006. 81(2):109-116.
  10. Forozeshfard M, Hosseinzadeh Zoroufchi B, Saberi Zafarghandi MB, et.al. Six month follow-up study of ultrarapid opioid detoxification with naltrexone. Int J High Risk Behav Addict. 2014; 3(4):e20944.
  11. 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.
  12. Gooberman LL. Rapid opioid detoxification. JAMA. 1998; 279(23):1871-1872.
  13. Gowing L, Ali R, White J. Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal. Cochrane Database Syst Rev. 2010;(1):CD002022.
  14. Kienbaum P, Scherbaum N, Thurauf N, et al. Acute detoxification of opioid-addicted patients with naloxone during propofol or methohexital anesthesia: a comparison of withdrawal symptoms, neuroendocrine, metabolic and cardiovascular patterns. Crit Care Med. 2000; 28(4):969-976.
  15. O'Connor PG, Kosten TR. Rapid and ultrarapid opioid detoxification techniques. JAMA. 1998; 279(3):229-234.
  16. Salimi A, Safari F, Mohajerani SA, et al. Long-term relapse of ultra-rapid opioid detoxification. J Addict Dis. 2014; 33(1):33-40.
  17. Scherbaum N, Klein S, Kaube H, et al. Alternative strategies of opiate detoxification: evaluation of the so-called ultra-rapid detoxification. Pharmacopsychiatry. 1998; 31(6):205-209.
  18. Seoane A, Carrasco G, Cabre L, et al. Efficacy and safety of two new methods of rapid intravenous detoxification in heroin addicts previously treated without success. Br J Psychiatry. 1997; 171:340-345.
  19. Solomont JH. Opiate detoxification under anesthesia. JAMA. 1997; 278(16):1318-1319.
  20. Teplin D, Raz B, Daiter J, et al. Measurement of symptom withdrawal severity in a 24-hour period after the anesthesia-assisted rapid opiate detoxification procedure. Am J Drug Alcohol Abuse. 2005; 31(2):327-335.

Government Agency; Medical Society; and Other Authoritative Publications:

  1. American Society of Addiction Medicine. National practice guideline for the use of medications in the treatment of addiction involving opioid use. May 2015.Anesthesia-assisted withdrawal management. Available at: http://www.asam.org/magazine/read/article/2015/06/02/asam-releases-national-practice-guideline-for-the-use-of-medications-in-the-treatment-of-addiction-involving-opioid-use. Accessed on November 1,  2016.
  2. American Society of Addiction Medicine. Public policy statement on rapid and ultra-rapid opioid detoxification. (formerly public policy statement on rapid and ultra rapid opioid detoxification. April 2000). Revised April 2005. Available at: http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2011/12/15/rapid-and-ultra-rapid-opioid-detoxification. Accessed on November 1, 2016.
  3. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination for Treatment of Drug Abuse (Chemical Dependency). NCD #130.6. July 2016. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_Part2.pdf . Accessed on November 1, 2016.
  4. National Institute for Health & Clinical Excellence (NICE): National Collaborating Centre for Mental Health. Drug misuse: Opioid detoxification. National Clinical Practice Guideline: the British Psychology Society and the Royal College of Psychiatrists. July 25, 2007. Available at: http://www.rcpch.ac.uk/sites/default/files/asset_library/Research/Clinical%20Effectiveness/Endorsed%20guidelines/Drug%20Misuse%20-%20Psychosocial%20%28NICE%29/Drug%20misuse%20-%20opioid%20detoxification.full%20guideline.pdf. Accessed on November 1, 2016.
Websites for Additional Information
  1. American Society of Addiction Medicine. Available at: http://www.asam.org/. Accessed on November 1, 2016.
  2. Substance Abuse and Mental Health Services Administration (SAMHSA). Available at: http://www.samhsa.gov/. Accessed on November 1, 2016.
Index

Anesthesia Assisted Detoxification
Opioid Detoxification, Opioid Antagonists
Rapid Detoxification
Ultra-Rapid Detoxification

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History

Status

Date

Action
Reviewed 02/02/2017 Medical Policy & Technology Assessment Committee (MPTAC) review.
Reviewed 01/20/2017 Behavioral Health Subcommittee review. Updated the Rationale and Reference sections.
Reviewed 02/04/2016 MPTAC review.
Reviewed 01/29/2016 Behavioral Health Subcommittee review. Updated Description, Background and References. Removed ICD-9 codes from Coding section.
Reviewed 02/05/2015 MPTAC review.
Reviewed 01/30/2015 Behavioral Health Subcommittee review. Updated Description, Background and References.
Reviewed 02/13/2014 MPTAC review.
Reviewed 02/07/2014 Behavioral Health Subcommittee review. Updated Rationale, References and Websites.
Reviewed 02/14/2013 MPTAC review.
Reviewed 02/08/2013 Behavioral Health Subcommittee review. Updated References and Websites.
Reviewed 02/16/2012 MPTAC review.
Reviewed 02/10/2012 Behavioral Health Subcommittee review. Updated References and Websites.
Reviewed 02/17/2011 MPTAC review.
Reviewed 02/11/2011 Behavioral Health Subcommittee review. Updated Description, Rationale, References and Websites.
Reviewed 05/13/2010 MPTAC review. References updated.
Reviewed 05/21/2009 MPTAC review. References updated.
Reviewed 05/15/2008 MPTAC review. Updated background and references.
  02/21/2008 The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed 05/17/2007

MPTAC review. Rationale and references updated.

Reviewed 06/08/2006

MPTAC review. Updated references.

 

11/22/2005 Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised 07/14/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations Last Review Date Document Number Title

Anthem, Inc.

 

03/20/2003

BEH.00001 Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification
WellPoint Health Networks, Inc.

06/24/2004

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