Friday 29 May 1998

Report
On

UROD ( ULTRA RAPID OPIATE DETOXIFICATION )

Medical Documentation collected through the Internet

May 1998

Processed and compiled by : D.V.N. 2018 Antwerpen, Belgium. Tel: + 32 (3) 237.81.11 chrysale@skynet.be

INDEX
1. 2. 3. 4. 5. FOXNEWS : 30-Jan-1998 Sick and Tired The process and the profit: origins of rapid detox Naltrexone ---- a tool, not a cure. The secrets of their success : the alternatives debate, gauging success No easy way out. http://www.foxnews.com/health/features/heroin/

Sick and Tired

Fifteen bags of heroin a day for 25 years. Thats the habit Michael Neal is trying to kick at Metropolitan Hospital in Upper Manhattan. Its the fifth time the 47-year-old merchant marine-turned-flea marketeer has entered detox. And his previous four exits arent cause for encouragement - twice he fled mid-process for a snort or a skin pop to kill the physical agony of withdrawal; once he entered methadone maintenance, but returned to heroin after less than a week; and once he went cold turkey and got clean, only to relapse soon after. I just drank a couple of bears and detoxed of my own, he says. I was the worst feeling on earth. You just hurt all over. They say it wont kill you, but it will make you feel like you want to die. You are in hell. Todays attempt, though, is a detox with a difference: Neal, a pseudonym, has made his way here from his home in Virginia and plunked down $ 7,500 - almost the whole of his inheritance from a recently-deceased uncle - for a procedure that will reduce from about seven days to around seven hours the time it takes to purge the heroin from his body. The technique will also make him insensate to the muscle cramps, chills and sweats, nausea, vomiting and diarrhea that drives many junkies to abandon detox for a fix. Neal, a burly, black-haired man with a moustache who says he acquired his habit at age 22 while serving in Vietnam, figures the steep fee could be worth it. Feeding his habit currently costs him more than $ 1000 a week - its wiped him out financially - and he has begun to suspect the price may soon skyrocket. Iam sick and tired of being sick and tired, he says. If I dont get clean this time I will probably die.

The process and the profit: origins of rapid detox

The procedure Neal is about to undergo goes by various names, among them ultra-rapid opiate detoxification and rapid anesthethic-assisted detoxification. All follow largely the same basic pattern: Put a patient into an anesthesia-induced sleep, then give him or her naltrexone , a drug that strips the heroin from the opiate receptors in the brain, throwing the patient into an immediate, intense and foreshorted withdrawal, the symptoms of which are reduced by a second drug, clonidine . all the major textbooks say never give an addict an opiate antagonist like naltrexone since it will so speedily induce extremely painful withdrawal, says Dr. Clifford Gevirtz, the blue-eyed, boyish-yet-balding licensed anesthesiologist overseeing Neals detoxification. But because our patients are asleep we can. Rapid detox is a new alternative to traditional processes in which users slowly reduce or suddenly eliminate their heroin intake, and either use painkillers to reduce withdrawal symptoms or just tough it out. Still others rely on substitution therapies, such as methadone maintenance, in which a legally obtained and less-potent opiate is administered in place of heroin. The rapid detox technique, which arrived in the United States last fall after trials in countries such as Israel, spain and Italy, is now available in at least three out-patient facilities in America, and as an in-patient procedure at hospitals in Chicago, Los Angeles, Miami and, of course, New York, where it made its U.S. DEBUT. The out-patient programs cost about $ 2,500 abd rekease the oatient the same day. The in-patient programs are partnerships between the host hospital and the Center for the Investigation and Treatment of Addiction (CITA) , an international for-profit corporation that claims credit for developing the rapid detox method, and , with an eye toward a public stock offering, is aggressively promoting its version of the treatment. Having, by its own account, performed about 5,000 detoxes worldwide, CITA has become the high-profile standard-bearer for the technique, and so absorbs the brunt of both its kudos and it s critiscisms. About 300 of its 5,000 detoxes have occured in the United States where, of the $ 7,500 charged for the service, $ 3,000goes to the hospital, which provide the bed, equipment, drugs and doctors and nurse, and $ 4,500 goes to CITA, which licenses its procedure, solicits patients and administers the program. CITAs critics question the ethics of privatizing a medical process, pointing out that a process is different from a product, despite the corporation claims that its protection of UROD is no different from a pharmaceutical firm patenting a drug it developped. But their more immediate concern is that the corporations expressed desir(e for large profits - a motivation CITA celebrates with an overtness difficult to find among most practitioners or HMOs - may compromise its care-giving. This fear is discounted by the hospital-affiliated doctors carrying oout the procedure in the United States, who view themselves as guardians of the patients interests. Whenever you have any for-profit organization working in a non-profit setting there will naturally be tensions, Dr. Gevirtz says. But we will not put aside our good medical judgment - thats the safeguard. My responsability is to the patient, not to making CITA happy campers. Soon after, Gevirtz administers the anesthesia, and later the naltrxone to Neal. Michael, are you doing OK? Gevirtz asks. There is no reaction, no sign that Neal is in any way aware of the slight arching and twitching of his body that has already begun. Rapid detox is an outgrowth of a more fundamental discovery in the treatment of heroin addiction: the origins of rapid detox. Although CITA literature and representatives say Spanish psychologist Juan Jos Legarda, the brother-in-law of CITA Founder and Israeli surgeon Andr Waissman, developed rapid detox, there is considerable controversy as to who actually did so, qith another researcher Colin Brewer of Great Britain - also claiming authorship. It is an isuue that CITA representatives acknowledge and respond to only when it is raised. I feel badly for those who may have simulthaneously discovered the technique, Oppenheim says But you need a certain style to do what it takes to bring that discovery to the public and get the credit for it , and thats what Dr.Legarda did. Whoever pioneered it, the technique is far from revolutionary. It is, rather, another logical step in a long series of modifications to the real groundbraking work, which took place in the 1970s and 1980s at Yale University. There at a time when vertually all programs to get additcts of heroin focused on replacing it with another narcotic, researchers C.E.Riordan and Herbert Kleber were looking for a way to treat users with non-narcotics. They wanted to help addicts get clean instead of providing them with a new, perhaps more manageable habit to substitute for their heroin addiction and also were searching for a way to shorten the detox process itself. Eventually, they developed

away to do both, discovering that they could reduce to three days the usually week-long detoxification regimen by giving patients naltrexone and reducing the resulting heightening of withdrawal symptoms with clonidine , both non-narcotic and non-addictive. Although they wanted to cut the detox-time even further, they found that administering the naltrexone any faster created such discomfort patients would abondon the program. In 1990, the Austrian scientist N. Loimer determined that, if he heavily sedated his patients, he could, without driving patients away, give them the naltrexone faster and reduce detox to six hours. The problem was this: Heavy sedation can make patients throw up, and they can choke to death on the vomit or it can enter their lungs and lead to pneumonia. But setting up safeguards required painful procedures difficult to carry out on a conscious patient. The solution seems almost obvious - put the patient under general anesthetic. Although it is unclear who arrived at it first - Legarda or Brewer - it is apparent that it was another outgrowth of Riordan and Klebers work.

Naltrexone ---- a tool, not a cure.

CITA literature and representatives make many suggestive - and widely disputed - claims about their detox technique, which they have dubbed Ultra-Rapid Opiate Detoxification (UROD). For example, although their assertion that all their patients succesfully detox is true, they exaggerate the failings of other available methods, some of which achieve success rates above 90 percent. But the crucial issue, experts say, is whether CITAs higher detox rate delivers a lower relapse rate than other therapies. Detoxification is the first step into treatment, says Dr. Herbert Kleber, an eminent addiction specialist at Columbia University whose research at Yale in the 1970s and 1980s laid the groundwork for the rapid detox technique. The average addict has been detoxified numerous times. The benefit has to lie in whether three months after detox there are more people off heroin. Dr. Gevirtz (photo) agrees that relapse rate is the crucial issue: Thats the gold standard, he says. In a bid to improve relapse rates, CITA has made naltrexone a pivotal part of its post-detox aftercare program. In addition to being used to strip the heroin from the brains opiate receptors during detox, the drug is employed immediately afterwards to block heroin from reaching those receptors, staunching the satisfaction provided by the opiate so that lapses, which often occur within days of detox, dont rekindle regular use. What is radical, dont rekindle regular use. What is radical about employing naltrexone like this is that Dupont Merckx, the drugs manufacturer, warns against administering it as a heroin blocker until at least 10 days after detox, as well as cautioning against ever utilizing it as a heroin stripper. But the post-detox naltrexone strategy is less than it seems: an addict insulated by the drug can still get hihg by taking about five times their usual dose of heroin, a likely prescription for an overdose; and, with the exception of a study funded by CITA, most evidence indicates that very few detoxed addicts stay on their naltrexone, tearing holes in what some CITA representatives call the bullet - proof vest of their aftercare. Dr. Kleber, though, hopes to change at least the latter, by insuring compliance through the development of a long-acting naltrexone. He has already made a proposal to the National Institute on Drug Abuse to study a naltrexone injection that would provide a month of prophylaxis, and expects to start that research within six months.

The secrets of their success : the alternatives debate, gauging success

CITAs procedure has never killed a patient, and its representatives say the odds of such a tragic outcome occurring are heavily outweighted by the likelihood of death resulting from heroin use and its attendant lifestyle. The minimal risks of our procedure seem justified when you consider that each year one to two percent of all heroin addicts die for reasons related to their drug use, Dr. Gevirtz says. Our critics have overstated the dangers of the procedure, properly performed. Still, unlike other techniques, which pose no danger of mortality, rapid detox does present life-threatening risks, mostly due to the inherent hazards of general anesthesia and of an undetoxed addict being administered naltrexone without sufficient anesthetic or sedation or both. As a result, patients can die from heart attacks, water in the lungs or choking on their own vomit. Although such outcomes are statistically unlikely - at most one in 15000 - at least two rapid-detox patients and perhaps as many as four, have died from such reactions. Both deaths occurred at out-patient clinics, in part due to such facilities lack of life-saving equipment. As a result, legislation to require that rapid detox take place in a hospital is currently being considered in some states. An occasional mortality might be easier to swallow if the relapse rates for rapid detox were, as its proponents contend, considerably lower than other procedures It is a claim that CITAs literature and representatives make for UROD. But some experts express doubts about the corporations follow-up figures. One thing they point - and CITA representatives make for UROD. But some experts express doubts about the corporations follow-up figures. One thing they point to - and CITA representatives acknowledge this - is the deart of independent studies on the technique. Experts also suspect that CITAs self-reported success rates - which have grown progressively less impressive with initial claims of 20 percent relapse rates rising to, in its most recent accounts, 45 percent may be due to its patients being better-equipped to succeed tan average users. These are people who can afford to pay $ 7,500, Dr. Kleber says. Access to money may imply a greater degree of social and family support and higher educational and vocational attainments, which may translate into a greater ability to recover and a greater stake in recovery. The general sample in a study of heroin-addicted individuals is very poor and without resources. We do need to do a controlled study that would include indigent patients, Dr. Gevirtz says, adding that all addicts could access the program if the state would approve citas request to make UROD Medicaidfinancied and if health insurers would agree with the reimbursement of the technique. But, according to Oppenheim, such a study is unnecessary given that, of the nearly 150 people treated by CITA at Metropolitan Hospital, indigent, blue collar and affluent patients have had identical relapse rates. If CITAs long-term success rate is, in fact, any better than most other procedures, say experts, it is likely due to its detox not its aftercare results. In other words, because the number of CITAs patients who make it through detox is higher, the same or even somewhat lesser success in aftercare will still produce a lower overall relapse rate. If CITA had come forward and said We have improved detox, then you could say More power to them, because even though detox is only the first step of a long journey, first steps are important, Dr. Kleber says. But UROD is not a cure for narcotics addiction, which is what CITA seems to suggest. This is hype; its trying to sell something. Oppenheim responds, saying: We want to provide the proof to back up what everyone is calling the hype so all the critics will be silenced and if we can not then we deserve every shot we have taken.

gauging success

No easy way out

Neals detox is nearing its end. He sleeps soundly, no withdrawal symptoms any longer evident. Dr. Gevirtz performs a test to make sure all the heroin has been forced from Neals system. It has. The detox is over and the still-heavily sedated patient is wheeled out of intensive care into recovery. The next morning, as Neal begins to stir, he thinks about his wife since six years, an heroin addict as well. She is back home in Virginia where she is also struggling to kick her habit. The couple did not have enough money to pay for both to enter UROD. They decided his problem was so bad that he would get the nod. Theres no easy way out, he says, his voice still shaky and barely audible, seven days after detox. This wasnt as hard as what she is going through, but Im still so weak I cant hardly move. Its a lot easier than going cold turkey and a lot quicker, but I thought it would easier than this. There are indications that this is a frequently heard refrain from rapid-detox patients. Some CITA brochures talk about the procedure being painless, Dr. Gevirtz says, and some people feel thats inaccurate. Some CITA patients say they believed their post-detox discomfort weeks of sleeplessness, diarrhea and stomach pain - were withdrawal symptoms until corporation representatives told them that, as one patient put it , it was my body feeling the the effects of feeling after years of numbness. But until this explanation is studied, Dr. Kleber says he will remain unconvinced: For all we know, CITA may get 100 percent success on day one and far less success in the days that follow. Neal didnt escape this apparent syndrome. He felt so badly post-detox that, despite agreeing pre-detox to be interviewed for this story only hours after his procedure, it turned out to be a week before he was up to such a discussion. When he is though, he speaks thankfully about being straight and hopefully about his post-detox naltrexone. Yet, like so many addicts, its the therapy portion of Neals aftercare regimen - his emphasis is on the 12-step Narcotics Anonymous program - that he believes is central to his avoiding a relapse. I feel fortunate that I got clean so quickly this time, but I dont think thats going to make it easier to stay clean, he says. I think the meetings are really the most important part of recovery. You need others help to maintain when you are used to opening your eyes in the morning and the first thing on your mind is I got have that wake-up. And this time I dont have nothing to go back to - except maybe death. FOX News Network 1997. All Rights Reserved

http://www.hivpositive.com/f-NewsLine/f-ManufacturersNews/m-Opiate-1209.html

Pharmaceutical Manufacturer Update One-Day Opiate-Dependency Treatment Gives Addicts The Holiday Gift Of A Renewed Life
MIAMI BEACH, Fla., December 9, 1996. With illegal drug use on the rise, and expected to be at an all-time high during this holiday season, CITA (Center for the Investigation & Treatment of Addiction) is introducing its pioneered Ultra Rapid Opiate Detoxification (UROD) treatment through its flagship center at Mount Sinai Medical Center in Miami Beach. "For most of us, the holidays signify a time of celebrating and spending time with loved ones, but for drug addicts, this time of year signifies an end to another year of hopelessness," said John Eustace, M.D., medical director of Mount Sinai's Fletcher Addiction Treatment program. "We want 1997 to be a year of beginnings and hope that this innovative treatment will bring the possibility of a clean new year to as many addicts as possible."

UROD, pioneered by CITA, is a one-day, opiate-dependency treatment that detoxifies users of heroin, methadone, pain killers and other opiates within six hours. According to David Yerushalmi, President and CEO of CITA, the patient experiences no painful withdrawal symptoms while under anesthesia and the procedure is 100% effective in ridding the body of all opiate traces. The program includes a medical and psychological assessment, a six-hour detoxification in a hospital, and a six-month aftercare program. "It's usually around the holidays when everyone, including addicts, begins thinking about their New Year's resolutions and how they are going to live out the next year," said Shannon Stellmacher, director of Mount Sinai's CITA program. "We hope that as many individuals as possible will take advantage of this proven drug rehabilitation program." CITA centers are located throughout Europe, the Middle East and the U.S. Presently, in the U.S., CITA has centers at Mount Sinai Medical Center and Metropolitan Hospital in New York. Treatment centers will be opening in Chicago and Los Angeles before the end of the year. The long term success of the program has been remarkable compared to traditional drug rehabilitation programs, said Eustace. In Europe, more than 4,000 patients have been treated with a long-term 73% success rate and in the Middle East, after a year and a half, 60% of the patients treated have successfully rehabilitated. For more information about the CITA method, contact Shannon Stellmacher or Michael Retto at Mount Sinai Medical Center, toll-free 888-212-CITA. The office is open Monday-Friday 8:00 AM - 6:00 PM.

In with the Good, out with the Bad: UROD cleanses the system of heroin in four hours, but what about the rest of your life?
By Aaron Howard (5-Dec-1997) http://www.publicnews.com/issues/733/cover.html)

The addict thinks: If I can detox quickly, all my problems will go away quickly. That's a kind of addict thinking. It's also an American way of dealing with life. People don't want to till the field. They just want to harvest the grain.-- Terry Rustin, Houston Recovery Campus Heroin and the other 'downs', natural and synthetic, are not polite. These drugs effectively eliminate the painful aspect of existence, which, nowadays, is almost all of it.'-- P.J. O'Rourke, Modern Manners

Heroin is hard to kick. It's the perfect addictive drug. A marshmallow euphoria the first time you take it. Heroin erases all of your worries. No more pain. But the high doesn't last. To get there again, you have to take more. And more. The euphoric feelings go away. Once you get strung out, the driving force is that if you don't take the heroin, you start to feel bad -- real bad. Nobody dies from coming off heroin, but it's a trip through hell. The pain is horrible. Think of the worse case of the flu you've ever had and multiply it tenfold: running nose, watery eyes, goose bumps, severe myalgia (muscle aches and pains), lethargy, severe diarrhea. No wonder that as soon as an addict gets a little of the sinking feeling, he or she gets frightened. So what if there was a treatment that let a person kick heroin in four hours without any pain? That's the promise of ultra-rapid opiate detoxification (UROD), an experimental treatment now being used at one location in New Jersey. In July, two more UROD centers are scheduled to open in New York and New Jersey. And UROD physician-providers are talking about expanding to Texas. UROD treatments work by putting the addict under a general anesthetic and giving him or her opiateantagonist drugs such as ReVia (naltrexone) or Narcan (naloxone). The opiate antagonists displace the opiates and allow the drugs to be flushed out of the body. Physical withdrawal happens under anesthesia. The person wakes up and can immediately begin work on the task of staying clean. Terry Rustin is an assistant professor in the UT-Houston Medical School's Department of Psychiatry and Behavioral Science and director of the clinical program at Houston Recovery Campus. As he explains, opiods, such as heroin, Percocet, codeine and methadone, attach to various binding sites (receptors) in the body. "Opiods attach to Mu receptors in the body. The ones in the brain give a feeling of euphoria. There are other Mu receptors. The ones in the bowel cause constipation," says Rustin. "In the process of the opiods coming off, the body reacts with withdrawal symptoms which are painful. Withdrawal is something akin to pulling off a Band-Aid: you can do it slowly or rapidly. Either you have a lot of pain for a short period of time or less pain over a long period." The standard today is outpatient methadone detoxification, which takes the heroin addict down by one milligram each week over months. It's done so slowly that the person doesn't notice a lot of difference from day to day. You can detox with methadone in less time, with real withdrawal symptoms. You can also detox without methadone. Inpatient detox treatment uses medications, like clonidine or guanabenz, that alleviate withdrawal symptoms of nausea, bone pain, sleeplessness and so on. UROD combines clonidine and an opiod antagonist (ReVia or Narcan) that knocks heroin off the receptor site and puts people into withdrawal. "That puts all the heroin into the circulation which goes out with the urine," says Rustin. "How fast do you want to do that? The ultra-rapid concept puts people under anesthesia and does it over an hour or so. It's not a magic dream but a way of taking heroin off the receptor sites quickly." The problem is, says Rustin, all you've done is detoxify the person. You still have to treat the addiction. "Let's say you are an addict who dropped out of school in the seventh grade. All you know how to do is sell drugs, steal TVs and take heroin. You get instantly detoxed. Did they give you a high school degree? A job? Did that patch up your marriage? You can get rapidly detoxed. But has it treated your addiction? The answer is no. UROD is simply a faster way to detox." Dr. Jim Flack, director of Chemical Dependency Services at Methodist Hospital, isn't taking a position on UROD right now. But if the treatment can provide a painless withdrawal, he says, it has potential. "Fear of withdrawal does perpetuate dependency," says Flack. "If ultra-rapid detox can be proven to be a less painful way of withdrawal for narcotic addicts, that would be clinically significant. "For the late-stage narcotic dependent patient, fear of the pain from withdrawal can be the single factor that continues their dependency. They are so overwhelmingly frightened of the pain of detox. But once they go through detox, they still have to struggle for the rest of their lives to stay sober and clean." One problem with UROD is that it puts a person under general anesthesia, a procedure which shouldn't be taken lightly. While nobody ever died undergoing traditional detoxification, anesthesia carries serious risks, including death. Of course, it can also be argued that the serious risks of heroin addiction are far more statistically significant than the risks of anesthesia. Then there is UROD's cost, between $2500 and $7500 at present, depending on what's included in the program. Methadone programs generally cost $50 a week. That raises the question: Who pays for most of the detox programs? Clients usually pay for methadone maintenance themselves. For those who need residential or hospital treatment, insurance will pay for a certain amount. If they have none, the public picks up the cost. "The ultra-rapid program would add a lot (to) insurance costs," says Rustin. "It's expensive since you have to pay for the anesthesiologist and operating room. Even if a program could be set up like a day surgery, most likely they'll keep the patient overnight because you've put a heroin addict into withdrawal. His first response is to go use more heroin." At present, people pay for UROD treatment out of their own pockets. As information is gathered through clinical trials, it is certain that providers will apply to have UROD paid for under insurance and Medicare/Medicaid funding. The providers will have to show that UROD

not only is cost effective but is successful on relapse rates as compared to cheaper treatments. The relapse rate from any heroin treatment is high. Depending on which study you use, between 80 and 90 percent of addicts go back to heroin within a year. That's why physicians, nurses, former addicts and people who counsel addicts agree: It's what you do after detox that is so important. Interestingly, according to Rustin, insurance companies have provided less and less funding for rehabilitation over the past 15 years. Meanwhile, the rate of heroin and amphetamine use are rising very significantly, especially in white suburban areas. The drug is currently very available. It also comes in a much more powerful strength than it did a generation ago, which allows it to be smoked and snorted as well as injected. Yesterday's portrait of the typical heroin addict as an inner-city seventh-grade dropout doesn't cover the middle-class kids who are becoming today's heroin addicts. Even if UROD does not become Medicare/Medicaid funded, it has a future if insurance companies pay for it. And a lot more middle-class white kids are still covered by insurance than are poor people of color. Flack sees UROD as a potentially useful tool if it gets people into long term treatment. "The question we need to ask is: If more addicts are detoxed, where do they go from there? What do you do about learning more about the disease of addiction? How do you educate family members? How you develop a relapse prevention program? How do you connect them with Narcotics Anonymous? Detox is typically the easiest part of our job and the easiest part of the treatment." If the goal is to get detoxed quicker, Rustin says that if UROD's costs are reasonable and the risks are small, there's no reason why rapid detox shouldn't be used. But he's suspicious of people who see UROD as a magical solution to the addiction problem. "Most of the public just wants the problem to be solved. But we really haven't found a fast, quick way to rehabilitate people," says Rustin. "The addict thinks: if I can detox quickly, all my problems will go away quickly. That's a kind of addict thinking. It's also an American way of dealing with life. People don't want to till the field. They just want to harvest the grain."

