Letter to the Editor

There has been much media speculation in Australia about the rapid detoxification (RD) process now being performed at a number of locations overseas as a treatment for heroin dependence.

Despite some claims of '100% success' in thousands of patients, there have been few if any research reports on the progress of patients treated using this procedure. Hence most of our information on the subject comes from word-of-mouth, anecdotal reports and the mass media.

A patient I have seen personally was a 25 year old male who was literally on his way to the airport to travel overseas to have the procedure performed. He requested an authority to import naltrexone which is prescribed following the RD.

This young man gave an eight year history of cannabis, LSD, amphetamine and ecstasy use. Recently he had taken to using injected heroin and had committed some crimes to obtain money for drugs. He had no venous scarring and only a small number of recent venepunctures at a single site. He stated that he would join a 'heroin trial' if such an option was open.

After completing a brief questionnaire sent by fax to the institute overseas, the patient was apparently accepted for rapid detox. I was told that there was no referral from his family doctor, nor was any detailed history, examination, urine or blood test requested. His family was put to considerable financial hardship in obtaining the $A16,000 required for the treatment, air fares and hotel expenses.

On his return to Australia, the patient's mother reported to their family doctor that there was a return to illicit drug use within four days. While this has not yet been confirmed, the mother is known to be a reliable witness.

There have also been a number of indirect reports relating to problems associated with this type of treatment. One was of a death reported in the London Times, allegedly in the context of a rapid detox-type procedure. Another 10 or more deaths have been allegedly associated with the treatment in North America. I received a note from a methadone patient in Illinios who had a friend, a professional person, who 'nearly died of vomiting and dehydration after the rapid detox (RD)'. Legal action was threatened by the patient's family. A Sydney patient's companion who had attended the hospital during the procedure said that the staff reported that during the anaesthetic there were two episodes of 'straight line' (cardiac arrest) needing urgent resuscitation.

Summary of recommendations to doctors and counsellors:

• Obtain a comprehensive history, physical examination and investigations where relevant.
• Inform the patient of the potential dangers of the procedure.
• Inform the patient that the procedure is not an evaluated intervention and is considered experimental by many doctors in the field.
• Inform the patient of the dual nature of (1) the detox procedure and (2) the prescribing of naltrexone subsequently.
• Ensure that the patient has had an opinion from a D&A specialist.
• Suggest that your patient consider delaying the procedure.
• Inform the patient that the cost of the treatment may not be proportional to its complexity.
• Inform the patient that despite an ethical obligation to share knowledge of new treatments, few reports appear to have been submitted, reviewed or published.
• Inform the patient that one small preliminary survey showed in excess of 40% of patients had relapsed to periods of daily heroin use by six to twelve months.
• Inform the patient that methadone treatment can now be offered in a variety of settings and dose levels. Other acceptable alternatives are also being trialled in Australia with numerous reports in the medical literature. When properly administered, the mortality associated with methadone and other 'maintenance' treatments is close to zero. Patients who desire drug-free treatment should be directed to traditional detox wards, rehabs or Narcotics Anonymous groups.
• All health professionals have a duty to report their own observations concerning new treatments in order to augment knowledge on the subject.

Dr Andrew Byrne, General Practitioner, Drug and Alcohol, Redfern, Sydney
Email ajbyrne@ozemail.com.au

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