Naltrexone‐mediated opiate detoxification: a matter of terminology!

One of the most controversial issues in the treatment of opiate addiction is the choice of procedure bywhichanaddict ismovedtoanopiate-freestateat the start of their treatment. There are currently threemajor categories of detoxification protocol in use: tapering programmes (e.g. methadone reduction), transitional/substitute programmes (e.g. buprenorphine or lofexadine) and treatment programmes based on the use of the opiate antagonist naltrexone to accelerate withdrawal (the so-called rapid opiate detoxification). Each technique has advantages and disadvantages, both in terms of the patient and cost. However, all too often the detoxification process is ‘prescriber/cost/locality’centred rather thanclient-centred.Anecdotes from service users suggest that they are directed to the treatment prescribing services’ preferred modal, irrespective ofwhether it is themost appropriate for that individual. This must change, with clinical teamsbeingmoreopenabout the treatmentoptions they are willing to offer service users. Clearly, in addiction, one size does not fit all. Of the available detoxification regimes, the most under-used and least understood are those techniques employing naltrexone-precipitated withdrawal. Invariably, when discussing naltrexone-assisted detoxification, the term ‘rapid opiate detoxification’ (ROD) is used. In the eyes of many, ROD equates to a risky, last resort treatment practiced under general anaesthesia requiring high-dependency facilities. In practice, naltrexone detoxification programmes are massively varied, both in duration, risk and method of withdrawal. For this reason, the terminology we employ must be both better considered and used more appropriately than is currently the case. Failure to do so will continue to cause both naivety and prejudice against this model of treatment, which for many service users may offer a detoxification process with high programme completion (detoxification) rates. A programme of this type may be particularly appropriate to a client who has failed to complete other detoxification treatment protocols, but also for appropriately assessed service users at any stage of their treatment programme, such as those with an unrealistic fear of withdrawal that prevents them seeking treatment [1]. All naltrexone/naloxone-based protocols should be termed more correctly ‘accelerated procedures’. Within this an accurate categorization is required, rather than using the blanket term ROD with all the contention this holds. To an extent this is already carried out within the field. The term ‘ultra-rapid opiate detoxification’ (UROD) is used widely (but not exclusively) to describe detoxification under general anaesthesia. This type of procedure using naloxone infusion to precipitate withdrawal was published originally in the late 1980s and was subtly revised by several workers over the following decade in terms of aesthetic regime and naltrexone delivery rates (for review see [2]). The procedure is normally complete in less than 4 hours. This type of detoxification has been used extensively and very successfully throughout the world by both commercial and public health organizations; however, its use has resulted, on occasion, in the death of patients. The evidence suggests that complications arising from a general anaesthetic are the predominant cause. This therefore raises the question of the risk to benefit of such a procedure. However, any condemnation of this procedure should be seen in the light that many of the individuals undergoing UROD often have many previous failed attempts at detoxification, with this as a last resort. The potential for low quality and duration of life for these individuals may well make UROD an acceptable risk. Addiction Biology (September 2003) 8, 267 – 269