Ultra-Rapid Opiate Detoxification (UROD)

What does this treatment involve?

The addict is put to sleep using an I.V. (intravenous catheter) in an intensive care unit environment. He or she is monitored using sophisticated medical devices under strict approved medical standards. While unconscious (asleep) the patient (the addict) is given a medication called naltrexone which reverses the effects of heroin and causes a controlled withdrawal reaction. Because the patient is asleep, he or she does not experience the extremely unpleasant side effects of going through an awake withdrawal. Because withdrwawal is caused by medication given by a medical doctor, the doctor can carefully give right amount of medication to make the withdrawal reaction occur in a way which is safe and effective. This detoxification procedure typically lasts from 4 to 6 hours, during which time the patients is asleep. After the major withdrawal reaction has occured, the patient is allowed to wake up. (The sleep is also carefully controlled by a doctor who is an expert in anesthesiology). Upon awakening, the patient for all intent and purposes is detoxified.

How long does the treatment last?

After the procedure is carried out, the doctor writes a prescription for naltrexone pills which the patients takes orally, usually once a day at first, for the next few months. These pills have two important effects: one, they cause a decreased craving for narcotics, and; two, they tend to make the effects of heroin ineffective. Eventually, the pills are discontinud. The intensive rehabilitation treatment followed by oral pills have proven to be extremely effective. Seventy-five to eighty percent of addicts treated do not use heroin 6 months after the treatment according to published reports. 100% of patients are reported to effectively undergo the "sleep therapy" procedure.

Is the treatment safe?

All medications administered are FDA approved drugs. While no medical therapy can ever be declared to be 100% safe or without risk, there is ample evidence to suggest that relative to other medical treatments and procedures, this is a safe procedure.

Has this treatment been used before?

Naltrexone has been used to treat heroin and opiate addiction for a number of years. The one stumbling block has always been patients compliance. In other words, it was hard to get a heroin addict to go through the treatment while awake. Over 3500 patients have now been treated using naltrexone and "sleep therapy." Between 150 and 350 patients are currently treated each month.

http://people.delphi.com/sleepdr/PROD2.html PUGET SOUND RAPID OPIOID DETOXIFICATION CONSULTANTS, INC. P.S. Seattle, Washington PHONE: (206) 240-PROD (240-7763) VOICEMAIL/PAGER: (206) 559-PROD (559-7763) FAX: (206) 985-1317 e-MAIL ADDRESS: sleepdr@delphi.com Please call us today for a confidential consultation without obligation. Every call to PROD Consultants is answered by one of our physicians, who will be happy to spend as much time on the telephone with you as may be necessary to answer any questions to your satisfaction. FREQUENTLY ASKED QUESTIONS ABOUT RAPID OPIATE DETOXIFICATION UNDER GENERAL ANESTHESIA Copyright 1997, PROD Consultants, Inc. P.S., all rights reserved. We believe that it is in your best interest to be fully informed about the nature of our treatment procedures as well as the associated benefits and risks; therefore, we have provided this information here. This pages contains answers to the most commonly asked questions about rapid opiate detoxification under general Anesthesia. For more specific information about the treatment procedures used by PROD Consultants, please refer to the PROD homepage (http://people.delphi.com/sleepdr/PROD.html) WHAT IS RAPID OPIATE DETOXIFICATION UNDER GENERAL ANESTHESIA? WHICH OPIATE DRUGS IS THE TREATMENT USEFUL FOR? HOW DOES THIS TREATMENT COMPARE WITH OTHER OPIATE DETOXIFICATION PROCEDURES? HOW DOES RAPID OPIATE DETOXIFICATION HELP THE PATIENT IN THE LONG RUN? WHAT ARE THE RISKS AND SIDE-EFFECTS OF RAPID OPIATE DETOXIFICATION? WHAT ARE THE RISKS AND SIDE EFFECTS OF NALTREXONE MAINTENANCE THERAPY?

THIS PROCEDURE SEEMS TOO NEW, AND SOUNDS TOO GOOD TO BE TRUE! IS THERE ANY EVIDENCE THAT IT IS SAFE AND EFFECTIVE? ARE THERE ANY PATIENTS FOR WHOM RAPID OPIATE DETOXIFICATION IS NOT APPROPRIATE? WHAT AFTERCARE PROGRAMS ARE AVAILABLE? THE COST OF THIS TREATMENT SEEMS QUITE HIGH. HOW DOES IT COMPARE TO THE COST OF OTHER DETOXIFICATION TREATMENTS? DOES MEDICAL INSURANCE COVER THE COST OF RAPID OPIATE DETOXIFICATION?

WHAT IS RAPID OPIATE DETOXIFICATION UNDER GENERAL ANESTHESIA? This is a procedure in which people who are dependent on opiate drugs are put to sleep with anesthesia (as though they were going to have surgery) and are given very large doses of opiate reversal drugs (antagonists, or antidotes). The opiate antagonists cause immediate onset of opiate detoxification by removing the opiate drugs from the sites in the brain where they produce their effects. Because the patient is anesthetized, very large doses of the antagonists can be given to rapidly displace opiate drugs, which greatly accelerates the detoxification process so that it lasts only a few hours. Also because the patient is anesthetized, the symptoms of opiate withdrawal are not experienced. When the patient is awakened from the anesthesia after a few hours, the detoxification process has been essentially completed. Rapid detoxification effectively and efficiently terminates the physical aspect of opiate dependence in a matter of hours. An aftercare program to address the psychological aspects of opiate dependence, and maintenance treatment with naltrexone to prevent relapse to opiate abuse, are strongly recommended. Rapid detoxification is not, in and of itself, a "magic cure" for opiate addiction. WHICH OPIATE DRUGS IS THE TREATMENT USEFUL FOR? Rapid opiate detoxification is effective for detoxification from all opiate narcotic drugs, including heroin, methadone (Dolophine), Orlaam, and all prescription opiates, such as morphine, codeine, meperidine (Demerol), hydromorphone (Dilaudid), fentanyl (Sublimaze), sufentanil (Sufenta), alfentanil (Alfenta), remifentanil, propoxyphene (Darvon), levorphanol (Levo-Dromoran), hydrocodone (Lorcet, Lortab, Vicodin), oxycodone (Percocet, Percodan, Tylox, OxyContin, Roxicodone), oxymorphone (Numorphan), tramadol (Ultram), buprenorphine (Buprenex, Subutex), butorphanol (Stadol), nalbuphine (Nubain), and pentazocine (Talwin). The treatment is not useful for dependence on drugs from classes other than the opiate narcotics (i.e., cocaine, amphetamines, benzodiazepines,marijuana, alcohol). However, people who are dependent on opiates as well as other drugs may still have their opiate addiction treated with rapid detoxification. This would require careful consideration by the treating physicians in order to assure that the usage of the other drugs does not unduly put the patient at risk for rapid opiate detoxification. It is important, therefore, that the patient discuss these issues with our physicians. HOW DOES THIS TREATMENT COMPARE WITH OTHER OPIATE DETOXIFICATION PROCEDURES? Rapid opiate detoxification occurs much more quickly than awake opiate detoxification (requiring only a few hours rather than several days or even weeks). Withdrawal symptoms are not experienced during rapid opiate detoxification. Rapid opiate detoxification guarantees a 100% rate of successful detoxification. Obviously, when you are asleep with anesthesia, it is not possible to give up, quit, or start using opiates during the detoxification process. Most people who attempt awake opiate detoxification fail to achieve detoxification because of the overwhelming desire to start using opiates again to terminate withdrawal symptoms. HOW DOES RAPID OPIATE DETOXIFICATION HELP THE PATIENT IN THE LONG RUN? During rapid opiate detoxification, the patient is given an initial dose of ReVia (naltrexone), an opiate blocking drug. After awakening, the patient can immediately tolerate full opiate-blocking doses of naltrexone. With awake detoxifications, the patient must wait 7 to 10 days before they can tolerate naltrexone without producing withdrawal symptoms. Thus, another benefit of rapid opiate detoxification is that the patient is immediately prepared for a long-term treatment program only a few hours after beginning detoxification. Naltrexone should be taken regularly for at least several months after any opiate detoxification to prevent relapse. It does this in two ways: 1) naltrexone blocks the craving to use opiates, and 2) naltrexone completely blocks any effects that opiates would produce if the patient tries to use opiates again while taking naltrexone. (This is not like Antabuse, which makes people feel quite ill if they drink alcohol while taking it; there will be no effect whatsoever produced by opiates that are taken while the patient is on naltrexone.) Thus, naltrexone provides an insurance policy to prevent relapse. WHAT ARE THE RISKS AND SIDE-EFFECTS OF RAPID OPIATE DETOXIFICATION? The only significant risk of the procedure is the risk of undergoing general anesthesia. In patients who have no other serious medical problems, the risk of general anesthesia is extremely low (you are more likely to get in a serious automobile accident on your way to the treatment facility than to suffer a major mishap from anesthesia), provided that the highest current standards of care are used in administering the anesthetic. The most recent studies suggest that the incidence of mortality arising from anesthesia is less than 1 in 220,000. PROD Consultants uses exclusively board-certified anesthesiologists (physicians) to administer its treatment procedures. All of the standards of the American Society of Anesthesiologists for the administration of anesthesia are strictly adhered to, and we employ state-of-the-art anesthetizing and monitoring equipment and techniques. After the treatment, patients are not discharged from the treatment facility until it is clear that it is no longer necessary for them to remain under continuous observation by medical personnel. If it is necessary for a patient to stay overnight until this is the case, PROD Consultants will allow this at no additional charge. After the rapid detoxification procedure, it is likely that patients will experience mild withdrawal-like symptoms that may last a few days. These are much less severe than the symptoms that patients experience during awake opiate detoxification. Most commonly, patients feel very tired for a few days after rapid detoxification, and yet have difficulty getting restful sleep. Appetite may be diminished as well. Other withdrawal symptoms, such as nausea and vomiting, diarrhea, anxiety, and restlessness occur less frequently. If these mild withdrawal symptoms are present, they are a residual effect of the initial detoxification process; taking more naltrexone at this point, as prescribed, will be unlikely to cause an increase in these symptoms. We will provide the patient with prescriptions for medications to manage any of these symptoms that might occur, and will be available by telephone at all times during the first 72 hours after treatment. We also request that a support person be available to stay with the patient during the first 48 hours after treatment. Many of our patients are able to return to work a few days after rapid opiate detoxification. WHAT ARE THE RISKS AND SIDE EFFECTS OF NALTREXONE MAINTENANCE THERAPY? There are two issues which all patients who undergo long-term therapy with naltrexone need to be aware of. First, since this drug blocks all of the effects of opiate drugs, it would be difficult to use opiates to treat a new painful condition that might arise in a patient taking naltrexone. However, if the naltrexone is stopped, the opiate-blocking effect will wear off in a few days, and opiates can then be used effectively to treat pain. In the meantime, alternative means to treat pain may need to be used. Secondly, when taking naltrexone, a patient can become sensitized to the effects of opiate drugs. Thus, if naltrexone is stopped there is a period of time after it wears off that the patient is likely to experience exaggerated effects of opiates. What this means is that a patient who stops using naltrexone and reverts to opiate use

is at risk to suffer potentially serious side-effects from a dose of an opiate which, prior to the detoxification process, merely produced a mild effect. This risk period would not be permanent, but would likely dissipate over a few days to a few weeks. Naltrexone is a drug that has remarkably few side-effects. Naltrexone therapy, at doses five-times greater than those prescribed to prevent opiate relapse, has been found to produce changes in laboratory tests that suggest mild liver dysfunction. These changes were completely reversed when the administration of these high doses of naltrexone was stopped. Similar changes in these laboratory tests were not seen in patients who took naltrexone chronically at doses used to prevent relapse (up to 50 mg per day). However, patients who have a history of pre-existing liver dysfunction should beginnaltrexone maintenance therapy only under the careful supervision of a physician, and periodic monitoring of laboratory tests that detect liver dysfunction should be considered. At very high doses in pregnant laboratory animals, naltrexone has been found to be harmful to developing fetuses. It is unknown whether naltrexone is excreted in breast milk, as many drugs are. Therefore, the use of naltrexone in pregnancy, in women who intend to become pregnant, or in nursing mothers should be considered only when the potential benefits justify the potential risks. THIS PROCEDURE SEEMS TOO NEW, AND SOUNDS TOO GOOD TO BE TRUE! IS THERE ANY EVIDENCE THAT IT IS SAFE AND EFFECTIVE? Rapid opiate detoxification has been available since the late 1980's. This procedure represents the state-of-the-art in advances to treat opiate dependence that have occurred over the past 20 years or so. It has long been known that giving opiate addicts sedative medications allows them to tolerate opiate antagonist drugs and thus accelerate the detoxification process. If very high doses of sedative drugs are given for this, the patient is at risk of becoming excessively sedated and may lose the ability to protect themselves from inhaling stomach contents that might be regurgitated as a result of the nausea and vomiting that frequently occur during opiate withdrawal. The maximum possible protection from this serious, and potentially fatal, complication is provided during rapid opiate detoxification, because a breathing tube is inserted through the mouth and into the lungs right after the patient goes to sleep with the anesthesia. (The breathing tube is removed as the patient is awakened at the end of the treatment, so that they usually have no awareness that it was ever in place.) A formal general anesthetic also permits the fastest possible detoxification by allowing the highest possible doses of opiate antagonist drugs to be given without significant psychological or physiological disturbances. Worldwide, tens of thousands of patients have undergone this treatment procedure. There are, unfortunately, very few detailed reports of long-term outcomes. Several treatment centers have described, in general terms, very favorable results. The few well-described results that have been published tend to support this. For instance, one study of 510 patients treated with rapid opiate detoxification under general anesthesia reported no serious side-effects or complications of the anesthetic in any of the patients. Some of these patients were followed with regular urine tests to detect relapse during 4 months while they continued to take naltrexone. Of the patients followed, 96% remained free of opiates for the entire follow-up period. These excellent results are not surprising. Patients that achieve opiate detoxification by any means and remain on long-term naltrexone therapy have a similar high rate of long-term abstinence. The difference with rapid detoxification is that all patients who undergo this treatment successfully achieve detoxification and are able to immediately begin naltrexone therapy, whereas most patients who attempt awake opiate detoxification are not. Once detoxification is achieved, the likelihood of remaining drug-free is increased by continuing with naltrexone maintenance the therapy and with counseling. ARE THERE ANY PATIENTS FOR WHOM RAPID OPIATE DETOXIFICATION IS NOT APPROPRIATE? Potentially, all patients who are dependent on opiate drugs can benefit from rapid opiate detoxification. However, if the patient has other significant medical problems, it is possible that the risk of general anesthesia might be too high in them to justify this treatment. Our physicians will review the patient's medical history and perform a physical examination prior to treatment to assure the safest possible anesthetic course. Also, we believe that it is inaccurate to characterize rapid detoxification as a "quick fix" for the serious problem of opiate addiction. We are dedicated to offering our treatment procedures in the context of a comprehensive approach to addictive disorders. Therefore, we will assist you in obtaining the necessary tools to maximize the likelihood of remaining drug-free once detoxification is achieved. Patients who will not agree to a medical and psychosocial follow-up plan afterwards, including regular use of naltrexone, will not be treated by PROD Consultants. We have several different avenues for aftercare available, and can tailor them to fit most individual patient needs. Patients who insist that all they need is to be detoxified and will not need to participate in aftercare will not be treated. Patients who are coerced to undergo rapid opiate detoxification by someone else and are not willing participants in the process will also not be treated. Finally, if a patient is dependent on an opiate drug that they are also using to treat an underlying pain problem, it will be necessary to establish alternative means of pain management before performing rapid opiate detoxification. WHAT AFTERCARE PROGRAMS ARE AVAILABLE? PROD Consultants is affiliated with several inpatient and outpatient substance abuse centers and Addiction Medicine specialists in the Pacific Northwest and across North America. Patients who are referred to us from one of these individuals or facilities may be returned to the referring agency after detoxification treatment for follow-up care. PROD Consultants can also provide follow-up care, which would have two major components. Medical aftercare consists of supervision of naltrexone maintenance therapy, and requires monthly appointments to meet with one of our physicians, who would also be available by telephone at any time during regular business hours throughout the followup period. Our psychosocial aftercare consists of several components, including an initial interview, individual counseling, group counseling, and counselor accessibility. An intake appointment with our counselor is scheduled prior to the detoxification treatment. During this intake, the patient meets the counselor and we collect information about the patient and discuss the recovery process. At that time, our counselor sets up weekly individual counseling sessions to begin after detoxification. We also offer group counseling twice a week for several months. One of these weekly sessions is a process group where we discuss each persons progress, changes, and problems. Those further along in their recovery often give suggestions to the newer members. The other group is focused on a weekly topic, such as loss and grief issues, reuniting and healing with families, and developing new non-drug activities. Since there is a wide variety of causes and situations that lead to opiate addiction, the groups are flexible and are often guided by the participants. The final aspect of our aftercare program is the availability of our counselor. Initially during the first week following detoxification, we like to make telephone contact once a day. For the entire duration of the aftercare program, the counselor is available by telephone at any time during regular business hours. For individuals who live distant from Seattle, the counselor will have telephone contact on a weekly basis. PROD Consultants can assist those who live far from Seattle in establishing aspects of their aftercare program, which may include support group meetings (such as Narcotics Anonymous), ongoing support from family and friends, and involvement in drug-free activities. Such patients also must establish medical follow-up with a physician in their community who is comfortable with supervising naltrexone maintenance therapy. THE COST OF THIS TREATMENT SEEMS QUITE HIGH. HOW DOES IT COMPARE TO THE COST OF OTHER DETOXIFICATION TREATMENTS? We are continuously striving to keep the fees for our treatment procedures as low as possible so that the greatest number of patients may benefit. Acute high-tech medical care of the sort we provide has become very expensive, and our costs to provide this care constitute the greatest portion of our fees. The costs of other forms of detoxification vary widely. Cold turkey detoxification is essentially free of all financial costs. Medically-managed awake detoxification can cost a few hundred dollars if done as an outpatient, or up to several thousand

dollars if done as an inpatient (for instance, some recovery centers in the Seattle area charge as much as $500 per day for an inpatient opiate detoxification, which can last up to 7 to 10 days). It is important, however, to examine all the costs of a given treatment in the context of the benefits which that treatment provides. Everyone who attempts cold turkey or awake, medically-managed detoxification invests considerable time in the effort, experiences significant discomfort from withdrawal symptoms, and may be at high risk for complications resulting from excessive sedation in the absence of a protected airway. More importantly, most people fail in their attempt to acheive detoxification in this fashion. In contrast, every single person who undergoes rapid opiate detoxification under general anesthesia successfully achieves detoxification and begins naltrexone therapy, with minimal discomfort or risk involved. Rapid opiate detoxification is a humane alternative to other detoxification methods, and is extremely efficient with regard to the use of medical resources, time, and money. We understand that, despite our efforts to keep our costs as low as possible, the nature of opiate addiction may make it difficult for many people who desire and would benefit from our treatment procedures to find a way to pay for them. In these cases, we can suggest options for long-term financing of our treatment fees which would enable you to make payments over an extended period of time after detoxification has been achieved. DOES MEDICAL INSURANCE COVER THE COST OF RAPID OPIATE DETOXIFICATION? In our experience, most medical insurers are unfamiliar with this new treatment procedure, and therefore may not pay for it. However, some patients have been able to obtain coverage from their insurers to pay for rapid opiate detoxification. As you might expect, this often requires a fair amount of effort and persistence. If your insurer agrees to pay for this treatment, we will accept their payment. We will also answer any questions your insurer might have about our treatment procedures. Many medical insurance policies do include coverage for chemical dependency treatment. In the context of rapid opiate detoxification, that coverage may be used to help pay for medical and psychosocial follow-up care. In addition, the cost of naltrexone prescriptions may also be covered by medical insurance. You may wish to discuss these issues with your insurance provider. The copyright for this material is held by PROD Consultants, Inc. P.S., and it may be reproduced only with our permission; all rights reserved. For more specific information about the treatment procedures used by PROD Consultants, please refer to the PROD homepage (click here). You can also read the text of an article about our clinic (click here) that recently appeared in a Seattle-area weekly newspaper. PUGET SOUND RAPID OPIOID DETOXIFICATION CONSULTANTS, INC. P.S. Seattle, Washington PHONE: (206) 240-PROD (240-7763) VOICEMAIL/PAGER: (206) 559-PROD (559-7763) e-MAIL ADDRESS: sleepdr@delphi.com (click here to send us e-mail) FAX: (206) 985-1317 Read newspaper article about PROD

