Anesthesia-Assisted Rapid Opiate Detoxification (AAROD) was developed during the 1980s with the goal of reducing the discomfort of withdrawal and thereby encouraging patients to enter substance abuse treatment. Few long-term studies of AAROD exist, but published data indicate that AAROD does not improve 12-month abstinence rates, compared with standard detoxification. AAROD does not reduce subjective opioid withdrawal symptom scores more than traditional opioid detoxification modalities. Furthermore, AAROD is associated with a substantial rate of serious adverse events in the research setting, 8.6% in one study.
Opioid abuse and dependence is a serious public health problem in the United States. During 1999–2008, emergency department visits, overdose deaths, and substance abuse treatment admissions related to prescription opioids increased substantially. Opioid dependence is a chronic and relapsing illness. Evidence-based treatment options include medication-assisted treatment (MAT) with long-acting opioid agonists (e.g., methadone or buprenorphine), maintenance treatment with opioid antagonists (e.g., naltrexone), or counseling and behavioral interventions. Treatment goals include long-term abstinence or reduction in illicit and nonmedical drug use.
MAT is considered first-line treatment among the evidence-based options listed previously and, compared with other treatments, is associated with lower mortality, improved treatment retention, and decreased incidence of comorbid illnesses, including human immunodeficiency virus infection. However, MAT treatment capacity is insufficient to meet demand in the United States, and patients frequently are placed on waiting lists.
Opioid detoxification refers to the discontinuation of opioid use under medical supervision and includes prescribing or administering medications to decrease withdrawal symptoms. Standard detoxification methods include administering gradually reduced doses of long-acting opioid agonists during a 3–21 day period or discontinuing opioids and administering non-opioid medications to block withdrawal symptoms. These methods ameliorate withdrawal symptoms and carry a less than one percent risk for serious adverse events. The effect of detoxification on long-term abstinence is negligible without the addition of longer term evidence-based substance abuse treatment. Medically supervised opioid detoxification, however, when closely associated with substance abuse treatment programs, can provide an entry point to care.
From August to September 2012, the New York City Department of Health and Mental Hygiene (DOHMH) was notified by the New York City Poison Control Center regarding three patients who experienced serious adverse events after AAROD at a local outpatient clinic. All three patients required hospitalization, and one subsequently died. The DOHMH issued an order requiring that the clinic cease performing AAROD pending an investigation and searched for additional cases of AAROD-related serious adverse events at the clinic and elsewhere in New York City for the period from September 2011 to September 2012. A serious AAROD-associated adverse event was defined as hospitalization for any cause or death less than 72 hours after undergoing AAROD in New York City from September 1, 2011 to September 5, 2012. That search found no serious adverse events at clinics other than the one implicated.
Of the 75 patients who underwent AAROD at the implicated clinic during January to September 2012, two died, and five others experienced serious adverse events requiring hospitalization. As a result of the findings, the New York State Department of Health, the New York Office of Alcoholism and Substance Abuse Services, and the DOHMH jointly issued a Health Alert informing New York health-care providers of AAROD-associated serious adverse events and recommending that they avoid use of AAROD in favor of evidence-based options for opioid dependence treatment.
AAROD procedures performed in the New York City clinic included 1) administration of medications (e.g., clonidine, anti-emetics, and antidiarrheal agents) that blunt withdrawal symptoms, 2) intubation and induction of general anesthesia, 3) precipitation of opioid withdrawal by intravenous infusion of high doses of the opioid antagonist naloxone or intramuscular injection of naltrexone, 4) maintenance of anesthesia until withdrawal symptoms were presumed to have subsided, and 5) extubation and monitoring during an overnight recovery. Median duration of anesthesia was 8.3 hours (range: 3.1–15.0 hours); median duration of opioid antagonist infusion was 3.9 hours (range: 2.1–14.0 hours). Median naloxone dose was 80 mg (range: 2–315 mg); median naltrexone dose was 133 mg (range: 25–300 mg). For patients with serious adverse events, the median naloxone dose was 80 mg (range: 4–88 mg) and median naltrexone dose was 150 mg (range: 0–150 mg). All patients were monitored overnight after the procedure.
DOHMH staff conducted two visits to the clinic. All four clinic staff members were interviewed, and medical records for all patients who underwent AAROD while the clinic was operational were reviewed. Records of emergency medical services calls to the clinic were obtained from the New York City Fire Department. Hospital records for all patients who were found to have made emergency department visits or been admitted to a hospital were reviewed. The practice's patient list was matched to mortality records by patient name and date of birth in New York City and the patients' usual states of residence. New York City's Poison Control Center toxicology database was searched for serious adverse events from other New York City health-care facilities.
No emergency medical services calls to the practice were reported other than those initially reported by the Poison Control Center. The mortality records and toxicology database searches yielded no additional AAROD-related serious adverse events from the implicated clinic or elsewhere. From the clinic's opening in January 26, 2012, until September 4, 2012, a total of 75 patients underwent AAROD; 62 (83%) were men (median age: 37 years; range: 20–63 years). Patient comorbidities included psychiatric disorders (55%), chronic medical conditions (23%), and polysubstance use (35%). In addition to the three adverse events reported, four additional adverse events, including one additional death, were identified during medical record review. All seven patients were men (median age: 31 years; range: 24–52 years). Four were prescription opioid users. Two used both prescription opioids and heroin. One used heroin alone. Four patients had psychiatric comorbidities. Two were polysubstance users. None of the patients had a documented chronic medical condition.
Government agencies and professional societies, including the American Society of Addiction Medicine, have recommended against using AAROD in clinical settings. Given the ongoing epidemic of prescription opioid dependence, further increases in the demand for substance use disorder services are to be expected. AAROD has substantial risks, including a risk for death, and little to no evidence to support its use. Safe, evidence-based treatments of opioid dependence (e.g., MAT) exist and are preferred.
See the CDC Report
See also Medical Law Perspectives, August 2012 Report: Anesthesiology Errors: Complications, Malpractice, and Catastrophe
See also Medical Law Perspectives, March 2012 Report: Off-Label Use of Prescriptions: When is this Medical Malpractice? Is the Pharmaceutical Company Liable for Overpromotion?