Rapid opioid detoxification (ROD) was a procedure developed during the 1980s to help people get off opioids. Due to safety concerns, it is not commonly performed in the United States today, but it is still offered in some settings. This article discusses what we know about ROD, including its mechanism of action, the associated risks, and its efficacy for the treatment of opioid withdrawal and opioid use disorder (OUD).
When people have been using opioids daily or almost daily and then stop, they commonly experience withdrawal symptoms, such as chills, nausea, vomiting, stomach cramps, fever, insomnia, irritability, dysphoria, crawling skin sensation, goosebumps, and craving. Unlike alcohol withdrawal, opioid withdrawal is not life-threatening (unless vomiting and dehydration cause volume depletion or electrolyte imbalances), but it is very distressing and uncomfortable. Untreated, it can last up to 10 days.
Detoxification is the first stage of OUD treatment, the main goals of which are to minimize discomfort and help people get engaged in long-term treatment. The second stage of treatment, maintenance, is also essential. Maintenance usually involves counseling and/or medications to heal the brain and help prevent a return to problematic drug use. In most settings, withdrawal is treated with clonidine and other comfort medications or with opioid-containing medications, such as methadone or buprenorphine, the latter two of which are given in a taper fashion over 3-21 days or continued indefinitely for relapse prevention therapy.
Buprenorphine/naloxone (Suboxone) is a combination medication containing two compounds, and this medication can also be used to treat withdrawal. Buprenorphine (which is a partial stimulator of the opioid receptor, counteracts withdrawal and craving but also reduces overdose risk, as it blocks high doses of opioids) and a second component called naloxone (which is a complete opioid receptor blocker, and prevents the medication from being abused). Suboxone is also one of the safest maintenance treatment options, commonly utilized, and effective at preventing relapse.
ROD is an umbrella term for several similar procedures designed to significantly shorten the withdrawal phase, with an aim to minimize distress and get people back to their lives more quickly. In ROD, rather than letting withdrawal occur naturally, opioid withdrawal is actually induced pharmacologically with medications that block the ability of opioids to bind to receptors in the brain, otherwise known as opioid antagonists. ROD is sometimes performed under simple sedation, using benzodiazepines, but in many cases, the procedure is performed under anesthesia [otherwise known as anesthesia-assisted ROD (AAROD)]. When anesthesia is utilized, the patient is unconscious while their body is undergoing withdrawal, so they don’t feel the discomfort, and the period of withdrawal is especially short (usually 4-6 hours).
Regular opioid use causes changes in the brain’s native (endogenous) opioid system, reducing the sensitivity of the brain’s opioid receptors. Low receptor sensitivity contributes to withdrawal and causes tolerance, where larger amounts of the drug are required to produce the same physical and emotional effects. During all ROD procedures, an opioid antagonist, usually naltrexone or naloxone, or in some cases nalmefene, is given. This restores the brain’s endogenous opioid system to its original state more quickly than would occur if withdrawal were allowed to take place at a natural pace.
Because the rapid induction of withdrawal with an opioid antagonist can be intense, when anesthesia isn’t provided, the opioid antagonist is given in a few escalating doses, in combination with a sedative, over several days. If the anesthesia is administered, people get a single large dose of the opioid antagonist, since they are unconscious during withdrawal. Additionally, traditional detoxification medicines, such as clonidine and antidiarrheals are given to reduce withdrawal symptoms at the beginning of most ROD procedures.
Although there was initially great hope that ROD would benefit people with OUD, it has become increasingly clear that ROD is high risk. As a result, several large agencies and professional societies in the US, UK, and Canada have come out to recommend against using AAROD due to the high rates of serious adverse events (SAEs) and advocate people with OUD seek-out evidence-based treatment instead. Compared to traditional detoxification approaches for which the risks of SAEs are minimal (<1%), AAROD has a high serious adverse event risk of 8-9%.
Although general anesthesia is associated with adverse events, ROD during anesthesia raises the risk of adverse events even higher. An extensive summary of the literature reports that although a 2002 study reported no SAEs following AAROD, a 2005 study reported several SAEs in their patient pool. Another 2008 case series reported that a quarter of their patients (none of whom underwent anesthesia) experienced delirium. In 2012, it was reported that, of 75 patients who underwent AAROD at a New York City clinic, two died, and five others experienced SAEs requiring hospitalization, which resulted in several agencies recommending against these procedures. Pulmonary edema, electrolyte imbalances, excessive catecholamine release, altered cardiopulmonary functioning, and acute lung injury have been observed and might have contributed to some adverse outcomes.
To top it off, ROD is expensive and not usually covered by insurance. Furthermore, after ROD, people lose their tolerance, and if they return to using opioids at their previous dose, they are at high risk of overdose, further increasing the danger of the procedure.
Not only is ROD risky, but experts have concluded that there is very little evidence that it works, either in the short or long term.
Initially, studies suggested that ROD might cause earlier peaking of, and lower scores for, withdrawal symptoms, compared to patients undergoing conventional detoxification, as well as better rates of engagement in long-term treatment. However, more recent studies (which are more likely to include buprenorphine as an agent for detoxification in the conventional treatment arms) conclude that AAROD does not reduce withdrawal severity. Moreover, few empirical studies (randomized controlled trials) have been done, and existing data are considered limited and of low quality.
Even though ROD was designed for detoxification, but not maintenance treatment, it was always hoped that ROD might help ease the transition to the second phase of treatment and minimize relapse in the long run. Unfortunately, studies show that AAROD does not hold any advantages over standard detoxification procedures in terms of short and long-term abstinence rates.
Although we’ve highlighted many downsides of ROD, a few caveats deserve mention. For one, AAROD protocols have varied considerably from clinic to clinic, making rigorous study difficult. Future well-controlled trials might better elucidate safety risks and potential benefits for opioid detoxification.
Furthermore, if safe protocols were established, ROD procedures might deserve exploration for treatment of opioid-associated pain syndromes or for induction onto long-acting naltrexone for OUD, which is the crux for the long-lasting efficacy of that maintenance-stage medication. Given that ROD is considered to be risky, current research suggests that medication for addiction treatment (MAT) for opioid use disorder has positive treatment outcomes, helping patients stay off opioids, reduce the risk of overdose, and live fulfilling lives.
Remember, opioid detoxification is almost never enough as a stand-alone treatment. After talking to their doctor, most patients should consider pursuing maintenance treatment for OUD, which helps prevent relapse. Evidence-based maintenance treatment usually involves intensive counseling (residential treatment, intensive outpatient group-based therapy, individual outpatient therapy) combined with opioid medications such as buprenorphine/naloxone (Suboxone), methadone, or opioid antagonists, such as long-acting naltrexone.
Extensively studied through numerous large clinical trials, medication for addiction treatment (MAT) for opioid dependence reduces mortality, improves treatment retention, and decreases the incidence of illnesses associated with IV drug use, like HIV. It is also covered by most insurances.
To learn more about the success rates and safety of Bicycle Health’s telemedicine addiction treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment here.