Drogenentzug - (k)eine Hexerei? UROD - ultraschneller Entzug (in Erprobung) source: http://www.deutsches-gesundheitsforum.de/themenforum/therapie/0109/0109.html "Rckfall"- ein Synonym fr Drogenentzug? Die mit der Entgiftung verbundenen schweren Entzugserscheinungen fhrenselbst in stationrer Behandlung bei rund 35 % der Patienten zu einemvorzeitigen Abbruch, bei ambulanter sind es bis zu 80 %! Warum dies so ist,hngt mit dem Nervensystem des Abhngigen zusammen: der Krperproduziert unter anderem auch Substanzen fr Anregung und Beruhigung.Beruhiger (z. B. Endorphine) und Anreger (Adrenalin) suchen bestndignach Gleichgewicht. Im Gehirn arbeiten Rezeptoren fr den Empfang derjeweiligen Substanzen. Opiate wie Heroin, Methadon oder Kodein ersetzendiese natrlichen Stoffe. Deshalb stellen sich die Rezeptoren auf dieZufuhr von auen ein, mit der Folge, da nur jene in Funktionbleiben, die Opiate weiter verarbeiten. Die restlichen selbst produzierendenZellen verkmmern immer mehr. Der Organismus versucht, weiterhin einGleichgewicht zwischen Anregern und Beruhigern herzustellen und steigertseine Adrenalinproduktion. Daher auch der wachsende Konsumbedarf des Drogenschtigen.Er braucht immer mehr Opiate, um das Gleichgewicht zu halten. Wird nun die Opiatenzufuhr gestoppt, kommt es zu schmerzvollen Entzugserscheinungen,weil die Anregerproduktion ihre Zeit braucht, um sich darauf einzustellenund der Organismus nicht mehr im Gleichgewicht steht. Der Schtigeleidet unter Erbrechen, Durchfall und Nervositt, an Muskelkrmpfenund Suchtdruck. Bis jetzt mute jeder Schtige diese Entzugserscheinungendurchleiden, um nachher geschwcht und von Suchtdruck geplagt den Neuanfangzu starten. Jetzt gibt es eine vielversprechendeAlternative: UROD UROD ist die Abkrzung von "Ultra Rapid Opiate Detoxification"und bedeutet ultraschneller Opiateentzug. Entwickelt wurde diese Methodevon CITA Spanien (Centro de Investigaciones y Tratamiento de las Adicciones")in Madrid, einem Zentrum zur Erforschung und Behandlung von Drogenabhngigen.Nach "UROD" werden alle Opiatabhngigen behandelt; dazu zhlenOpium, Heroin, Morphium, Kodein und Methadon. Was ist das besondere an dieser Methode? CITA's UROD ist eine aktiveEntzugstechnik, die den Abhngigen nicht nur in einen opiatfreien Zustandversetzt, sondern der Sucht auf der Ebene der vorher beschriebenen Rezeptorenwirksam begegnet. Dazu wird der Patient auf einer Intensivstation frsechs Stunden in eine tiefe Beruhigung (Narkose) versetzt, um das krperlicheUnwohlsein zu eliminieren. Gleichzeitig werden Medikamente eingesetzt. Das Ergebnis? Der Patient macht keinerlei Entzugserscheinungen durchund es wird eine beschleunigte, vllige Entgiftung erreicht: Sie lschtdie krperliche Abhngigkeit, setzt das Verlangen nach Drogenradikal herab und erreicht eine Abbruchrate von 0 % (Null Prozent)! Diebesten Voraussetzungen fr eine erfolgreiche, dauerhafte Rehabilitation. UROD :Clean sein und clean bleiben! Nach sechs Stunden erwachen die Patienten aus der Narkose, frei von Entzugserscheinungenund ohne Verlangen von Opiaten. Sie bleiben mindestens fr eine Nachtzur Beobachtung im Krankenhaus. Am nchsten Morgen erfolgen psychiatrischeund medizinische Untersuchungen. Meist kann die Entlassung nach zwei bisdrei Tagen erfolgen. Dies ist eine empfehlenswerte, fr Patienten unddessen Familie untersttzende Nachfolgezeit, in der Beratungsdienstehelfend zur Seite stehen. Der Patient kann also innerhalb weniger Tage nachHause und an seinen Arbeitsplatz zurckkehren.

Es schliet sich eine neunmonatige Therapie mit dem Wirkstoff Naltrexonean. Dies ist kein Ersatz fr Heroin oder andere Opiate und fhrtzu keiner (neuen) Abhngigkeit. Naltrexone blockiert die Opiatrezeptorendes zentralen Nervensystems; sie knnen sich wieder erholen. Bei erneutemDrogenkonsum wird kein euphorisches Hochgefhl erzeugt. Nach sechs Monaten UROD-Therapie waren 73 % "clean" und dieEingliederung in Familienleben sowie soziale Umgebung machte erheblicheFortschritte. UROD :Team und Konzept Der eigentliche Entzugsprozess fr jeweils vier Patienten erforderteinen Arzt (Ansthesisten) sowie Schwestern der Intensivstation undzwei Nachtschwestern fr die Nachbehandlung. Eine Person wird frAufnahme und Entlassung, ein Arzt fr die krperliche Untersuchungwhrend der Vor- und Nachbehandlung bentigt. Blutuntersuchungen,Urinanalyse, EKG und andere Tests knnen ambulant erfolgen. Ein Psychologefhrt die Aufnahmegesprche und ist fr die Nachfolgetherapiezustndig. Alle Teammitglieder werden speziell fr die UROD-Methodeausgebildet. Selbst Patienten mit Hepatitis-C und AIDS knnen behandelt werden.Obwohl UROD bei einer Abhngigkeit von Kokain, Alkohol, Benzodiazepinund Nikotin nicht wirksam ist, kann das Verfahren solchen Patienten helfen,die andere Drogen mit Opiaten mischen. Die Behandlung beginnt am Morgen mit einer medizinischen und psychotherapeutischbegleitenden Untersuchung. Dieser medizinische Check-up mit eingehendenBlutuntersuchungen liefert die Daten fr die Zusammensetzung der Medikamente,die auf die individuelle Situation der Patienten abgestimmt werden. Anschlieendwird der Patient auf die Intensivstation berwiesen. CITA-UROD auch in Deutschland? Nicht nur die Erfolge, sondern auch die Kosten sprechen fr dieseneue Methode: Wie bereits erwhnt, knnen die Patienten nach zweibis drei Tagen wieder nach Hause und an ihre Arbeitsstelle. Dies fhrteinerseits zu volkswirtschaftlichen Vorteilen, andererseits macht es auchdie Behandlung selbst billiger. Whrend eine herkmmliche Entgiftungohne die Kosten einer stationren Entziehung zwischen 16.000 und 20.000DM kostet, werden fr die UROD-Behandlung zwischen 10.000 und 12.000DM veranschlagt. Die Ersparnis fr Kranken- und Rentenversicherungstrgerergibt sich auch aus der verkrzten Arbeitsunfhigkeit und derweitaus geringeren Rckfallquote. Weil die URODMethode bisher in Deutschland nicht formell evaluiert wurde,sollten alle Zentren verpflichtet werden, Begleitfragebgen und Folgedatenzentral im Universittsklinikum Charit Berlin zusammenlaufenzu lassen. Dann knnte nach etwa drei bis fnf Jahren die Effektivittdieser Methode gegenber herkmmlichen Entzugsverfahren etabliertwerden. Gebr. Geiselberger Medien Gesellschaft mbH

Drogenentzug in Narkose source: http://www.fbklinik.de/drogen.htm Der vorliegende Aufklrungsbogen soll Sie eingehend ber die geplante Detoxikationsmanahme informieren. Er wird Ihnen helfen, sich auf das Gesprch mit dem Ansthesisten / Ansthesistin vorzubereiten. Sie werden ber Vor- und Nachteile sowie ber Risiken und Nebenwirkungen eingehend aufgeklrt. Sie haben die FELDERBACH-KLINIK wegen einer bestehenden Drogenabhngigkeit aufgesucht. Die Erkenntnis, da die Drogenabhngigkeit Sie seelisch und krperlich zerstrt, Ihre familiren Beziehungen erschttert und Ihre wirtschaftliche Existenz vernichtet, hat zu dem Entschlu gefhrt, von der Sucht loszukommen und ein neues Leben zu beginnen. Sie wissen, da der konventionelle Drogenentzug ("kalter Entzug") ein langwieriger Proze ist. Der Krper, der an Drogen gewhnt ist, stellt sich nur sehr zgernd auf die Abstinenz ein. Im Entzug wird ein Zustand durchlaufen, der einer schweren Erkrankung hnlich ist und der mit qulenden Begleiterscheinungen einhergeht. Als Alternative zum herkmmlichen Drogenentzug wird seit einigen Jahren ein neues Entzugsverfahren unter dem Namen UROD (Ultra Rapid Opiate Detoxification = Drogenschnellentzug) angewandt. Das Wesen der. Methode besteht in einer erheblichen Verkrzung der Entgiftungsphase auf einen Zeitraum von 8 bis 12 Stunden. Allerdings durchluft Ihr Organismus in dieser Zeit die gleichen Stadien, die sich beim "kalten Entzug" ber Wochen hinziehen. Dies bedeutet eine erhebliche Verstrkung der Entzugssymptomatik mit extremen krperlichen Belastungen, die ohne entsprechende Gegenmanahmen lebensgefhrlich wren. Deshalb fhren wir diese Behandlung auf einer Intensivstation durch und versetzen Sie in Tiefschlaf (Narkose). Die Narkose wird nach Verabreichung von Beruhigungsmitteln (Prmedikation) mit dem Einspritzen eines schnell wirkenden Schlafmittels begonnen und durch die kontinuierliche Gabe eines Narkotikums bis zum Ende der Detoxikations- manahme fortgefhrt. Das Narkosemittel wird ber eine Vene infundiert. ber einen. zweiten Venenzugang erhalten Sie ein Gemisch von Medikamenten, das Ihre Nervenzellen von Drogenmoleklen reinigt und wieder in den ursprnglichen Zustand versetzt. Whrend der Detoxikationsmanahme werden alle wichtigen Organfunktionen Ihres Krpers wie Puls, Blutdruck, Atmung, EKG, Sauerstoffgehalt des Blutes und Urinausscheidung berwacht. Dazu ist die Kanlierung einer Unterarmvene, die Einfhrung eines Magenschlauchs und die Installation eines Harnblasenkatheters notwendig. Um die kontinuierliche Freihaltung der Atemwege zu sichern und um zu verhindern, da Erbrochenes in die Lungen gelangt, wird ein Schlauch ber den Mund in die Luftrhre eingefhrt, durch den Sie selbst atmen. In Ausnahmefllen kann ber diesen Schlauch eine maschinelle Beatmung durchgefhrt werden. Da kein medizinischer Eingriff vllig frei von Risiken ist, mssen mgliche Nebenwikungen Erwhnung finden. Mgliche Nebenwirkungen und Risiken der Detoxikation in Narkose sind: Blutergsse und Infektionen im Bereich der Einstichstellen von Kanlen und Kathetern, Entzndungen der punktierten Gefe. belkeit, Erbrechen, bertritt von Mageninhalt in die Lunge und Entwicklung einer Lungenentzndung (besonders bei Nichtbeachtung des Nchternheitsgebots!) Schden an Zhnen und Zahnersatz (besonders bei lockeren Zhnen und Paradontose) durch die Intubation Schluckbeschwerden, Heiserkeit und Stimmbandschden durch die Einfhrung. des Beatmungsschlauches in die Luftrhre (Intubation) allergische Reaktionen auf die verwendeten Medikamente (Hautausschlag, Juckreiz, Kreislaufstrungen bis hin zum Kreislaufversagen und Atemstillstand) Strungen der Magen-Darm-Funktion (Krmpfe, Blutungen)

Grundstzlich sind die genannten Nebenwirkungen und Komplikationen jedoch uerst selten und knnen durch die ununterbrochene berwachung der Krperfunktionen sofort erkannt und behandelt werden. Acht bis zwlf Stunden nach Behandlungsbeginn werden Sie wieder erwachen. Sie werden sich unter Umstnden noch unwohl fhlen, aber ein Drang zu Drogen wird nicht mehr bestehen. Im Anschlu an Ihren Aufenthalt in der Intensivmedizinischen Abteilung werden Sie in der Psychiatrischen Klinik je nach Ihrer psychischen und physischen Befindlichkeit weiterbetreut, um damit einen unkomplizierten bergang in eine vorab von Ihnen zu organisierende psychosoziale Nachbetreuung zu gewhrleisten. Damit gemeint sind Langzeittherapien, gesprchstherapeutische Einzel- oder Gruppen- behandlungen, der regelmige Besuch von Selbsthilfegruppen oder andere Formen der therapeutischen Nachbetreuung. Ihr ambulanter Arzt wird Ihnen dabei

hilfreich zur Seite stehen, Sie bei einer nicht auszuschlieenden weiteren Suchtgefhrdung flankierend untersttzen und Sie dazu mit einem Medikament versorgen, das Sie ber einen lngeren Zeitraum einnehmen mssen. Es handelt sich dabei um Naltrexon (Nemexin), welches Sie als Tablette erhalten werden. Das Medikament untersttzt eine anhaltende Unterdrckung der Sucht. Die Erfahrungen mit der URODMethode hinsichtlich der Beendigung der Drogenabhngigkeit sind gut, eine dauerhafte Abstinenz knnen Sie jedoch nur erreichen, wenn Sie im Anschlu daran mit professioneller Hilfe eine tiefergrndige Bearbeitung der zur Sucht fhrenden Ursachen durchfhren. Mit allen Fragen und Problemen wenden Sie sich bitte in der Nachbehandlungsphase an Ihren betreuenden Arzt, der durch uns umfassend ber die Detoxikationsmanahmen informiert wird bzw. an eine der bekannten Drogenberatungsstellen. Ich willige ein, da die Therapie in Narkose ausgefhrt wird. Ich willige weiter in die vorbereitende und begleitende ansthesiologische Behandlung einschlielich der dazu erforderlichen Nebeneingriffe (z.B. Blasenverweilkatheter, Magensonde, zentraler Venenkatheter, etc.) ein. Mit medizinisch angezeigten nderungen und Erweiterungen bin ich einverstanden. Felderbach-Klinik FBKlinik@AOL.com Copyright 1997 Felderbach-Klinik Wuppertal 27.06.1997

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Afkicken onder narcose: Canard of waardevolle aanvulling?

G.H.A. van Brussel, Hoofd Drugsafdeling GG&GD Drs. A.F.W. Kok , Inspecteur voor de Verslavingszorg Amsterdam/ Rijswijk, 1997
http://zorgstad.amsterdam.nl/gemeente/gggd/naltrex.htm Inhoud 1.Inleiding 2.De methode: afkicken onder narcose 3.Literatuur over Naltrexon en Clonidine 4.Wat is er nieuw aan de methode Legarda? 1. Inleiding In het afgelopen jaar is in de pers veel aandacht besteed aan een nieuwe behandelmethode van herone-verslaving ontwikkeld door dokter Legarda, verbonden aan CITA, een internationaal centrum voor onderzoek en behandeling van drugsverslaving, oorspronkelijk gevestigd in Spanje en Isral. Inmiddels zijn er vestigingen in de U.S.A., Itali en Engeland. Vele honderden clinten zouden met succes door CITA behandeld zijn. In de krant en op televisie werd en wordt de methode gebracht als een zeer effectieve behandeling, ook bij die drugsclinten waarbij alles is mislukt. Gelet op het gegeven dat Nederland/Amsterdam een niet onaanzienlijk drugsprobleem heeft, verzocht de wethouder MGZ, mevrouw Van der Giessen, de GG&GD om een rapportage m.b.t. deze nieuwe behandeling en het al dan niet bruikbaar zijn van deze methode voor de Amsterdamse situatie. Ook werden Kamervragen over het onderwerp gesteld. In het daarop volgende onderzoek is door de Geneeskundige Dienst samengewerkt met de Hoofdinspectie voor de Gezondheidszorg. In deze rapportage wordt ingegaan op datgene wat er bekend is van de bedoelde behandeling. Tevens wordt gepoogd de behandelmethode te plaatsen binnen bestaande drugshulpinterventies zoals die in Amsterdam (Nederland) gebruikelijk zijn. Een probleem bij het verzamelen van informatie bleek dat er door CITA niets is gepubliceerd in de gangbare wetenschappelijke tijdschriften. De methode van de combinatie van opiaat antagonisten als Naloxon/Naltrexon met sedatie c.q. anesthesie met behulp van respectievelijk Midazolam dan wel barbituraten blijkt overigens door Loimer beschreven te zijn in 1989 (1) en in 1991 (2). CITA claimt de behandeling, beschreven door Legarda in 1994 (3), die overigens een sterke gelijkenis vertoont met die van Loimer, verfijnd te hebben. Het behandelrecept wordt in de volgende paragraaf samengevat. Van de zijde van CITA is dit protocol recent nader verfijnd in een concept-publicatie d.d. 1996 (4). Voor het overige is de informatie beperkt tot folders en mondelinge mededelingen van CITA-medewerkers, waaronder collega Ovaa, anesthesist en medisch directeur van CITA Nederland, die overigens coperatief op de vele vragen reageerden. In verband met het ontbreken van wetenschappelijke documentatie, is een sessie georganiseerd waarbij in aanwezigheid van CITA-medewerkers door ondergetekenden gesproken kon worden met een aantal (n=4) Nederlandse clinten die de behandeling hadden ondergaan. Drie van hen waren nog in nazorg. Tevens werd veel inzicht verkregen tijdens een symposium in Londen d.d. 6 september 1996, georganiseerd door "The Stapleford Centre", een privkliniek die deze behandeling aanbiedt, eveneens tegen forse tarieven. Zie bijlage voor een korte beschrijving. In deze notitie wordt achtereenvolgens ingegaan op de volgende punten: afkicken onder narcose, het behandelrecept literatuur over met Naltrexon geforceerde detox en de daarop volgende onderhoudstherapie wat is er nieuw aan de methode? effectiviteit en plaats van de behandeling in het spectrum van de verslavingszorg. 2. De methode: afkicken onder narcose Bij deze methode, voor het eerst beschreven door Loimer in 1989, in 1994 door Legarda en Gossop aangepast en beschreven in het tijdschrift Alcohol and Drug Dependence, gaat het erom heronepatinten onder narcose te brengen. Daartoe worden anesthetica als kortwerkende barbituraten en ook wel roesbenzodiazepines als Dormicum (Midazolam) gebruikt. Tijdens deze anesthesie/diepe sedatie wordt betrokken clint behandeld met Nalexon dan wel Naltrexon, het tegengif voor herone en overige opiaten, in hoge doseringen. Deze stoffen verdringen herone van de specifieke opiaatreceptoren in het brein. Naltrexon, ook in orale vorm beschikbaar, blokkeert deze gedurende circa 24 dan wel 72 uur (afhankelijk van de hoogte van de oplaaddosering Naltrexon). Hierdoor werkt herone gedurende deze tijd niet. De acute onthouding is dragelijk door de anesthesie en wordt verlicht door clint te behandelen met Clonidine of Estulic, centraal werkende alfa-adrenerge anti-hypertensiva. Door de narcose "merkt" de patint zeer hevige onthoudingssymptomen niet. De anti-hypertensiva stabiliseren de circulatie-toestand en verminderen de door onthouding opgewekte "centrale" onrust. Voor specifieke onthoudingsklachten als braken en diarree worden specifieke symptoombestrijdende middelen bijv. Octreotide ingezet. De met hoge doseringen Naltrexon te weeg gebrachte zeer intensieve en acute onthouding in combinatie met de vele soorten symptomenbestrijdende medicatie die tijdens de narcose worden toegediend heeft tot gevolg dat de methode alleen verantwoord is met medewerking van een gekwalificeerd anesthesist en in een goed geoutilleerd ziekenhuis met intensive care unit. Tijdens de anesthesie, 8 uur, wordt de maag van patint afgezogen en ligt hij/zij aan hartbewaking, is gentubeerd etc. Na het wakker worden uit de anesthesie kan clint na enkele uren het ziekenhuis verlaten. De onthoudings-symptomen zijn dan meestal vrijwel verdwenen en patint is "clean", d.w.z. zonder opiaten. Essentieel onderdeel van de behandeling is dat clint minstens gedurende 6 maanden doorgaat met dagelijks orale Naltrexonbehandeling. Mits dit middel trouw, dus dagelijks, wordt geslikt is patint beschermd tegen het terugvallen in heroneverslaving doordat Naltrexon de opiaatreceptoren in het brein bezet houdt. Door deze blokkade, die overigens niet absoluut is merkt men niets van de eventueel toch nog genomen herone. Op basis hiervan zal - mits men doorgaat met Naltrexon - het verslavingsgedrag geleidelijk aan uitdoven en herstelt de clint. Cruciaal in de gehele behandeling is het doorgaan met Naltrexon. Bij voorkeur wordt hierbij een niet-druggebruikend familielid of goede vriend betrokken. Tevens wordt vanwege deze reden veel nadruk gelegd op psychologische counselling bij de nazorg. In de nazorgperiode na de anesthesie, wordt wisselende medicatie verstrekt. Er bestaat in deze verschil tussen CITA en The Stapleford Centre. CITA is zeer terughoudend met middelen. Men verstrekt: Naltrexon, obligaat, gedurende langere tijd benzodiazepinen Clonidine indien nodig en gedurende een beperkte periode 5.De effectiviteit van de behandeling in relatie tot overige op abstinentie gerichte behandelingen 6.De plaats van de CITA-behandeling Literatuur

Brewer, Stapleford Centre geeft indien nodig een breed en fors gedoseerd pakket van slaapmiddelen en zo nodig zelfs amfetaminen voor extreme vermoeidheid. Overigens wel gedurende een beperkte tijd. Essentieel bij de beoordeling van medische behandelingen, ook die voor heroneverslaving, is niet alleen inzicht in het beloop van de procedure en de logica ervan maar ook in de effecten op termijn. Beklijft het

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succes, bij wat voor patinten werkt het wel, bij welke niet. Zijn er ook slechte effecten te melden na verloop van tijd. Bijv. hoe zit het met de frequentie en terugval in de verslaving, inclusief ook dodelijke overdoseringen, eventueel verergering van de psychiatrische toestand van de betrokken clint. Over deze gegevens kunnen we kort zijn: ze zijn er niet. Noch van CITA, noch van Loimer, noch van Brewer (Stapleford Centre) zijn follow-up gegevens beschikbaar. Men stelt nog bezig te zijn de behandeling te verfijnen en te werken aan deze follow-up. Voorlopige gegevens uit Itali van Gerra laten zien dat het terugvalpercentage zeer aanzienlijk zou zijn, in de orde van grootte van 80%. Overigens is dit terugvalpercentage voor verslavingsbehandeling niet uitzonderlijk hoog, zie paragraaf 5 van deze notitie. Deze terugval is dan ook niet op voorhand de reden om dit behandelproces niet verder te doen ontwikkelen. De korte duur van de behandeling spreekt aan alsook het gegeven dat de behandeling ingebed kan worden in een nog nader te ontwikkelen pakket van nazorg. Immers in de beleving van de clint wordt deze relatief makkelijk en pijnloos ingesteld op een opiaatvrij bestaan dat met Naltrexon, al dan niet door middel van toedieing door familie, per dag verlengd kan worden. Volgens informatie van Brewer, overigens ook door CITA gesignaleerd, speelt op dit moment bij terugval vooral het verstoorde evenwicht van het gastro-intestinale systeem de behandelde clinten parten. Door de geforceerde uitdrijving van opiaten, niet alleen uit het brein maar ook uit de maag/darmweefsels, ontstaat bij nogal wat clinten een ernstige diarree met als gevolg gevaar voor uitdroging. Daar de meest effectieve anti-diarreemiddelen werken via opiaatreceptoren, die bij de betreffende behandeling nu juist geblokkeerd zijn, helpen deze middelen niet. Inmiddels vindt men baat bij octreotide, een recent ontwikkeld middel dat bij AIDS-diarree ingezet wordt. De in- en uitsluitcriteria van de behandeling zijn niet altijd even helder. Ernstige psychiatrische comorbiditeit wordt door alle behandelaren als contraindicatie gezien. Loimer beperkt zich tot uitsluitend zuivere herone- dan wel methadonafhankelijke clinten, dus alleen opiaatafhankelijkheid. Polydruggebruik, zeker als er alcohol in het spel is, is gevaarlijk tijdens de narcose met het oog op hartstilstand. De CITA-clinten gebruiken vaak cocane maar ook wel stoffen als benzodiazepinen en alcohol zonder dat dit als contra-indicatie wordt gezien. Ernstige lichamelijke problemen als AIDS, acute hepatitis B en C worden eveneens gezien als contra-indicaties. 3. Literatuur over Naltrexon en Clonidine Zoals in de inleiding reeds is gesteld is de literatuur over de totale behandeling inclusief narcose beperkt. Over deelaspecten van de behandeling is wel veel bekend. Het gaat dan om het inzetten van alfa-adrenerge anti -hypertensiva als Clonidine voor de bestrijding van opiaatonthouding (Gold, 1978,5) bij detoxificatie. Ook de combinatie van deze onthouding-blokkerende stoffen met Naltrexon is reeds veelvuldig beschreven in diverse doseringsschema's. Veel aangehaalde auteurs zijn Charney (1986,6), Senft (1991,7), Brewer (1988,8). Opvallend is het gegeven dat als kernpunt in de probleemstelling steeds gezien wordt, niet zozeer het afmaken van de detoxprocedure, wat in 80% of meer van de gevallen lukt, maar veeleer het doorgaan met Naltrexon in de maanden na de detoxificatie. Stopt men met Naltrexon, dan verdwijnt de heroneblokkade binnen korte tijd (n twee dagen) en kan men weer "genieten van deze verboden vrucht". Vanwege deze redenen, overigens in probleemstelling verrassend overeenkomend met die bij de anti-alcoholmiddelen als Refusal/Antabus, wordt geadviseerd familie, partner, zelfs werkgever en Justitie te betrekken bij "external support", gericht op het continueren van het doen innemen van Naltrexon (monograph van Lamepro, 1988,9). Indicatiekenmerken: De fabrikant van Naltrexon (Lamepro) adviseert het middel te gebruiken bij personen met een hoge sociale integratiesituatie, incidentele niet-verslaafde gebruikers, of personen die uitbehandeld zijn na opname in een verslavingskliniek. Eigenlijk gaat het hier dus om het clintprofiel dat in het huidige beleid vooral van de vrijwillige therapeutische op abstinentie gerichte klinieken gebruik maakt. Bijwerkingen: Clonidine: doorschietende, voorbijgaande ernstige bloeddrukdaling met als gevolg flauwvallen (verkeer!), sufheid etc. Naltrexon: leverschade in hoge doseringen (3x de therapeutische dosis). Acute hepatitis is dan ook een contra-indicatie. Over psychotische decompensatie als gevolg van (acute) detoxificatie van chronisch psychotische heroneverslaafde patinten, die opiaten gebruiken als zelfmedicatie, wordt in de beschikbare literatuur niet gerept. Evenmin wordt verslag gedaan van overdoseringen met herone bij terugval. Immers men is relatief ongevoelig voor herone zolang Naltrexon in het lichaam aanwezig is. Deze bescherming vervalt binnen twee dagen na de laatste dosis Naltrexon. Op dat moment is men zijn gedurende de verslaving verworven tolerantie voor opiaten kwijt. Clinten dienen dan ook gewaarschuwd te worden voor de kans op overdosis bij terugval. Overigens is de heroneblokkade dosisafhankelijk, grote hoeveelheden herone blijft men "voelen", ook als men trouw zijn/haar Naltrexon slikt. 4. Wat is er nieuw aan de methode Legarda? De behandeling met Naltrexon met psycho-sociale begeleiding als steun, in combinatie met de toediening van stoffen als Clonidine is reeds beschreven in 1986. In de ogen van CITA is het vernieuwende argument voor de methode Legarda de kostenbesparing door het terugbrengen van de opnameduur en vooral een verminderde uitval uit behandeling gedurende het detoxificatieproces. Daarnaast is de veronderstelling dat de therapietrouw van de vervolgbehandeling met Naltrexon na een dergelijke imponerende opname (echt ziekenhuis, inclusief intensive care afdeling, narcose, zeer plotselinge kortdurende detox - de verslaving wordt er als het ware uitgesneden!) hoger is dan bij de gebruikelijke inductiemethode waarbij men niet in narcose gebracht wordt. Zo bezien is vooral nieuw in de methode Legarda, overigens ook in die van Loimer, de anesthesie. Het is zeer waarschijnlijk dat de methode een belangrijk placebo-effect heeft. De werkzaamheid hiervan is uitsluitend door middel van zorgvuldig prospectief onderzoek aan te tonen, dat helaas tot nu toe ontbreekt. 5. De effectiviteit van de behandeling in relatie tot overige op abstinentie gerichte behandelingen Er zijn geen follow-up gegevens beschikbaar. Uit de wel beschikbare gegevens blijkt het meestal te gaan om redelijk sociaal gentegreerde en gemotiveerde clinten met een betrekkelijk korte verslavingsduur, + 5 tot 10 jaar, en een matig ernstige verslaving. CITA deelt desgevraagd mede te werken aan een follow up-onderzoek van tot nu toe behandelde clinten. Dit is op dit moment ter beschikking in voorlopige vorm. Zoals bekend is de gouden standaard voor evaluatie-onderzoek van een medische behandeling gerandomiseerd en gecontroleerd prospectief clintonderzoek. Door afwezigheid van deze informatie is een definitief oordeel over de methode nu nog niet mogelijk. Wel kan iets gezegd worden over de eventuele plaats van de behandeling in het pallet van de bestaande behandelingen. Het ontbreken van behandelevaluatie bij de beschreven behandelingsmethode krijgt veel aandacht in verband met de goede resultaten die voor de methode geclaimd worden, in combinatie met het hoge door de clint/familie te betalen tarief. De succesclaims kunnen op dit moment niet beoordeeld worden. Daar het hier gaat om een behandeling met als doel abstinentie dient afkick onder narcose plus nazorg vergeleken te worden met de reeds bestaande behandelingen met een dergelijk doel. In de praktijk gaat het dan om de langdurige opnamen in therapeutische gemeenschappen, waarvan er in een Nederland een groot aantal is. In het oog springen uiteraard de verschillen in opnameduur (enkele dagen vergeleken met maximaal 12 maanden). Zoals gezegd, follow-up gegevens ontbreken met betrekking tot dit "afkicken onder narcose". Overigens dient opgemerkt te worden dat in Nederland geen of zeer weinig onderzoeks-materiaal beschikbaar is met betrekking tot de effecten van op abstinentie gerichte verslavingsbehandeling. Een uitzondering in deze is het proefschrift van M. Kooyman (1992,10) over de effecten van intensieve langdurige

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intramurale behandeling bij clinten opgenomen in het tijdvak eind jaren '70 begin jaren '80 in de therapeutische gemeenschap van de Emiliehoeve. Kort geschetst is de abstinentiegerichte verslavingsbehandeling in het algemeen enigszins teleurstellend door de volgende trias van cumulerende fenomenen. De Amerikaanse situatie die waarschijnlijk voor Nederland ook opgaat wordt in deze door Gerstein (1992,11) gedetailleerd en duidelijk beschreven: Selectie de vr behandeling: Bij de intake wordt veel genvesteerd in diagnostiek. Is er een verslaving, hoe ernstig is deze, is betrokkene niet te "slecht" voor de behandeling in de zin van psychopathologie, is betrokkene gemotiveerd. Boven geschetste punten leiden meestal tot meer of minder intensieve intakeprocedures, waarbij een belangrijk deel van de clinten afhaakt. Percentages van uitval bij selectie worden in de beschikbare literatuur meestal niet gegeven. Uitgegaan moet worden van 50% bij die interventies waarvoor een reeks intakegesprekken vereist zijn. Uitval tijdens de behandeling: Na opname vertrekt een groot aantal clinten tegen advies uit de behandeling (50-80%). Meestal verloopt het afscheid tumultueus. In de regel begint men onmiddellijk weer met drugs na ontslag. De omvang van de uitval is evenredig met de duur en de intensiteit van de behandeling. De uitval wordt overigens verminderd door een zorgvuldige en langdurige intakeprocedure, waarbij ongemotiveerde of zeer beschadigde clinten afhaken dan wel niet tot het programma toegelaten worden. (Zie selectie.) Terugval na behandeling: Omgekeerd evenredig aan de duur en de intensiteit van de behandeling bestaat de kans op terugval in verslaving na het in eerste instantie succesvol beindigen van de behandeling. Opgegeven percentages wisselen tussen 60 en 80%. De "lichte" en korte behandelingen kennen een hoog percentage terugval. Gelet op deze ontmoedigende reeks problemen bij het bereiken van abstinentie uit verslaving door behandeling zijn de door CITA opgegeven succespercentages wel zeer opvallend. Zoals reeds vermeld zijn de overige behandelaren die vrijwel hetzelfde behandelaanbod hebben realistischer in hun verwachtingen. Gelet op het gegeven dat het een zeer korte interventie is die daardoor betrekkelijk goedkoop kan zijn betekent dit dat nader onderzoek wenselijk is.

6. De plaats van de CITA-behandeling Gelet op het mogelijk krachtige placebo-effect van de behandeling, immers snel, explosief, intensive care, expliciet benaderen van verslaving als "te genezen" ziekte, zonder overmaat aan schuldgevoelens, motivatie-testing etc. is het goed mogelijk dat deze behandelvorm effectief is. Mits toegepast bij geselecteerde, niet al te zeer beschadigde clinten met een resterende sociale omgeving die zich om hen bekommert. Een krachtige motivatietest in deze zijn de niet geringe kosten van fl. 10.500,--, die door CITA aan de clint, meestal de familie, in rekening worden gebracht. Overigens een tarief dat de 3.500 voor een vergelijkbare behandeling door the Stapleford Centre aardig benadert. Het is overigens wel gewenst dat clinten met psychiatrische klachten, die als auto-medicatie herone gebruiken, niet blootgesteld worden aan deze wel zeer abrupte detoxificatie. CITA deelt desgevraagd mee dat hier bij de intake opgelet wordt. Ook dienen clinten gewaarschuwd te worden voor overdosis-gevaar indien onverhoopt herone gebruikt wordt tijdens of na de ambulante nabehandeling met Naltrexon. Alvorens breed toegepast te worden dient de veiligheid en werkzaamheid van de behandeling getoetst te worden. In dit verband kan meegedeeld worden dat de Minister van VWS de Gezondheidsraad heeft verzocht om in de werkzaamheden van de commissie "Medicamenteuze interventie bij drugsverslaving" aandacht aan deze methode te geven. Zou de behandeling zoals voorgestaan door Legarda/CITA/Loimer/Brewer equivalent werken aan de bestaande langdurige intensieve en kostbare intramurale therapeutische interventies dan is er wat te zeggen voor het opnemen van de behandeling in het bestaande pakket van op abstinentie gerichte behandelingen. De doelgroep zijn de redelijk gentegreerde niet al te beschadigde heroneverslaafde clinten. Waar de behandeling gericht is op abstinentie is het aangewezen om een trial te doen die de al dan niet bestaande werkzaamheid inclusief placebo-effect deugdelijk onderzoekt. Is de beschreven nieuwe combinatie van oude behandelingen werkzaam dan verdient de behandeling een plaats in het spectrum van behandelingen van de verslavingszorg.. Literatuur 1. Loimer N., Schmid R.W. et al. Continuous Naloxon administration supresses opiate withdrawal symptoms in human opiate addicts during detoxification treatment. J. Psychiater Res. 1989, 23: 81-86. 2. Loimer N., Lenz K. et al. Technique for Greatly Shortening to Transition from Methadone to Naltraxon maintenance of patients addicted to opiates. Am. J. Psychiatry 1991, 148: 933-935. 3. Legarda J.L., Gossop M., A 24h impatient detoxification treatment for heroin addicts: a preliminary investigation. Drug.Alc.Dependence 35 (1994) 91-93 4. CITA, Center for Investigation and Treatment of Addiction. Ultra Rapid Opiate Detoxification Method (UROD). Treatment protocol and Scientific Background. Concept aug. 1996 5. Gold M.S., Redmond D.E., Kleber H.D., Clonidine in opiate whithdrawal. Lancet 1978.1.929-930 6. Charney D.S. et al. The Combined use of Clonidine and Naltrexon as a rapid, safe and effective treatment of abrupt withdraw from Methadone. Am. Journal Psychiatry 143: 7 July 1986 7. Senft R.A., Experience with Clonidine - Naltrexon for rapid Opiate detoxification. Journal of Substance Abuse Treatment, 1991, 8, 257-259 8. Brewer C. et al. Opioid withdrawal and Naltrexon induction in 48-72 hours with minimal drop out, using a modification of the Naltrexon-Clonidine Technique. British Journal of Psychiatry 1988, 153, 340-343 9. Lamepro B.V.: Trexan, Naltrexon hydrochloride in opioid addiction. A comprehensive product monograph. December 1988 10. Kooyman M. The therapeutic community for drug addicts. Parent involvement and treatment outcome, dissartatie Erasmus Universiteit Rotterdam, 1992 11. Gerstein and Dean R. The effectiveness of drug treatment in "Addictive States" edited by C.P.O. Brein and J.H. Jaffe, Raven Press, New York. 1992, 253-282 Terug naar voorpagina | Terug naar voorpagina zonder frames Pers: wie is wie in Zorg | Zorgagenda | Bestuur & Beleid | Jeugd | Ouderen | Amstelhuizen | Huisartsen | Dak- en thuislozen | GGZ | Drugs | Gezondheidsverschillen Bevolking Amsterdam | Stichting HVO | GG&GD | SIGRA | ZAO | Zorgdata in Piga Patinten | Inhoud van deze site | Zoek op trefwoord | Vragen & reacties | Links Deze pagina gemaakt door Dirk van der Woude laatst gewijzigd op 28-10-97 Copyright 1997 Zorgstad Amsterdam p/a GG&GD - Postbus 20244 - 1000 HE Amsterdam Tel. (#31)(0)20 555 5208 - Fax (#31)(0)20 555 5654 - MAIL: vdwoude@ggd.nl

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The UniQual Network http://www.uniqual.com/

dated: 24-Jan-1998

ABOUT THIS SITE THE MEDICAL LITERATURE MECHANISM FREQUENTLY ASKED QUESTIONS

DETOXIFICATION LOCATIONS QUALITY ASSURANCE AND ONE DAY DETOX Send Email : gonzales@heroin-detox.com DISCUSSION FORUM

ABOUT THIS SITE

http://www.heroin-detox.com/about.htm

This website serves as a base for education, promotion, and discussion related to naltrexone induced heroin detoxification under general anesthesia. To meet these goals, this website features: 1. 2. 3. 4. A review of the medical literature for public and professional audiences. References are cited and summarized. A discussion forum with moderated content. Here, visitors ask and answer questions, leave comments, and participate in developing this website. Answers to frequently asked questions (FAQ). A provider list. Find out where detoxification programs are located.

For the public, I suggest you start by reading discussion forum posts that have been placed by visitors to this website over the last year. (you can just click here). For medical professionals, I suggest you start by reading the mechanism and medical leterature sections. The active discussion forum contains up to date information for all visitors.

THE MEDICAL LITERATURE

http://www.heroin-detox.com/medlit.htm

The medical literature relevant to naltrexone induced heroin detoxification under general anesthesia consists of six studies with a total of 63 patients. I am aware of an additional published paper by Dr. Colin Brewer that evaluated aver 500 patients at several institutions. A hyperlink to the paper is included here for your review. The techniques vary between institutions and therefore do not conform to the format of this page..

RAPID OPIATE DETOXIFICATION AND NALTREXONE INDUCTION UNDER GENERAL ANESTHESIA AND ASSISTED VENTILATION: EXPERIENCE WITH 510 PATIENTS IN FOUR COUNTRIES.
Presented to:

The Royal College of Psychiatrists London, England July, 1996

AUTHORS Colin Brewer, MRC Psycho.; Mary Laban, MRCA; Charles Schmulian, FFA, (The Stapleford Centre, 25a Eccleston St., London SW1W 9 NP); Lance Gooberman, MD (ROD Treatment Center, Merchantville, New Jersey); Yiannis Kasvikis, MRC Psych . (Centre for Mental Health, Athens); Nabil Abdel Maksoud, MD (Cairo University) ABSTRACT This paper describes some modifications of the original Vienna method of rapid opiate detoxification under general anesthesia (RODA) and naltrexone induction. We use muscle relaxants and assisted ventilation, with propofol, isoflurane and thiopentone. Octreotide greatly reduced gastrointestinal secretions. There were no significant anesthetic complications. Most patients were fit for discharge within 24 hours. Heroin dose did not correlate with speed of recovery. Abstinence rates as high as 76% at four months were achieved. Patients were successfully withdrawn from as much as 200 mg of methadone daily. Post-detox management is discussed. INTRODUCTION Loimer et al (1988a; 1988b) first described the technique of opiate withdrawal precipitated and accelerated by opiate antagonists while the patient is anesthetized for a few hours. They used methohexitone or thiopentone for anaesthesia. Patients were intubated but not paralyzed. Initially, they used a naloxone infusion. Later, patients receiving methadone at doses up to 120 mg daily were detoxified and transferred to full doses of naltrexone in 4-6 hours (Loimer et al, 1991a). The Vienna group originally speculated that barbiturates, such as thiopentone, had a particular ability to suppress precipitated withdrawal symptoms but it appears that virtually any standard anesthetic agent can be used for this technique. Brewer (1989a) first described the use of propofol, which gives a very rapid recovery. Clonidine was given as a

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premedication because of its effectiveness in other techniques of precipitated withdrawal using sedation rather than anesthesia (Charney et al, 1986; Brewer et al, 1988; Senft, 1991). Naltrexone was administered during anesthesia via the nasogastric tube. RODA has become more widely used in the last three years. This is due partly to its commercialization and promotion by the Spanish-Israeli CITA group, who are attempting to patent the procedure (Brewer, 1996b). However, there is a growing realization although it is neither appropriate nor necessary for all patients and may attract many patients who find conventional withdrawal difficult and/or unpleasant. Some will not even contemplate withdrawal, so great is their fear (Milby et al, 1986). Furthermore, although rapid opiate detoxification under oral sedation (RODOS) is often a satisfactory alternative technique, some patients are difficult to sedate and may present nursing problems (Brewer et al, 1988; Brewer, 1989b; Senft, 1991). It is difficult to identify these patients in advance. We present some data on 510 patients having RODA at clinics in London (80 cases), Merchantville, New Jersey (355 cases), Athens (25 cases) and Cairo (50 cases), using similar techniques. PATIENT SELECTION AND CHARACTERISTICS The clinics in London and Athens offered several withdrawal techniques, and the final choice was largely left to the patient. In London, where methadone maintenance was also an option, several patients were advised to try a period of stabilization on methadone before reconsidering detoxification. Cairo patients were discouraged from detoxifying if they were thought to be motivated largely by external pressures. The New Jersey clinic offered only RODA. In Athens, of 60 consecutive patients seeking withdrawal, 35 (60%) chose other methods. All patients were told repeatedly that detoxification was usually only a stage in the treatment of addiction and that after-care, including supervised naltrexone was important. Few patients suffered from conditions which contraindicated general anesthesia. Two known HIV positive patients were treated in London, one with a CD4 count of 120. Of the Athens patients, 18 (72%) had hepatitis C. All Athens patients were heroin users (mean daily use 0.7 grams) as were most of the New Jersey and Cairo patients. In contrast, 30% of London patients were detoxified from methadone. Thirty-six percent of Athens patients and a similar proportion in London were also dependent on benzodiazepines. ANESTHETIC TECHNIQUES The main difference from previously described methods was that all patients had assisted ventilation, usually with atracurium as the relaxant. Propofol was the usual induction and maintenance agent, but isoflurane in a closed circuit was used in 18% of London cases and thiopentone was used in several cases in Cairo. Propofol is expensive and the use of muscle relaxants reduces the total amount needed for the procedure. Duration of anesthesia was four hours in New Jersey and four to six hours elsewhere. Pre-medication includes antiemetics, usually droperidol or ondansetron and a benzodiazepine. H2 blockers or proton pump inhibitors are given to reduce acid secretion in case of aspiration. Clonidine was used in all the centres. Diarrhea is poorly controlled by anti-withdrawal drugs and is not suppressed by anesthesia. Opiates are ineffective in the presence of opiate antagonists. Profuse liquid diarrhea is common in precipitated withdrawal. All centres initially used pre-treatment laxatives and/or enemas, but the growth-hormone analog octreotide, given IV or subq as a pre-medication greatly reduced diarrhea and bowel preparation is now unnecessary. A full report on octreotide's effectiveness is in preparation. Monitoring includes constant ECG, respiration, pulse, BP, SaO2, and end tidal CO2. A urinary catheter is inserted but removed before awakening. ADMINISTRATION OF OPIATE ANTAGONISTS In all centres, IV naloxone 1.6-2 mg was given initially. About 20 minutes later, naltrexone in doses from 12.5 mg to 25 mg is given as a suspension via the nasogastric tube. After the naloxone, New Jersey patients also receive 2 mg of IV nalmefene, an opiate antagonists with a half life of ten hours. Further doses of naltrexone are given two to three hours later to a total of 50 to 200 mg. Higher doses may cause more side effects, but by ensuring opiate blockade for up to four days may reduce the likelihood of early relapse. Following naltrexone administration, there are usually few signs of withdrawal. Piloerection may be seen and, more rarely, sweating. The dose of muscle relaxant is titrated for less than total paralysis and slight movements of the limbs may be seen initially. EMERGENCE FROM ANESTHESIA Patients vary in their behavior at this stage. Most are drowsy but all New Jersey patients get out of bed within 30 minutes and walk to the toilet with assistance before returning to bed, if necessary, for a period of observation. A minority of patients are restless and need further sedation. Further doses of antiemetics and octreotide can be given for nausea and diarrhea. These problems generally settle within a few hours. Octreotide greatly reduces gastric as well intestinal secretions. If necessary, clonidine should be given in adequate doses provided blood pressure is at least 80/50 and the pulse at least 50 per minute (Charney et al, 1986). Comparative studies are needed to show whether it is more effective if given as part of the premedication or whether it is equally effective if given before extubation. POST-ANESTHETIC MANAGEMENT The speed of recovery is very variable and seems to bear little or no relationship to the normal daily dose of opiate. Some patients are fit to walk out of the clinic unaided an hour after extubation. All New Jersey cases are treated as out-patients and leave the clinic after a few hours to go home or to stay at nearby hotels where they can receive regular medical or nursing visits. In Athens, Cairo and London, the patients stay in the hospital over night. Occasionally a second night seems advisable, especially if home circumstances are less than ideal (the original Vienna patients stayed in the hospital for five to seven days but all were ambulant by the second day and their treatment was paid for by the state health service). POST-DETOX MANAGEMENT Management varied in the four centres, reflecting both cultural differences and expectations and the clinical background of the physicians involved. All patients were advised to take naltrexone for at least six months under family supervision. In addition, New Jersey patients, treated by an internist, were strongly encouraged to join or rejoin 12-step groups in line with the importance attached to this approach in the US. Athens and London patients, treated by psychiatrists were offered individualized programs using cognitive behavior concepts. In Cairo, where treatment was coordinated by a medical toxicologist, regular urine testing and family involvement were emphasized. If patients seemed to have few underlying problems, management largely involves being generally supportive and available. RESULTS WITHDRAWAL SYMPTOM RATINGS The most complete set of data relates to the Athens patients. Using a 20 item 4-point withdrawal rating scale developed by Bradley et al (1987), patients were rated on admission before RODA and again the following day before discharge. The overall rating was slightly, but not significantly worse after RODA (paired T-tests pre- vs. post- = 8.5 vs. 12.5, t=1.5). However, on symptom by symptom comparison (Wilcoxon matched pairs), diarrhea (7=2.8, p less than 0.005), feeling cold (Z=2.4 p less than 0.01) and hot and cold flushes (Z=2.6, p less than 0.0l) were significantly worse. Neither age of patient, duration of opiate use, nor usual opiate dose correlated with symptom severity (Pearson correlation).

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COMPLICATIONS No serious anesthetic complications were encountered using these methods. One New Jersey patient developed bradycardia and first degree heart block, probably related to clonidine which responded to beta-adrenergic agonists. ABSTINENCE RATES DURING FOLLOW-UP RODA was first used in Cairo in October of 1995 and the follow-up data are unusually complete. Of the first 30 patients representing all patients detoxified at least four months ago, only five patients have not been regularly followed-up, usually because of living or working abroad. Regular urine tests have been done in the remaining 25 cases. As of July, 1996, only one out of the 25 had relapsed to opiate use, though in four cases, urine has been positive for cannabis. The very high 'success rate' in the Cairo patients - 76% even if all patients lost to follow-up are assumed to have relapsed - probably reflects both the rigorous selection of well-motivated patients and the suitability of closeknit Egyptian family structures for treatment involving family supervised naltrexone, which increases abstinence rates considerably compared with conventional treatment programs (Gerra et al, 1995). Follow-up data are less complete for the other centres. RODA patients probably don't have better long-term results than comparable patients who complete conventional in-patient withdrawal programs. However, "It seems likely that a significant proportion of patients who would fail (or have failed repeatedly) to complete conventional withdrawal will succeed with the help of anesthesia or sedation. This is one important reason for putting these techniques on the therapeutic menu." (Brewer, in press). IS WITHDRAWAL MORE DIFFICULT FROM METHADONE? Many addicts and addiction physicians believe that withdrawal from methadone is worse than from heroin but patients who receive methadone treatment may not be representative of the majority of heroin abusers. They may take methadone precisely because they have withdrawal symptoms, which are worse than average. Animal studies show that the severity of withdrawal symptoms is, at least in part, genetically determined (Suzuki et al, 1987). The same is probably true of humans. Withdrawal severity correlates poorly with daily opiate dose (Kosten et al, 1989). To answer the question objectively, a group of methadone addicts would have to be randomized to remain on methadone or take equivalent doses of morphine for at least a week before RODA. Some pure methadone addicts recover quickly even from doses up to 200 mg daily. Some pure heroin addicts take longer than average. However, even in the worst cases, patients with jobs can usually return to work within a week. DISCUSSION These results confirm that RODA is not only rapid and humane, but also an effective and acceptably safe method of opiate withdrawal. It is clear that most patients have relatively mild withdrawal symptoms which soon improve and the findings in the Athens group are similar to those previously reported by the Vienna group (Lormier et al, 1991b). However, claims that patients experience no withdrawal symptoms are manifestly untrue (CITA informs its patients that any discomforts they experience on waking are not withdrawal symptoms, but a "a sign that the body's immune system has begun functioning again). Furthermore, a small minority have persistent, if largely subjective symptoms, in which can be very distressing even if they cannot always be assessed on the standard withdrawal rating scales. Appropriate medication can assist the recovery process. Apart from naltrexone and clonidine or lofexidine, hypnotics were the most widely prescribed class of drugs. Sleep patterns can take several weeks to normalize. Anti-depressants have not been frequently prescribed. Farrell (1994) claims that because death from uncomplicated opiate withdrawal is virtually unknown, it is not justifiable to introduce the potential hazards of anesthesia. However, the relatively slight hazards of modern anesthesia in generally young patients (without the added risks of a surgical procedure) must be set against the frequent and sometimes lethal complications of continuing opiate abuse, especially IV abuse. It should equally be said that since nobody dies from bad teeth, an unshapely nose, or the pain of childbirth, it is unjustifiable to offer general anesthesia for the management of these conditions. Provided that the risks are small and adequately explained, patients are surely entitled to take them (Brewer, 1996a). Punitive attitudes to drug addicts apparently make some health professionals feel that they do not 'deserve' good symptom relief (Brewer, 1995). RODA and early discharge mean that, compared with conventional withdrawal programs, many more patients can be treated during a given period. Unconscious patients do not manipulate nursing and medical staff or smuggle opiates into the ward.. 1.Continuous Naloxone Administration Suppresses Opiate Withdrawal Symptoms in Human Opiate Addicts During Detoxification Treatment. 2.Opiate Detoxification Under General Anesthesia by Large Doses of Naloxone. 3.Acute Blocking of Naloxone-Precipitated Opiate Withdrawal Symptoms by Methohexatone. 4.Similar Efficacy of Abrupt and Gradual Opiate Detoxification. 5.Technique for Greatly Shortening the Transition From Methadone to Naltrexone Maintenance of Patients Addicted to Opiates. 6.A 24-Hr Inpatient Detoxification Treatment for Heroin Addicts: a Preliminary Investigation.

MEDICAL LITERATURE

(NALTREXONE INDUCED HEROIN DETOXIFICATION UNDER GENERAL ANESTHESIA)

1. Continuous Naloxone Administration Suppresses Opiate Withdrawal Symptoms In Human Opiate Addicts During Detoxification Treatment J. Psychiat. Res, (23) 1, pp 81-86 (1989) Loimer, Schmid, Presslich, Lenz Psychiatric Univ. Hospital of Vienna, Austria. Note: This is the first published study evaluating the method of naltrexone induced heroin detoxification under general anesthesia. The authors conclude that the process is safe and effective. Patient Characteristics NALTREXONE DETOX Number 6 Age 21 to 28 yr. Sex unknown Opiate abused unknown Duration of abuse unknown Methods NALTREXONE DETOX Premed Morphine 270mg/day x 3 days Anesthesia induction / maintenance Methohexatone 500 - 1000mg Airway management Intubated

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Naloxone 10 mg IV over 10 min. 0.4mg/hr infusion x 72 hr Duration of withdrawal 30 to 50 minutes Vital signs monitored BP & HR Evaluation of withdrawal Self rating (Kolb) ; Clinical evaluation (Kolb) Follow up None after detox Results Post-detox self evaluation: "Limited susceptibility to opiate withdrawal symptoms". Post-detox clinical rating: "No patient showed severe withdrawal signs". Vitals: No change in BP and HR during detox. Follow up: None Issues 1.The first post-detoxification evaluation (Kolb) occurred on the morning after detox. Therefore, it is unknown if patients showed evidence of withdrawal immediately after detoxification. 2.Rating scale results were not specific, i.e. vague terms like "limited susceptibility," and "no severe withdrawal signs" leave the possibility that some evidence of withdrawal was present. 3.This study suggests that the hemodynamic changes seen during detoxification are mild.

2. Opiate Detoxification Under General Anesthesia by Large Doses of Naloxone Clinical Toxicology, (27), pp 263-270 (1989)Presslich, Loimer, Lenz, Schmid Dept. of Intensive Care Psychiatric Univ. Clinic, Vienna, Austria Note: This is the first and only study where invasive catheters were placed for monitoring of hemodynamics. Additionally, this is the only study that offers an evaluation of withdrawal signs immediately after detoxification. The author concludes that this detoxification method is safe and effective. Patient Characteristics NALTREXONE DETOX Number 6 Age 25 to 35 yr. Sex All male Opiate abused unknown Duration of abuse 8 to 10 yr. Methods NALTREXONE DETOX Premed Morphine, ? dose 12 hr. prior to detox Anesthesia Induction Thiopentone 1000mg Anesthesia maintenance Thiopentone 5000mg Airway management Intubated Naloxone 10 mg IV over 1 hr.;0.4mg/hr infusion x 24 hr Duration of withdrawal At least 3 hr." Vital signs monitored BP, HR, SV, SVR Evaluation of withdrawal Clinical evaluation (Wang) Follow up None Results Post-detox (Wang): "no significant withdrawal signs". Although, 2/6 patients did have nausea, vomiting, or muscle pains for 4 to 6 hr.post-detox. Vitals: Prior to Detox During/After detox Mean BP 95 105 HR 90 95 SVR 1200 1200 SV 70 85 Complications: None reported. Follow up: None Issues 1.Good study revealing minimal hemodynamic changes during detoxification and only mild withdrawal signs immediately after detoxification. 2.No data regarding post-detoxification recidivism was obtained.

3. Acute Blocking of Naloxone-Precipitated Opiate Withdrawal Symptoms by Methohexatone British Journal of Psychiatry (157), pp 748-752 (1990) Loimer, Schmid, Lenz, Presslich, Grunberger Note: This study offers evidence that naloxone, not the anesthetic, is responsible for compressing the duration of withdrawal to within four hours.Additionally, this study offers documentation that no severe withdrawal signs are present immediately after emerging from anesthesia. Mild withdrawal symptoms may persist for six days post detoxification. Patient Characteristics Number Age Sex Opiate abused Duration of abuse Methods Premed Anesthesia induction Anesthesia maintenance Airway management Naloxone Duration of anesthesia Response to naloxone 2 mg IV administered immediately after CONTROL GROUP 9 unknown 2 to 18 yr. CONTROL GROUP DETOXIFICATION GROUP Morphine 100 - 300 mg PO daily x 2 days ; Detox 12 hr. after last dose Methohexatone 100 mg IV Methohexatone 400mg IV Intubated None 10 mg IV bolus 0.8mg/hr infusion x 48 hr Unknown; (duration of methohexatone effect) Severe withdrawal signs Minimal withdrawal signs DETOXIFICATION GROUP 9 20 - 35 3 female, 15 male

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Methohexatone 250 mg, None Naloxone 10 mg IV bolus 0.8mg/hr infusion x 48 hr Vital Signs monitored Unknown Unknown Unknown Evaluation of withdrawal Immediately after detox and daily - Wang (signs) Daily - Kolb (self rating) Follow up Daily for 6 days post detoxification Results a) All patients in the control group (did not receive naloxone during anesthesia) emerged from anesthesia and responded to a test dose of naloxone 2 mg IV with signs of severe withdrawal. b) After control group patients were re-anesthetized and treated with naloxone, they emerged from anesthesia and responded to naloxone 2 mg IV with "minimal withdrawal signs". c) All patients in the treatment group (did receive naloxone during anesthesia) emerged from anesthesia and responded to naloxone 2 mg IV with"minimal withdrawal signs". d) There were no changes in the Wang scale during the 48 hr naloxone infusion. e) Post-detoxification self rating scores increased on day 2, then slowly returned to baseline by day 6. f) Vitals: Not available g) Complications: None reported in either group. h) Follow up: None after the 7 day treatment period. No data regarding recidivism was given. Issues 1.This study strongly suggests that naloxone, not anesthesia, is responsible for compression of the duration of withdrawal. 2.Post-detoxification withdrawal evaluation consisted of objective signs only and did not include subjective symptoms. Therefore, it is possible that patients emerged from anesthesia and had only "minimal withdrawal signs" but may have had significant withdrawal symptoms.

emergence from anesthesia Further treatment

4. Similar Efficacy of Abrupt and Gradual Opiate Detoxification American Journal Drug Alcohol Abuse, (17) 3, p.p. 307-312 (1991)Loimer, Linzmayer, Schmid, Grunberger Dept. of Intensive Care Psychiatric Univ. Clinic, Waehringer Guertel Vienna, Austria Note: This study suggests that the quality of detoxification is similar when comparing naltrexone induced detoxification under general anesthesia with slow detoxification utilizing methadone taper. Patient Characteristics Number Age Sex Opiate abused Duration of abuse Methods Premed Anesthesia Induction Anesthesia maintenance Airway management Naloxone Duration of withdrawal Vital signs monitored Evaluation of withdrawal NALTREXONE DETOX 15 unknown 2 female, 13 male unknown 2 to 18 yr. 1 to 14 yr. NALTREXONE DETOX Morphine 240mg12 hr.; prior to detox Methohexatone 100mg None Methohexatone 400mg Intubated 10 mg IV bolus 0.8mg/hr infusion x 72 hr Unknown; (duration of methohexatone effect) Unknown Pupillary measurements, Self rating (Kolb) 6 days post detox METHADONE DETOX 29 unknown 8 female, 21 male unknown METHADONE DETOX Methadone 50mg 24 hr. prior to detox None None None 20 +/- 5 days Unknown Pupillary measurements, Self rating (Kolb) Entire detox period

Follow up Results Self rating (both groups): "no significant difference was obtained between pre-detoxification and post-detoxifcation symptoms" Pupillary diameter: No difference between naltrexone and methadone groups. Kolb (self rating) : No difference between naltrexone and methadone groups. Vitals: Not available Complications: None reported in either group. Follow up: All naltrexone patients completed detoxification. Four methadone patients signed out against medical advice. No data regarding recidivism was given. Issues 1.The first post-detoxification evaluation (Kolb & Papillary) occurred when urine samples tested negative for opiates (heroin/morphine/methadone); this took up to six days. Therefore, it is unknown if patients in the naltrexone detox group experienced symptoms of withdrawal immediately after detoxification. 2.This study offered no information regarding changes in vital signs, duration of anesthesia, complications, or follow up.

5. Technique for Greatly Shortening the Transition From Methadone to Naltrexone Maintenance of Patients Addicted to Opiates. American Journal. Psychiatry, (148), pp 933-935 (1991) Loimer, Lenz, Schmid, Presslich. Dept. of Intensive Care Psychiatric Univ. Clinic, Vienna, Austria Note: This study investigated the possibility of reducing the cost of naltrexone induced detoxification under general anesthesia. The authors attempted to avoid "anesthesia" by using heavy "sedation". The study supports the conclusion that this method is safe and effective. Patient Characteristics Number Age NALTREXONE DETOX 7 20 to 36 yr.

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Sex 3 female, 4 male Opiate abused unknown Duration of abuse 3 to 13 yr. Methods NALTREXONE DETOX Premed Methadone 40 to 120 mg/d for 12 days Anesthesia "sedation" induction Midazolam 30mg IV bolus Anesthesia "sedation" maintenance Midazolam 50 to 75 mg repeated bolus Reversal of anesthesia "sedation" Flumazenil, 2 to 6 mg repeated until awake Airway management Not Intubated Naloxone 4 mg IV infusion, ? duration Naltrexone 50mg PO qd, until urine opiate free Duration of withdrawal Unknown; (duration of naloxone infusion) Vital signs monitored BP, ECG Evaluation of withdrawal Clinical signs (Wang) Follow up None after end of clinical study(urine free of opiates) Results Clinical rating (Wang): "No objective withdrawal symptoms were recorded." No increase in withdrawal symptoms after the administration of naltrexone. Vitals: "Remained stable during whole treatment period." Complications: None reported. Follow up: Two patients chose to continue naltrexone treatment at the end of the study. No data regarding recidivism was given. Issues 1.The first post-detoxification evaluation (Wang) occurred on the morning after detoxification. Therefore, it is unknown if patients had evidence of withdrawal immediately after detoxification. 2.It is unclear how long the patients were anesthetized "sedated". 3.The author states that the patients were "sedated" instead of anesthetized. It could be effectively argued that midazolam administered at this dose, 50 to 75 mg, induces general anesthesia, or at least, reduces airway reflexes significantly. This technique subsequently leaves the airway unprotected in a patient at risk for aspiration. 4.This is the first study incorporating oral naltrexone in the medical regimen. Thus, introducing the potential benefit of long term therapy.

6. A 24 Hr Inpatient Detoxification Treatment for Heroin Addicts: A preliminary Investigation. Drug and Alcohol Dependence (35), pp 91-93 (1994)Legarda, Gossop Note: One of two studies utilizing midazolam as the anesthetic agent. Naltrexone, given orally, was the only opiate antagonist administered for detoxification. The authors conclude that the process is safe and effective. NALTREXONE DETOX 11 26.5 yr., S.D.= 4.6 all male heroin only 6.5 yr., S.D. = 5 NALTREXONE DETOX Guanfacine 1 -2 mg/hr repeated until BP < 90 mm Hg Loperamide 4 mg PO Odansetron 8 mg PO Anesthesia induction / maintenance Midazolam 0.5 - 0.7 mg/Kg IV Airway management Not intubated Naloxone 0.8 mg IV test dose after detoxification Naltrexone 50 mg PO immediately prior to midazolam administration. Then 50 mg PO qd x 3 mos. Duration of withdrawal 4 hours Vital signs monitored BP & HR Evaluation of withdrawal Bradley opiate withdrawal scale Follow up Outpatient once a week x 4 wk. Results All patients experienced slight psychomotor agitation, piloerection, and sneezing during detoxification. "Levels of opiate withdrawal symptomatology were found to be at normal baseline levels after detoxification". No signs of withdrawal were observed in response to the daily naltrexone administration. Vitals: "No clinical incidents were observed". Follow up: After four weeks, all patients were still taking naltrexone. All but two patients challenged naltrexone with opiate use. Issues 1.The first post-detoxification evaluation occurred the morning after detox. Therefore, it is unknown if patients showed evidence of withdrawal immediately after detoxification. 2.Rating scale results were not specific. It is unknown if subjective symptoms or objective signs were evaluated. 3.It is not clear if patients' vital signs were stable during detoxification. Although, there does seem to be an implication that no significant changes occurred. 4.The patients in this study did not have a protected airway during detoxification. The following discussion focuses on issues of patient population, anesthetic agent, airway management, duration of anesthesia, antagonist use, withdrawal symptoms, changes in vital signs, complications, and follow-up. Patient Characteristics Number Age Sex Opiate abused Duration of abuse Methods Premed

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Patient characteristics Study No No. of patients Sex Age Opiate abused Duration of abuse 1 6 Unknown 21-28 yr. Unknown Unknown 2 6 All male 25-35 yr. Unknown 8-10 yr. 3 18 15 male 3 female 20-35 yr. Unknown 2-18 yr. 4 15 13 male 2 female Unknown Unknown 1-14 yr. 5 7 4 male 3 female 20-36 yr. Unknown 3-13 yr. 6 11 11 male 22-30 yr. Heroin 1.5-11.5 yr.

All patients met DSM III-R criteria for opiate addiction. Only Study no.6 included patients using substances other than opiates. The authors of the first five studies did not mention if patients used heroin or methadone as their standard opiate source. Any significance regarding the type of opiate addiction or concurrent use of other substances prior to naltrexone induced heroin detoxification under general anesthesia remains to be evaluated. Anesthetic, airway management, and duration of anesthesia 1 2 Study Pre-med None None

3 None

4 None

5 None

6 Guanfacine Odansetron Loperamide Midazolam 0.5-0.7mg/kg No Midazolam ? dose 4 hr

Induction Intubation Maintenance Duration

Brevital 500-1000mg Yes None 30-50 min

Thiopentone 1000mg Yes Thiopentone 5000mg 3 hr

Brevital 100 mg Yes Brevital 400 mg 30-40 min

Brevital 100 mg Yes Brevital 400 mg Unknown

Midazolam 30 mg No Midazolam repeated 50-75mg Unknown

These studies can be separated into two major groups. In Studies no.1-4, barbiturates were used for induction and maintenance of anesthesia. All patients were intubated (tube in the wind pipe to protect the lungs in case the patient vomits). In Studies no.5 & 6, midazolam (like valium) was used for induction and maintenance of anesthesia. No patients were intubated. The duration of anesthesia lasted from thirty minutes to four hours. One may consider whether the anesthetic or naltrexone was responsible for reducing the duration of withdrawal to within four hours. Results of Study #3 suggests that naltrexone was the responsible agent. Loimer divided 18 patients into two groups. Group A patients received the standard antagonist (naltrexone type of drug) induced detoxification procedure under general anesthesia. Group B patients, a control group, were placed under general anesthesia but were not treated with an opiate antagonist. Upon emergence from anesthesia (wake up), only patients in group B showed evidence of opiate dependence. These patients were subsequently reanesthetized and received the standard antagonist treatment. What is the best anesthetic for this procedure? Barbiturate and midazolam were used successfully in these studies. Propofol (an IV anesthetic) has been utilized successfully in one preliminary study (personal communication). The use of inhalation agents (newer, ether type of anesthetics) has not been reported. Any anesthetic, except of course narcotics, may be adequate. Further studies will be needed. Should all patients be intubated? Patients in Studies no.5 & 6 were not intubated and experienced no complications. However, San (medical literature reference: High Risk of Ultrashort Noninvasive Opiate Detoxification. Am Journal of Psychiatry, (152) 6, pp 956 (1995); San, L., Puig, Bulbena, Farre ) et al described a patient who vomited and became hypoxemic (low oxygen in the blood) while anesthetized for detoxification. This was probably due to aspiration (contents from the stomach entering the lungs). Since opiates reduce intestinal motility, and detoxification is associated with nausea and vomiting, all patients should have a protected airway (windpipe) with an endotracheal tube. What is the optimal duration of anesthesia? The above six studies suggest that 30 minutes to four hours is adequate. In another study, Resnick obtained detoxification within 24 hr. in 13 awake patients (Fig 1). Note that the severity of withdrawal signs increased dramatically soon after naloxone administration (Segment A). Then, symptoms decreased quickly over the next 2-3 hours (Segment B) with a slower decrease over the rest of the day (Segment C). The purpose of the anesthetic is to avoid the severely exacerbated withdrawal signs provoked by naloxone administration (Top of Segment A). Emergence (wake up from anesthesia), then, should occur at the latter part of Segment B. The trade-off includes waking up early with the possibility of significant withdrawal symptoms vs. waking up later with less symptoms but longer anesthesia, cost, and risk. Results from the measurement of pupillary diameter, in Study no.4, suggests that mild withdrawal signs may be present for up to six days. Rat models suggest that three days may be necessary for complete resolution of withdrawal signs.

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A clear progression of antagonist administration is observed. Initially, 10 mg of naloxone was administered intravenously over one hour followed by an infusion at 0.4mg/hr x 24 hr. In Study no. 4, 10 mg of naloxone was administered as an IV bolus and the infusion was increased to 0.8mg/hr x 72 hr. Oral naltrexone was utilized in Studies no.5 & 6. Further studies will be needed to determine the optimal antagonist regimen. Opiate antagonist treatment must continue as long as agonist (heroin or methadone) is present. Resnick administered naloxone to awake addicts over a two day period. On the second day, naloxone precipitated an acute exacerbation of withdrawal symptoms. The author postulated that systemic antagonist levels decreased overnight, allowing agonist to rebind to its receptor which re-instituted the dependent state. Long term antagonist levels can be maintained with oral naltrexone therapy. Evidence of Withdrawal After Detoxification Study 1 2 3 4 5 6 Signs or Symptoms of Withdrawal "limited susceptibility to opiate withdrawal symptoms", "no patient showed severe withdrawal signs" "no significant withdrawal signs", 2/6 patients did have nausea, vomiting, or muscle pains for 4 - 6 hr. "minimal withdrawal signs" "no significant differences were obtained" when comparing pre-detoxification and post-detoxification withdrawal symptoms "no objective withdrawal symptoms were recorded" All patients experienced slight agitation, piloerection, and sneezing "levels of opiate withdrawal symptomatology were found to be at normal baseline levels after detoxification"

The majority of these studies offer a poor evaluation of withdrawal signs and symptoms. Most of the post-detoxification evaluations occurred on the day after detoxification. It is not clear if evidence of withdrawal was present immediately after emerging (waking up) from anesthesia. Some studies evaluated signs of withdrawal, i.e. nausea, diarrhea, shakes etc. Other studies evaluated symptoms of withdrawal, i.e. restlessness and anxiety. In general, subjective symptoms,as compared to signs, are more prevalent after detoxification. As mentioned previously in the section, "duration of anesthesia," mild withdrawal signs may be present for up to 6 days. Vitals, Complications, and Follow-up Most of these studies suggest that changes in blood pressure and heart rate are minimal during detoxification. There were no reported severe hypertensive episodes. Invasive pulmonary and femoral artery catheters were used in only one study. No significant complications were reported. Only one study offered follow-up data for greater than one week. All patients were still taking naltrexone, and all but two patients challenged naltrexone with opiate use. Please see the FAQ and discussion forum sections for an elaboration of issues raised in this review.

MECHANISM

http://www.heroin-detox.com/mechanis.htm

There is no clearly agreed upon mechanism that explains physical dependence to opiates. Possibilities include up and down regulation of receptors, changing levels of natural opiates in the brain, and activity of specialized nuclei within the brain. This discussion will present evidence suggesting that activity of the locus coeruleus (a nucleus of cells located in the brainstem that release a substance similar to adrenaline) is important for opiate dependence, tolerance, and withdrawal. What happens to opiate addicted patients when they are given naltrexone (see fig.1 page 8)? Resnick administered naloxone 1.2 mg IM (intramuscular) every 30 minutes to 13 awake opiate addicted patients and obtained detoxification within 24 hours.Note that the severity of withdrawal increased dramatically soon after naloxone administration (Segment A). Then, symptoms decreased quickly over the next 2-3 hours (Segment B) with a slower decrease over the rest of the day (Segment C) Fig1. Ideally, we would like to correlate the temporal course of withdrawal signs to activity of specific areas in the brain. Unfortunately, the only known nucleus with activity that does correlate with signs of withdrawal, the locus coeruleus, is too small to image or measure in humans. Subsequently, it is necessary to look at data obtained from a rat model and evaluate applicability to humans. Rasmussen ( medical literature reference: Opiate Withdrawal and the Rat Locus Coeruleus: Behavioral, Electrophysiological, and Biochemical Correlates. The Journal of Neuroscience, (10) 7, pp. 2308-2317, July 1990. Rasmussen, K., Beitner-Johnson, Krystal, Abhajanian, Nestler, Yale Univ. School of Medicine. ) placed a measuring device in the locus coeruleus of opiate dependent rats. Subsequently, he administered naltrexone while simultaneously recording the activity of the L.C. and signs of withdrawal. Similar to the results obtained by Resnick in human subjects, withdrawal signs increased dramatically, then decreased in two phases; quickly over four hours then more slowly over 72 hours. Activity of the locus coeruleus paralleled signs of withdrawal revealing all three phases of increasing and decreasing activity. I urge you to review Rassmussen's paper. It is impressive how closely the data in the rat model correlates to the human data obtained by Resnick ( medical literature reference: Naloxone - Precipitated Withdrawal: a Method for Rapid Induction Into Naltrexone. Clinical Pharmacology and Therapeutics, (21) 4, pp 409-413 (1977); Resnick, R.B., Kestenbaum, Washton, Poole. New York Medical College.) .

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The structure and function of cells in the locus coeruleus have been well studied. Functionally, these cells show evidence of opiate tolerance and dependence. Fig.2 is a representation of such a cell with specific receptors for opiates and clonidine on the cellular membrane.Basically, when opiates or clonidine bind to their respective receptor, the intracellular cAMP system is down regulated. This, in turn, opens potassium channels while simultaneously closing sodium channels. In effect, cellular activity is inhibited. When opiates are administered to the cells of the locus coeruleus chronically, a very different situation occurs. The cells adapt to the presence of opiates by up-regulating the intracellular levels of cAMP and protein kinase. The mechanism for this action is unknown. At this time the cell becomes active again and exhibits tolerance to further opiate administration. In other words, it takes more opiate to produce the same effect observed prior to chronic opiate administration. An opposite effect is observed when opiate is removed from its receptor by the administration of an antagonist, i.e. naloxone or naltrexone. The previously dependent cell becomes hyperactive, functioning at five times its normal activity. Soon thereafter, activity decreases to 2 times normal within four hours, followed by a slower decrease in activity over the next 72 hours. In summary: The central neurological mechanism for opiate dependence, tolerance, and withdrawal is not clearly understood. However, in a rat model, activity of the locus coeruleus seems to play a major role. On a cellular level, there is evidence of opiate tolerance and dependence. On a clinical level, activity of the locus coeruleus closely mirrors signs of withdrawal. While one must be cautious in applying data from a rat model to humans, the temporal and quantitative similarities in signs of withdrawal are intriguing at least.

FAQ - INDEX

http://www.heroin-detox.com/faq.htm

1.What is naltrexone induced heroin detoxification under general anesthesia? Naltrexone induced heroin detoxification under general anesthesia refers to a heroin or methadone (or other opiate) detoxification procedure where an opiate antagonist, naltrexone or naloxone, is administered to compress the duration of withdrawal to within four to six hours. Naltrexone administration induces severe withdrawal symptoms, therefore the patient is anesthetized for the procedure. 2.What is the difference between naltrexone and naloxone? Functionally, they are the same type of drug. They compete with heroin at the receptor level and block the effect of heroin. Naloxone is administered intravenously and lasts for approximately 20 minutes. Naltrexone is administered orally (pill form) and can last for 1 to 2 days. 3.Is naltrexone beneficial for other types of addiction? Naltrexone may decrease the craving for alcohol. Cocaine and amphetamine addiction would not be treated with this drug. Naltrexone should be beneficial for any type of opiate addiction, including drugs like heroin, morphine, methadone, dilaudid, percocet, demerol, fentanyl, and vicodin. Currently, the studies in the medical literature that have evaluated naltrexone detoxification have included patients who were using either methadone or heroin. 4.What evidence is there that naltrexone induced detoxification under general anesthesia works? There are six studies in the medical literature where this procedure was evaluated. These studies have been reviewed and the results are available in this website (medical literature). It has been reported that thousands of successful detoxifications have occurred. Unfortunately, the group that claims this success has not published their results for critical review. As the discussion forum contained in this website develops, you may be able to read about individual experiences with the procedure. Even though the discussion forum will be moderated, comments for and against the procedure are encouraged. 5.How does naltrexone reduce the duration of withdrawal? This is a difficult question to answer since the mechanism for opiate tolerance, dependence, and withdrawal is not clearly understood. Evidence does exist that implicates the locus coeruleus (a group of cells in the brainstem that release a substance similar to adrenaline) as a major contributor. This data has been summarized and is presented in this website. 6.Is naltrexone induced heroin detoxification under general anesthesia safe? No adverse events were reported in the studies evaluating naltrexone detoxification. Caution should be exercised, though, in providing this procedure to a patient without a protected airway (a breathing tube in the windpipe). San has published a report describing a patient who vomited while anesthetized for naltrexone detoxification. The patient became hypoxemic (low oxygen in the blood) and probably aspirated (stomach contents in the lungs). This is a very serious complication that is avoided by placement of a "breathing tube". General anesthesia does have risks, although when compared to the mortality and morbidity associated with heroin use, it is relatively safe when administered by a specialist trained in the delivery of anesthesia. Caution should also be exercised in deciding who administers the anesthetic. Currently, it is legal in the United States for a nurse anesthetist to administer an anesthetic without the supervision of an anesthesiologist as long as a physician supervisor is available. As a result, some addiction specialists providing this service may hire a nurse anesthetist and choose to supervise the nurse him or herself. This would be a cost saving measure. An addiction specialist (unless also trained as an anesthesiologist) is NOT capable of providing anesthetic support or consultation should an adverse event occur during the peri-detoxification period. Be sure that an anesthesiologist (a doctor trained in the administration of anesthetics) is either providing the detoxification or supervising the nurse anesthetist. Detoxification is only part of treating the addicted patient. Identifying appropriate patients and providing post-detoxification rehabilitation are mandatory. Therefore, make sure that an addiction specialist (doctor specifically trained in the management of addicted patients) is part of the team providing the detoxification service. Other issues concerning safety also exist, i.e. liver toxicity, pulmonary edema, and opiate overdose. If these issues interest you, please send your question to gonzales@heroin-detox.com and I will respond. 7.Is naltrexone induced heroin detoxification under general anesthesia likely to increase the recidivism rate? The withdrawal syndrome may be beneficial in motivating addicts to stay clean after a successful detoxification. Since patients do not experience withdrawal symptoms with naltrexone induced detoxification under general anesthesia, it is possible that the recidivism rate may increase. On the other hand, up to 50 or 60 percent of addicts who want to stop using heroin fail to successfully complete detoxification and subsequently never get a chance to benefit from rehabilitation. A prospective randomized controlled clinical trial will be necessary to effectively answer this question.

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8.Can I place a web link in an article posted to the discussion forum? Not by yourself. Please write your link in the format http://www."site name"."domain"; i.e. (http://www.heroin-detox.com). The link will then be made by me using administrator software. You may also want to send me a reminder to process your link. My e-mail address is gonzales@heroin-detox.com. 9.How do I use the discussion forum? The discussion forum is designed for use by the public and medical professionals. You can read, post, or reply to any article. If you later decide that the information you posted is incorrect, or, you want to change some information, just send me email gonzales@heroin-detox.com and I will make the changes for you. A common mistake visitors make involves posting or replying to articles. After you type your text, you must click the "Post Article" button located BELOW the text box. The "Post" button above the text box is not the correct button and will not work (Sorry, but this is the way the software is written). Note that you can also search the discussion forum for specific information. 10.Are there any government reviews concerning naltrexone induced detoxification under general anesthesia? Yes. A group of "expert" consultants produced a report to the National Institute on Drug Abuse (NIDA). I could not find the document on the web so I have reproduced it here for you to review. Personally, I am surprised at the lack of understanding the "experts" show with respect to this detoxification method. Some of their comments are simply incorrect. I have written a response directed towards these incorrect statements. (Look at the end of this text the italics !) 11.Are there any guidelines for One Day Detox programs? Currently there are no clear guidelines for providers of the one day detox method. I have listed some guidelines for potential consumers to consider when searching for a one day detox program. 12.Why do some patient seem to have a good outcome from one-day detox while others seem to have a terrible experience? Poor outcomes must be the result of either patient variation or detox procedure variation. Only a good scientific study will be able to determine the true etiology, although, I tend to believe that the variation lies in the detox protocols. Some are good and some are bad. The public should be aware that many current providers of one-day detox have not subjected their detox protocols to standard academic scientific study. Loimer, Pressiech, and Legarda are the only authors who have published their specific methods and results. Unfortunately, in my opinion, all of these published protocols lack significant components required for consistent good outcomes. All other one-day detox providers just "say" they have good results; This includes CITA and Dr. Lance Gooberman. As most people who regularly visit this forum know, I have helped to develop a one-day detox program called the UniQual Network. We could have started detoxing patients over a year ago. Instead we decided to accumulate as much scientific and clinical information as possible and create a protocol based on sound scientific principles. Currently,(12/6/97), our detoxification protocol is being tested and evaluated at St. Elizabeth's Medical Center in Boston. Our preliminary results reveal a stable detox and post-detox pattern. Researchers at St. Elizabeth's told us from the beginning that outcomes from our detox protocol will be published whether the results are good or bad. The primary concern from these investigators was that the method receive unbiased evaluation. Once our protocol proves to be safe and effective, UniQual will open clinics throughout the United States, with each program utilizing the same protocol. UniQual will separate itself from all other providers by publishing our specific methods for peer review, duplication, and criticism. No other current provider in the United States has subjected their protocols to such stringent academic study. I can anticipate the comments from my statements regarding the importance of rehabilitation. "Detoxification without rehabilitation is useless!!" I agree. My comments here were specifically directed towards current detoxification protocols. UniQual is pursuing development and study of rehabilitation protocols parallel to development of the detoxification protocols. Response to NIDA (National Institute on Drug Abuse. USA) Scott Gonzales, MD This paper is written by me in response to a report presented by Dr. Barbara Herman and Dr. Dorynne Czechowicz titled NIDA Scientific Report of Ultra Rapid Detoxification with Anesthesia (UROD): Opinion of the Consultants and Criteria Relating to Evaluating the Safety and Efficacy of UROD, Feb 23, 1996. We are fortunate that such reports are made public. In this case, several statements are incorrect. Additionally, some arguments need further elaboration for clarification of the respective issue. I will finish this letter with some of my own opinions regarding the proper role of government agencies and providers of the UROD method (Note: In the report by Dr. Herman, UROD is used generically to represent a detoxification technique using opiate antagonist and general anesthesia. For clarity purposes, I will use the term this way. It should be noted that the name "UROD" is property of CITA and represents their specific detoxification protocols and methods). Heroin addiction is quickly becoming a major health care threat in the United States. In testimony before the house Subcommittee on National Security, International Affairs and Criminal Justice on September 9, 1996, Thomas A. Constantine, Administrator of the DEA, estimated that there are currently approximately 2,000,000 heroin users in the United States, 600,000 are hardcore. Relying on research from Cornell University, Mr. Constantine testified that "the number of middle class people requesting treatment for heroin addiction has increased tenfold in the past two years." He further stated that the number of heroin-related emergency room visits rose from 34,000 in 1990 to 76,000 in 1994. A driving factor in increased heroin use is recent purity levels. In the 1970s and early 80s, street heroin averaged only between 2 and 7 percent heroin. At those levels, getting high was not easy; a user had to inject the drug intravenously. Today, according to Mr. Constantine, "it is not uncommon to find heroin purity as high as 80% being sold on the street." High grade street heroin is an easy high which allows needle-averse user to avoid intravenous administration and smoke or "snort" the drug to get stoned. A national survey conducted by the Substance Abuse and Mental Health Services Administration found that between 1988 and 1993, the number of hospital emergency department visits related to snorting or sniffing heroin jumped by 470%. In light of the increasing use of heroin and the report presented by Dr. Herman, I offer the following statements and clarifications. The risk/benefit ratio is unacceptable as a detoxification procedure. There is no good data to support this statement. The medical literature currently includes only six studies evaluating 63 patients who were treated with the UROD method. In these studies, no significant morbidity or mortality was reported. Additionally, no follow-up was obtained. Therefore, the benefit experienced by the patient is not known. The consultants to Dr. Herman did not perform a risk/benefit analysis of UROD, rather they compared the incidence of complications associated with standard opiate detoxification to the incidence of "serious adverse events" associated with general anesthesia. This comparison is very difficult to make. First of all, if one is looking at the risk of morbid events for the patient, one should compare the risk of general anesthesia to the risk of continued use of heroin. Clearly, general anesthesia is safer than heroin use. Additionally, statistics regarding the morbidity and mortality associated with anesthesia vary greatly depending on the study cited. The consultants for Dr. Herman cite "serious events" in 1 in 15,000 anesthetics. Dr. E.C. Pierce, former President of the American Society of Anesthesiologist and current President of the Anesthesia Patient Safety Foundation, quoted a 0.05 in 10,000 incidence of mortality associated with general anesthesia in his keynote lecture at the American Society of Anesthesiologists Annual meeting held in Atlanta, Oct 1995. The consultants continue by discussing the possibility of patients aspirating gastric contents while participating in UROD. I completely agree with this statement and I am amazed that any competent provider of anesthesia services would allow a patient to have this procedure performed without protecting the airway with an endotracheal tube. This is certainly below acceptable standards of care in the United States. Another subject discussed by the consultants regarding the risk of UROD involves the association between naloxone and pulmonary edema. Unfortunately, the consultants show a superficial knowledge of this issue and do not draw the correct conclusions. It is true, good case reports exist describing pulmonary edema immediately following naloxone administration in post-operative surgical patients who were diagnosed with respiratory depression.1,2 Unfortunately, no mention was

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made regarding the mechanism by which pulmonary edema occurs and whether or not patients participating in UROD would be at risk for this complication. All of the authors reporting pulmonary edema in post-operative patients cite the neuro-surgical literature regarding the mechanism for pulmonary edema. In these studies, the investigators developed a cat model where they injected mock cerebral spinal fluid into the cerebral ventricles of cats, thus causing hypertension and pulmonary edema. Further studies by the same group revealed that pulmonary edema could be avoided if pulmonary pressure was controlled. 3,4,5 The point is, pulmonary hypertension, not a direct effect of naloxone, caused pulmonary edema in these patients. Why then were post-operative patients experiencing pulmonary edema? This question has not been answered; although, logical assumptions can be made. These patients all had respiratory depression. Therefore, by definition, they had respiratory acidosis and high pCO2 levels. High pCO2 levels cause high pressure in the pulmonary artery. In addition, these patients immediately hyperventilated after naloxone administration, thus increasing negative intrathoracic pressures. This leads to movement of volume into the chest which also increases pulmonary pressure. Patients participating in UROD would not necessarily be exposed to these predisposing factors and therefore probably will not be at risk for pulmonary edema. As additional support suggesting naloxone does not cause pulmonary edema, it should be noted that anesthesiologist frequently administer naloxone to awake patients who have received intrathecal or epidural opiates. There is not one case, as far as I know, in the medical literature describing pulmonary edema in this patient population. The consultants cite the case report by San as evidence that pulmonary edema may occur in UROD patients. Certainly, San states that his patient experienced pulmonary edema. What is not mentioned by the consultants is that Sans patient experienced hypoxemia approximately four hours after the naloxone bolus in the setting of vomiting without a protected airway. 6 It seemed clear to me that the patient became hypoxemic due to aspiration, not pulmonary edema. In all of the other case reports describing pulmonary edema following naloxone administration, pulmonary edema immediately followed the administration of naloxone. This is consistent with the proposed mechanism for pulmonary edema. San actually cites the neuro-surgical literature, previously described, as the mechanism for pulmonary edema in his patient. His conclusions do not fit this model. As you can see, there are serious problems regarding the supporting documentation used by the consultants in order to support their statements that "the risk/benefit ratio of UROD is unacceptable as a detoxification procedure." The expense and elaborate nature of UROD is not justified since there are several other less expensive and less elaborate detoxification methods. The consultants state that "an elaborate intensive care or operating room inpatient facility equipped with appropriate medical and nursing staff and equipment would be needed for this procedure, especially if anesthesia is used." The consultants should have reviewed the "Guidelines For Non-Operating Room Anesthesia Locations" provided by the American Society of Anesthesiologist on their web page. These guidelines require the following: 1) source of oxygen, 2) source of suction, 3) In any location where inhalation anesthetics are administered, there should be an adequate and reliable system for scavenging waste anesthetic gases, 4) resuscitative bag for positive pressure ventilation, 4) adequate anesthesia drugs, supplies and equipment for the intended anesthesia care, 5) adequate monitoring equipment, 6) sufficient electrical outlets to satisfy anesthesia machines and monitoring equipment requirements, 7) adequate illumination of the patient and monitoring equipment, 8) availability of battery powered illumination 9) sufficient space for equipment and personnel, 10) emergency cart with a defibrillator, emergency drugs and equipment adequate to provide cardiopulmonary resuscitation, 11) two way communication to request assistance. These criteria in no way require an intensive care unit or an operating room. Additionally, there is clear precedence to administer anesthetics in other areas such as the postanesthesia care unit, PACU, where all of these criteria are met. At the Massachusetts General Hospital, where I trained in anesthesia, we commonly administered general anesthesia in the PACU for Electrical Convulsive Therapy. The consultants stated "if just detoxification costs are considered, UROD is not cost effective as compared with other inpatient procedures." This is a meaningless comparison. Using this logic, one could state that cold turkey detoxification is the detoxification treatment of choice since it is free. It seems that the consultants consider the effectiveness of the detoxification and discomfort for the patient insignificant. The UROD method potentially results in 100% successful detoxification rates without the discomfort associated with withdrawal. Certainly, the UROD technique will be expensive at first. This is common to all new treatment modalities. UROD, when considering only the detoxification itself, is basically a 4 to 6 hour anesthetic. As familiarity with the technique improves and market forces take effect, I am sure that the cost of the procedure will drop tremendously. Final costs should lie in the $3,000 range. Medication without Psychosocial Support Has Little Impact on Opiate Addiction. I agree completely with this statement. Providing UROD without effective rehabilitation is a serious injustice to the patient. The report states, "Dr. Waismann has probably supervised more detoxifications (at least 1,000 by his own admission) using UROD than any other individual. In addition, Dr. Walsmann is in the process of patenting a UROD technique, as he has indicated that he will not reveal the precise medications/doses used until his patent is secured." Additionally, "Dr. Walsmann states that utilizing his UROD treatment, our patients wake up 100% cured of their physical addiction, period and that the success rate (patients kept drug free for more than six months) is 80%." The fact that the owners of the UROD method do not publish their data leads me to be very suspicious of their methods in general and question their stated success with high skepticism. It seems unlikely that medical professionals would keep such a highly successful method away from people who need it; especially if the only reason is profit. They deal with patients addicted to heroin on a daily basis and therefore know that patients are dying from heroin every day. Setting profit as the priority would be highly unethical and would not be tolerated by the medical community in the United States. Finally, my opinions regarding the appropriate role of government agencies and providers of the UROD method. I see a current move to set restrictions on providers of medical care in the United States who are interested in this technique. Why are new standards necessary? We already have rules and regulations forcing physicians in the United States to provide care at a level consistent with that available by most physicians in the community. Failure to practice at these standards results in serious penalties and restrictions on ones ability to practice medicine. It should be clear to all physicians providing UROD that the detoxification involves an anesthetic (some may argue that it is only heavy sedation; regardless, the patient is receiving medications that cause unconsciousness and at least reduce airway reflexes). Consequently, the procedure should be provided by, or at least supervised by, an anesthesiologist. Similarly, there is ample documentation in the medical literature that detoxification must be followed by rehabilitation in order to provide quality long term care for the patient. Therefore, meaningful rehabilitation should be an integral part of any program developed to provide the UROD method. An anesthesiologist who "opened shop" and provided only the detoxification would not be looking out for the best interest of the patient. The treatment of opiate addiction is complex and requires management from experts trained in this field. Groups planning to provide addiction treatment programs that include detoxification under general anesthesia will be wise to have an addiction specialist supervise all activities. Physicians in the United States are leaders in the medical community. As new techniques emerge, they are investigated intensely and refined using the scientific method and peer review. This process is currently occurring, with respect to the UROD method, at major academic institutions in the United States. I am certain that the results of these studies will be published in order to confirm or refute the technique. I urge government agencies to allow the medical community to utilize their resources to evaluate UROD and expand the method if studies confirm its usefulness. If there are concerns that a specific provider is not practicing at a standard of care that is acceptable, then specific reviews and penalties should be directed towards that individual or group. Sincerely, Scott Gonzales, MD

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References: 1. Taff, R. Pulmonary edema Following Naloxone Administration in a Patient Without Heart Disease. Anesthesiology. Vol. 59, pp. 576-577, 1983. 2. Partridge, B. Phil, D. Pulmonary Edema Following Low-dose Naloxone Administration. Anesthesiology. Vol. 65, pp. 709-710, 1986. 3. Theodore, J. Robin, E. Pathogenesis of Neurogenic Pulmonary Edema. The Lancet. pp. 749-751, 1975. 4. Hoff, J. Nishimura, M. Garcia-Uria, J. Miranda, S. Experimental neurogenic pulmonary edema, Part 1. J. Neurosurgery. Vol. 54, pp. 627-631, 1981. 5. Garcia-Uria, J. Hoff, J. Miranda, S. Nishimura, M. Experimental neurogenic pulmonary edema, Part 2. J. Neurosurgery. Vol. 54, pp. 632-636, 1981. 6. San, L. Puig, M. Bulbena, F. High risk of ultrashort noninvasive opiate detoxification. Am. J. Psychiatry Vol 152 (6), p956, 1995.

.
NOTE: This paper was sent to me by Dr. Czechowicz from the Department Of Health & Human Services. It is not my work. The report was written for NIDA by the authors listed in the report. The report contains important information regarding naltrexone induced opiate detoxification under general anesthesia. Since I did not write the paper, I am not responsible for the poor grammar. This review paper does not represent the official position of NIDA. NIDA Scientific Report of Ultra Rapid Detoxification with Anesthesia (UROD): Opinion of the Consultants and Criteria Relating to Evaluating the Safety and Efficiency of UROD.February 23, 1996 Authors of Report Barbara H. Herman. Ph.D., Director, Clinical Opioid Medications Program (COMP), Clinical Trials Branch (CTB), MDD, NIDA, NIH. Dorynne Czechowicz MD, Treatment Research Branch (TRB), DCSR, NIDA, NIH Consultants: Charles OBrien, MD. Ph.D., Professor of Psychiatry, Chief of Psychiatry, VA Medical Center (VAMO). treatment Research Center, University of Pennsylvania School of Medicine and Joseph R. Volpicelli. MD. Ph.D. of the same institution; Herbert 0. Kleber, MD, Professor Psychiatry, Director, Division of Substance use, College of Physicians and Surgeons of Columbia University; Annie Umbricht, Scheiter, MD. Medical Director, Clinical Center, NIDA intramural Research Program. Addiction Research Center; and Thomas Kosten, MD. Professor Psychiatry, Department of Psychiatry, Yale University School of Medicine (see Attachment A). Based upon the available information, it is the opinion of selected experts in the U.S. who are prominent in the opiate addiction field, that the UROD anesthesia method is currently without ethical, medical, scientific, or financial justification as a clinical detoxification treatment at the present time based upon the following six criteria: 1.Risk:Benefit Ratio is Unacceptable as a Detoxification Procedure. 2.Detoxification is Not a Cure for Opiate Addiction. 3.The Expense and Elaborate Nature of UROD Is Not Justified Since There are Several Other Less Expensive and less Elaborate Detoxification Methods. 4.Medication without Psychosocial Support Has Little Impact on Opiate Addiction. 5.Only one Double Blind Study and Few Research Reports Systematically Documenting the Nature of the UROD Treatment and Its Safety or Efficacy for both Immediate Detoxification and longer Term Relapse Prevention. 6.No Double Blind Studies Indicating that Ultra Short Detoxification Procedures are More Successful in Decreasing Relapse to Opiates than Longer Duration Treatments. The rationale underlying each of these criteria are detailed below with scientific justification. However, if subsequently proven safe and effective with rigorous scientific investigations, UROD (1 to 2 days duration) may have some use in the treatment of extremely high risk individuals who are dependent upon opiates and who would otherwise turn down more conventional detoxification procedures (Including 5 day detoxification methods). This assumes that such patients undergoing detoxification will subsequently be encouraged to participate in follow-up long term relapse prevention treatment. Therefore, additional research evaluating UROD should be undertaken only in very carefully considered and rigorously designed studies. 1. Risk:Benefit Ratio of UROD Is Unacceptable as a Detoxification Procedure. Unlike detoxification from barbiturates, benzodiazepines or alcohol, opiate detoxification has no known mortality risk in uncomplicated cases (Farrell, 1994; Jaffe, 1992 & 1995; Mattick & Hall, 1996; personal communication from H. 0. Kleber to B.H. Herman on 02/07/96). In contrast, there is a risk of serious adverse events including death with the use of anesthetics. The rate of serious adverse events including death with anesthetics depends upon many factors including the anesthetic and dose being used, the patient population, etc.. Peter J. Cohen. MD, JD. of MDD, NIDA, former Professor of Anesthesia of Pennsylvania Medical Center has estimated that if one averages across all of the above factors, then the risk of serious AEs including death is about 1 in 15,000. Besides direct causality associated with inadvertent anesthetic overdose, there is also the risk of indirect causality related to possible aspiration and choking from emesis that may occur when an anesthetized or heavily sedated individual is detoxified while asleep. This is of special concern since the UROD technique involves the administration of an opiate antagonist such as naloxone or naltrexone to precipitate withdrawal during anesthesia or sedation. The risk of the latter is eliminated with the use of intubation and ventilation which is typical during general anesthesia. However, intubation does not appear to be employed in several of the studies where heavy sedation (benzodiazepines were used). Therefore, in the latter case, if an open airway is not available, the patient may choke to death on his own vomit. Several researchers in this field have used ondansetron to reduce the risk of emesis during opiate antagonist precipitated withdrawal during UROD (e.g., Legarda & Gossop, 1994; Loimer et al., 1990), although doses to achieve this effect have not been documented. Finally, administration of high doses of naloxone by the intravenous (iv) route, may also be associated with life-threatening adverse events during the UROD procedure. Often, the UROD procedure involves a bolus injection of very high doses of naloxone (10 mg, i.v.) followed by a slow infusion of low dose naloxone (0.4 - 0.8 mg/h i.v. for 24 - 48h) (e.g.. Loimer et al., 1988; Presslich et at., 1989). Early studies suggested that naloxone reversal of high-dose anesthesia was not accompanied by significant cardiovascular changes in surgical patients (e.g., Freye, 1973; Longnecker et al., 1973). However, more recent studies have indicated a small but significant incidence in

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cardiovascular complications including cardiac arrest (e.g.. Andree, 1980; Michaelis et al., 1974 ) and pulmonary edema (Partridge & Ward, 1986; Prough et al., 1984; Taff, 1983) following i.v. naloxone administration to surgical patients. There is at least one very recent report in the literature that during anesthesia i.v. administered naloxone (high dose) lead to a life threatening adverse event (pulmonary edema) when the UROD procedure was used (San et at., 1995). 2. Detoxification is Not a Cure for Opiate Addiction. Detoxification is a brief (although important) bridge between maintenance and relapse prevention in the treatment of opiate addiction (see Herman et al., 1995). For recent reviews of detoxification procedures for opiate addiction see Fishbain et al., 1993; Gold, 1993; Jaffe, 1995; Mattick & Hall, 1996; O'Brien & McLellan, 1996). An evaluation of the efficacy of detoxification programs was recently described by Mattick and Hall (1996), who state that "...detoxification should not be regarded as a treatment for dependence per se, since prospective controlled studies show that people who have undergone detoxification are no less likely to relapse to drug use than those who have not (e.g.. Gerstein et at., 1990; Institute-of-Medicine, 1990; Simpson et al., 1982). For example, Ball and Ross (1991) have shown that about 82% of opiate-dependent individuals previously maintained on methadone relapse to i.v. opiates about 1 year following cessation of methadone therapy. Mattick and hall (1996) consider that a safe and humane detoxification from the drug of dependence is a worthwhile aim in itself. Therefore, these authors suggest that criteria for assessing the effectiveness of detoxification should be based upon: (1) rates of completion of the process, (2) severity of withdrawal symptoms (both psychological and physical distress), and (3) medical complications. In a recent review article by O'Brien and McLellan (1996), a rationale is presented to support the notion that opiate addiction is a chronic disorder much like diabetes, hypertension and asthma. Therefore, the authors argue that no acute care procedure including detoxification is sufficient in of itself in the treatment of addiction. As stated by these authors, "As with other chronic disorders, the only realistic expectation for the treatment of addiction is patient improvement rather than cure." Given the high relapse rate for opiate addiction following detoxification, the "benefit" of risky, elaborate or expensive detoxification procedures are not justified. 3. The Expense and Elaborate Nature of UROD is Not Justified Since There are Several Other Less Expensive and Less Elaborate Detoxification Methods. An elaborate intensive care or operating room inpatient facility equipped with appropriate medical and nursing staff and equipment would be needed for this procedure, especially if anesthesia (verses moderate doses of a sedative) is used. This is not the case for other more conventional types of inpatient detoxification procedures which require no elaborate facilities or equipment other than the ideal of a locked ward or outpatient detoxification procedures. As of July of 1995, there were at least 5 clinics practicing UROD in the world with either a direct or indirect connection with Dr. Andre Waismann of Israel or with Dr. Juan Jose Legarda of Spain. These clinics are called CITA clinics and include centers in: (1) Seville, Spain, (2) Rishon, Israel, (3) Tel Aviv, Israel (4) Bologna, Italy, and (5) New Jersey, USA. The cost of treatment in Israel for a 1 to 2 day UROD treatment with a six month follow-up is $5,000 (The Jerusalem Report, July, 1995), while the cost for the 1 to 2 day treatment in New Jersey is about $7,500 (personal communication from H. D. Kleber, MD to B.H. Herman, Ph.D. on 02/07/96). In the U.S., an estimate of the cost for inpatient detoxification (about $285 per day) procedures are as follows: for a 5 day period (e.g.. rapid detoxification with clonidine + naltrexone) is about $1,425 and for various types of methadone detoxification is about $2,850 for a 10 day period, $3,705 for a 13 day period (typical if inpatient option is used and patient requires stabilization from other substances), $5,700 for a 20 day period (estimate provided by Daryl Stockdale, M.S.W., Business Manager, Psychiatry Service, VAMC, Treatment Research Center, Philadelphia PA to B. H. Herman, Ph.D. on 02/23/96. Estimates of conventional inpatient detoxification programs in the U.S. include psychosocial support to assist the patient during this period. Therefore, it is estimated that the cost of UROD is about 2-3 times the cost of more traditional inpatient methadone detoxification procedures of 10-13 days in duration. In short, if just detoxification costs are considered, UROD is not cost effective as compared with other inpatient detoxification procedures. 4. Medication without Psychosocial Support Has Little impact on Opiate Addiction. In a prospective study. McLellan et al. (1993) have demonstrated that opiate dependent individuals receiving maintenance treatment of 60 mg of methadone show the lowest illicit opiate abuse when their treatment is paired with the most comprehensive psychosocial support. This nonmedication effect was so striking that 70% of individuals who were provided with medication but with just emergency counseling were "protectively transferred" to standard care (regularly scheduled drug counseling) because of "unremitting" use of opioids or cocaine or psychiatric emergencies. An example of the importance of psychosocial support to detoxification outcome is illustrated in a double-blind study by Banys et al. (1994) in 76 opiate-dependent individuals indicating that there was no significant difference between a low dose (40 mg) versus a high dose (80 mg) of methadone maintenance therapy in a 180-day methadone detoxification program with the adjunct of intensive psychosocial support. (In the absence of intensive psychosocial support, it has been well established that the most effective maintenance dose of methadone is between 50 and 100 mg (Ball & Ross, 1991; Cooper, 1992)). If the description of the UROD approach of Dr. Waismann in The Jerusalem Report of July, 1995 is accurate, then it appears that Dr. Waismanns program also includes a six-month follow-up involving "social workers and psychologists, after the physical addiction has been dealt with"(p.21). However, from this brief description it is not clear exactly what services are performed by these social workers and psychologists. Therefore, unless medication and psychosocial support are instituted following detoxification, there is a low probability that any detoxification procedure (including UROD) will produce a lasting respite from opiate abuse in former opiate dependent individuals (see OBrien & McLellan, 1996). Gerra et al. (1995): A rigorous and pharmacologically comprehensive double-blind placebo controlled study using rapid detoxification (detox) in awake individuals was recently reported (Gerra et at., 1995). This study included both a medication detoxification protocol and a medication relapse protocol and psychosocial support all conducted in outpatient individuals with a documented history of opiate dependence. Results of this study illustrate both the efficacy of clonidine in combination with an opiate antagonist as a detoxification treatment, but also the importance of follow-up naltrexone plus psychosocial support to prevent relapse to opiates. Methods: For the 4 day detoxification period, the patients underwent i.v. therapy with an indwelling venous cannula, in an outpatient recovery center. Medication was then given orally during a subsequent 3 month relapse prevention (RP) period. The study was conducted In 152 heroin-abusing individuals comparing four different detoxification treatments using the rapid detoxification (detox) method in awake individuals and the groups included: (1) placebo (IV - Detox); placebo P.O.(RP); (2) clonidine (clonidine IV - Detox); placebo P.O. (RP); (3) clonidine + naloxone (clonidine IV + naloxone IV- Detox); naltrexone P.O. (RP); and (4) clonidine + naltrexone (clonidine IV + naltrexone P.O. - Detox); naltrexone (P.O. - RP). Intensive psychosocial support was provided for all four groups to the same degree. Results. Results indicated that for the first 24h of Detox, objective opiate withdrawal scores were significantly greater in the placebo versus the other 3 groups. By 48h, withdrawal scores were highest in the placebo group, about equal in the clonidine + naloxone or clonidine + naltrexone groups, and lowest in the clonidine group. By 72h, all three clonidine groups (either with or without naloxone or naltrexone) showed virtually no withdrawal symptoms while those for the placebo group were still manifesting significant withdrawal symptoms. Conclusions. These data substantiate the efficacy of clonidine in treating opiate withdrawal symptoms, and suggest that the addition of an opiate antagonist to clonidine decreases the duration of withdrawal symptoms to 2 days while increasing the actual expression of symptoms on the 2nd day. The group ordering at 6 months following detoxification indicated that the percentage of individuals with "dirty" urines was about 70% in the placebo group, 60% in the

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clonidine group, and about 20% in the two groups who had received clonidine + opiate antagonist during detoxification and just naltrexone during relapse prevention. The latter data indicate the efficacy of naltrexone as a treatment for decreasing relapse to opiates in medically detoxified individuals when combined with intense psychosocial support. 5. Only one Double-Blind Study and Few Research Reports Systematically Documenting the Nature of the UROD Treatment and its Efficacy for both Immediate Detoxification and Longer Term Relapse Prevention. In attempting to evaluate the efficacy of UROD, one small double-blind study (Loimer et al., 1990), several short research reports (Legarda & Gossop, 1994; Loimer et al., 1989, 1991a and 1991b; Presslich et al., 1989a 1989b) and several clinical reports (mostly Journal letters) (Brewer, 1988; Loimer et al.. 1988,1993) were found. All of these reports are in English with the exception of Presslich et al. (1989b) which has an English abstract and a German text. The major problem in rendering a firm scientific opinion on UROD at this time is that the majority of published reports on UROD are not single or double-blind controlled trials, research reports are conducted with relatively small numbers of patients, and the only other available information are clinical reports. Finally, since as many as seven medications (e.g., Legarda & Gossop, 1994) may be used in the procedure it is difficult to systematically determine which medication may be responsible for alleviation of opiate withdrawal symptoms. Therefore, pending further rigorous research, these data suggest the very tentative possibility that UROD may be used to detoxify opiate dependent individuals from opiates relatively quickly (1-4 days). Without additional rigorous scientific studies, this interpretation will have to remain a "medical impression". Two of the most rigorous studies are detailed below. Loimer et al. (1990); There is one double-blind placebo-controlled study of the UROD technique utilizing anesthesia (Loimer et al., 1990) in 18 opiate dependent individuals examining the contribution of naloxone versus placebo in combination with methohexitone (barbiturate) anesthesia in achieving opiate detoxification. Method. All patients abusing drugs other than opiates were excluded (EMIT). Patients were admitted to the hospital 1 day before treatment. There were two outcome measures: (1) observer rated modified Wang (1974) test: scale of physical symptoms of withdrawal used both before and after a provocative challenge with naloxone (2 mg, iv.), and (2) patient rated Kolb and Himmelsbach (1938) scale: included both physical and psychological symptoms of withdrawal. Initially, patients were stabilized on morphine (pg., 100-300 mg) on Days 1 and 2 to ensure that patients would not be in withdrawal before detoxification. Then, 12h after the final morphine dose, detoxification began and included the following regimen in the order indicated: 1. methohexitone (by injection, 100 mg), 2. Intubate + ventilate; 3. methohexitone (by injection, 400 mg); 4. random doubleblind assignment to one of two groups; either- placebo (i.v., bolus) (N=9), or naloxone (i.v.. bolus 10 mg) (N-9); 5. first evaluation Wang test - no naloxone, 30-40 min after methohexitone; 6. second evaluation - Wang test - naloxone (i.v., 2 rng), 3 & 6 min following naloxone; 7. further methohexitone (up to 250 mg) if severe withdrawal (e.g., placebo group); 8. all patients given naloxone (i.v., bolus 10 mg) (N=I8); 9. naloxone (i.v., 0.8 mg/h) for 48H (N=18) open design. Results. Results are somewhat difficult to interpret since there is no side by side comparison of numerical data in the placebo versus naloxone groups in the figures or the text. Therefore, evaluation of results rely in part on investigator's interpretation of their unpublished data. Fig. 1 (p.749. Wang test) shows the results for the placebo group indicating that when methohexitone wore off there was little withdrawal symptoms. However, when these patients were challenged with naloxone (0.2 mg), Wang scores increased significantly (from mean of 3 to 15) reflecting severe withdrawal. This state was immediately inhibited by subsequent anesthesia. During this second anesthesia, patients were given first a 10 mg naloxone bolus then a 2 mg naloxone bolus, and results suggested only mild withdrawal (Wang mean of about 5). In contrast, the "naloxone group" who initially received the 10 mg naloxone during the original anesthesia demonstrated only minimal symptoms both during and after anesthesia (data not shown). Further, a follow-up 2 mg naloxone Wang test was also negative for withdrawal in this naloxone group (data not shown). Therefore, these results suggest that the barbiturate, methohexitone, in of itself significantly inhibits physical opiate withdrawal symptoms. The addition of a high dose of naloxone (10 mg) (versus placebo) administered during anesthesia induced further reductions in the expression of opiate withdrawal symptoms both during and following anesthesia (as revealed by a 2 rng naloxone Wang challenge test). This latter effects may relate to the expected acceleration of detoxification with naloxone. Self-rating of withdrawal distress by the patients themselves (Kolb & Himmelsbach, 1938) (N=18 combined), indicated a decline in opiate withdrawal symptoms during the days following detoxification with "normal" levels reached by 6 days. Conclusions. Results provide very tentative suggestions that both barbiturates and high doses of naloxone induce short-term decreases in opiate withdrawal. Evaluation of these data would be aided by a side-to-side comparison of the numerical Wang scores obtained in the two groups during and after methohexitone anesthesia when patients were successively challenged with a 2mg dose of naloxone. The same side-by-side group comparison would be helpful in evaluating the self-report data. Legarda and Gossop (1994). One of the most systematic (though open) studies of UROD with sedation was reported by Legarda and Gossop (1994). The UROD technique was investigated in 11 opiate dependent individuals with abuse or dependence to other drugs (e.g., cocaine, benzodiazepines, alcohol). The primary medication regimen was to sedate patients with midazolam (a benzodiazepine) and to precipitate opiate withdrawal during this sedation with naltrexone (p.o.) In an intensive care unit. Method. However, there were seven medication steps in total for detoxification which included in the order of their administration: (1) guanfacine (to decrease blood pressure and heart rate prior, during and shortly after detoxification), (2) naltrexone (p.o., to precipitate withdrawal), (3) loperamide (to decrease diarrhea), (4) ondansetron (to decrease vomiting), (5) midazolam (i.v., to induce sedation). (6) naloxone (i.v., to test detoxification states about 4h after sleep induction), (7) guanfacine (continued administration in decreasing doses when patient begins to wake up from sedation. Results. Statistically significant decreases in the Opiate Withdrawal Scale (Bradley et at., 1987) were selfreported by the participants before versus after sedation. All participants were given naltrexone (p.o., 50 mg) the morning after detoxification, and the investigators report (although no data presented) that there were no physical or subjective symptoms of opiate withdrawal in response to naltrexone. Follow-up for relapse treatment occurred for a one month period and included daily naltrexone (p.o., 50 mg) administration and once a week visits to the outpatient center (nature of psychosocial support not specified). Authors state that after 30 day follow-up, all subjects were taking naltrexone, but these results are difficult to substantiate since no hard markers (in urine or blood) for either naltrexone or opiates were presented. Conclusions. In short, the results of this report suggested that UROD with sedation performed in an intensive care unit could be used to detoxify heroin addicts during a 4h period and transition these individuals to naltrexone during a one month relapse prevention phase. However, this preliminary study will need to be replicated utilizing a double-blind design, greater number of participants, and more systematic outcome measures before a rigorous scientific interpretation of this methodology can be generated. With seven medications, it will be difficult to generate a double-blind design, although at a minimum it would seem to be reasonable to have two arms using the identical medication regimen but varying naltrexone/placebo. With the numerous medications often involved in this procedure (e.g., primary medications such as the anesthetic or sedative, naloxone i.v. bolus, naloxone i.v. slow infusion, and naltrexone and adjunct medications such as ondansetron, loperamide, guanfacine) it will be difficult to develop systematic and rigorous studies. In the meantime, there are few well controlled studies to articulate a rigorous scientific opinion other than risk assessment which has been detailed above. Andre Waismann, MD use of UROD as reported in (The Jerusalem Report, July, 1995). Also attached is a news article (The Jerusalem Report, July, 1995) on UROD including an interview with Dr. Andre Waismann of Israel on his clinical experience with this technique. The importance of the latter is that Dr. Waismann has probably supervised more detoxifications (at least 1,000 by his own admission) using UROD than any other individual. In addition, Dr. Waismann is in the process of patenting a UROD technique, and he has

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indicated that he will not reveal the precise medications/doses used until his patent is secured. We were not able to locate any published research articles by Dr. Waismann on this subject. In The Jerusalem Report of July, 1995, Dr. Waismann states that utilizing his UROD treatment "Our patients wake up 1OO percent cured of their physical addiction, period (p. 21)".. and that "the success rate - patients kept drug free for more than six months - is 80 percent" (p.20). The success rate for relapse prevention described by Dr. Waismann is believable given the results of the carefully controlled study reported by Gerra et al. (1995). (This does not the negate the importance of empirical demonstration by Dr. Waismann in a proper report with a detailing of these data). However, it is more than likely that the critical element is the 6 months of treatment with naltrexone for relapse prevention combined with the unusual nature of his patient population. As stated above, in the Gerra et al. (1995) study, administration of naltrexone as a relapse medication over a six month period resulted in a drug free patient rate of 80 percent in patients given a different detoxification procedure - i.e., an awake therapy of either clonidine + naloxone or clonidine + naltrexone over several days. The capacity of naltrexone to reduce relapse in alcoholics is now well substantiated (e.g., Volpicelli et at., 1992; OMalley et al., 1992), and in certain opioid dependent populations under certain conditions as well. In The Jerusalem Report of July, 1995, the article on Dr. Waismann also maintains that, "many of his patients are soldiers who suffered serious injuries, underwent numerous operations, and over months of painful treatment became addicted to morphine" (p 20). The nature of this patient population may be relevant to Dr. Waismann's rate of treatment success. 6. No Double-Blind Studies Indicate that Ultra Short Detoxification Procedures are More Successful in Decreasing Relapse to Opiates than Longer Duration Treatments. As stated in a review by Jaffe (1995, p.371). "It is not yet clear if these rapid and ultrarapid methods of opioid detoxification are superior to more traditional gradual ambulatory withdrawal in producing tong-term abstinence from illicit opioid use." Conclusions. Therefore, based upon the available information, it appears that the UROD anesthesia method is currently without ethical, medical, scientific, or financial justification as a clinical detoxification treatment at the present time based upon the criteria described above. However, if subsequently proven safe and effective with rigorous scientific investigations, UROD (1 to 2 days duration) may have some use in the treatment of extremely high risk individuals who are dependent upon opiates and who would otherwise turn down more conventional detoxification procedures (including 5 day detoxification methods in awake individuals). This assumes that such patients undergoing detoxification will subsequently be encouraged to participate in follow-up long term relapse prevention treatment. Therefore, additional research evaluating UROD should be undertaken only in very carefully considered and rigorously designed studies. .

DETOX LOCATIONS

http://www.heroin-detox.com/detox.htm

The following programs offer one-day detoxification. Programs with a * next to the name are UniQual Network members and therefore follow all guidelines for quality one-day detox programs. While I personally will not refer patients to non-UniQual programs, many physicians and visitors to this website believe very good, high quality care is given at other programs. Therefore, hyperlinks to all programs that I am aware of are listed. UniQual Network Members: 1.Beverly Hospital * Herrick St. Beverly, MA 01915-2757 UniQual Network 781-304-3171 2.Duke University Medical Center * UniQual Network 781-304-3171 3.Mercy Hospital * 144 State St Portland, ME, 04101-3776 UniQUal Network 781-304-3171 4.St. Elizabeth's Medical Center, Boston* 736 Cambridge St. Brighton, MA 02135 617-789-2574 or UniQual Network 781-304-3171

5.UniQual programs will open soon in New York, Los Angeles, Chicago, and Miami. The UniQual Network will have programs available in most states within the next year. Non-UniQual Programs: Providers that participate in the discussion forum: 1.Lance L Gooberman MD PC One south Centre Street Merchantville, New Jersey 08109 1-800-978-0808 609-663-4447 Fax 609-488-6380 email lgooberman@aol.com www.detox-center.com Other providers: 1.AMGI 2.Addiction Treatment Center of Canada 3.CITA 4.CITA Israel 5.CITA America 6.CITA Spain 7.NEURAAD 8.NUTMEG 9.ORGA http://amgionline.com/ http://www.endaddiction.com/ http://www.opiates.com/ http://cita-israel.com/ http://www.cita1.com/ (see separate document ) http://www.neuroadaptation.com/ http://www.neuraad.com/ http://www.2nutmeg.com/ http://www.detox-center.com/

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10.PROD

http://people.delphi.com/sleepdr/PROD.html

Medical care providers who are interested in starting a high quality rapid detox program should contact the UniQual Network for information. Call Harry Barnett at 781-304-3171, or see the UniQual web site by clicking http://www.uniqual.com/.

Guidelines

http://www.heroin-detox.com/guidelin.htm

Currently, the American Society of Addiction Medicine (http://207.201.181.5/ ) and the American Society of Anesthesiologists (http://www.asahq.org/ ) do NOT offer specific guidelines to consumers or providers of the one day detox method. Therefore, I will offer these guidelines to consumers in an attempt to help you in asking important questions from providers and choosing an appropriate one day detox facility. These guidelines are based on issues of safety and professional medical responsibility. Guidelines for One Day Detox programs. 1.An anesthesiologist or nurse anesthetist should be by the patient's bedside during the entire detoxification period. Some providers will try to call the procedure "sedation" instead of "anesthesia." This is only a play with words in an attempt to save total costs. In all cases of one day detox, the patient is unconscious, does not respond to verbal commands, and is at risk for aspiration unless an endotracheal tube is placed (the patient is pre-disposed to vomiting and may have stomach contents enter the lungs if appropriate precautions are not taken). Anesthesiologist and nurse anesthetists are the only professionals specifically trained to manage patients in this state of consciousness. I refer you to general guidelines adopted by the American Society of Anesthesiologists. Specifically noted are 1) "Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care". 2) During all anesthetics, the patient's oxygenation, ventilation, circulation and temperature shall be continually evaluated" (note the word "continually" - this is a basic standard of care). 2.One day detoxification programs should have linkage to post-detox rehabilitation services. It is clear that detoxification without rehabilitation results in poor long-term abstinent rates. Scientific studies will need to be done to evaluate whether or not simple referral to a rehabilitation program is efficient. For now, I recommend that specific rehabilitation is linked directly to the detox program. 3.A medical professional specifically trained in the management of addictions (preferably a member of the American Society of Addiction Medicine) should have oversight of the entire detoxification and rehabilitation program. This statement is self-explanatory and underscores concerns regarding providers who offer one day detox without having education and experience in treating opiate dependency. 4.Providers should make an attempt to select patients who show evidence of maintaining long term abstinence from opiates. The one day detox procedure should not be a revolving door detoxification. 5.No patient should be forced to participate in one day detoxification. The procedure is potentially beneficial only for those patients who want to quit using opiates. As far as I know, providers from the UniQual Network are the only programs these guidelines.

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U.S. DETOX TREATMENT FOR OPIATE ADDICTION

http://www.detox-center.com/

We are dedicated to offering drug dependent patients a humane, cost-effective and rapid detoxification treatment in a compassionate environment conducive to beginning a lifelong 12-step recovery program. We begin by opiate reversal under a general anesthetic, and this is followed by a program with naltrexone maintenance therapy in conjunction with participation in 12-step recovery programs. After pre-medication with anti-withdrawal drugs and anesthesia, we use opiate antagonists (heroin blocking drugs) to speed up the withdrawal process. The antagonists push heroin, methadone and other prescription pain killers off the body's opiate receptors so that instead of taking two to five days for withdrawal to peak, the worst of the withdrawal symptoms are over within a few hours. This treatment is performed by experienced medical personnel in the privacy of our Intensive Treatment Unit (ITU). During this acute phase, patients are sedated, under close nursing supervision after being anesthetized by a Certified Registered Nurse Anesthetist. This assures that during the acute phase of withdrawal, there will be no suffering. Another advantage of this technique is that maintenance therapy can be initiated immediately. This is done by the implantation of a pellet containing naltrexone which gradually dissolves over time, releasing the blocking agent into the blood stream. This will protect the addict from the use of opiates while in the home environment. Continued treatment is necessary in the form of participation in a 12-step recovery and the use of naltrexone. Naltrexone enters the brain and nervous system and attaches itself to small areas called receptor sites. For heroin to produce its effect, it must attach to these receptor sites, but naltrexone stops heroin from attaching to them. Therefore, the patient does not get "high" and therefore avoids relapse. We recommend that the naltrexone be continued for at least six months. Naltrexone implants are put in initially at the time of the opiate reversal under general anesthesia. OPIATES : Prescription Pain Killers includes drugs such as Methadone, Morphine, Demerol, Codeine, Percocet, Vicodan, Tylenol #3, Tylenol #4, Darvon, Darvocet, Stadol, Nubaine and others. NALTREXONE PELLET MAINTENANCE THERAPY : After an area is anesthetized with 2% Lidocaine with epinephrine, it is prepared and draped in the usual manner. An incision is made with a #15 blade, approximately one-half inch in length. A pocket is created in the area adjacent to the incision by spreading with blunt curved Metzenbaum scissors. A 1 gram naltrexone pellet is inserted into the pocket and the wound is closed with 3 vertical mattress sutures of #3-0 Vicryl and the wound is dressed. The patient is instructed that should any bleeding occur, to apply pressure. He is further instructed to expect bruising and swelling.Should any infection develop, it is treated with Duricef 600 mg p.o. b.i.d. for ten days. Frequently Asked Questions http://www.detox-center.com/faq.htm 1. What is Ultra Rapid Opiate Detoxification (UROD)? Opiates, like heroine and methadone have their effects on specific receptors of the nerve system. When an addicted person stops consuming opiates, the withdrawal syndrome appears, which lasts five to ten days. UROD cleans the receptors of the nerve system, taking off every part of the opiates, while the person is adequately sedated. When the person wakes up, the receptors not only have been cleaned but also they are blocked so that opiates can not have any effect. 2. What is neuroadaptation? Drugs alter the neurones of our brain. These alterations are repaired while the patient is sleeping during UROD. If the patient would only be detoxified, the illness would still persist. That is why the neuronal adaptation during UROD is so fundamental. 3. What are the advantages of UROD? The individual does not suffer during the detoxification. He doesnt go through the withdrawal syndrome, which is the major reason for drop-out in the actual treatments. With this procedure no patient drops out during detoxification. Even further, many individuals who would never get to start a rehabilitation, can begin it without suffering. 4. What are the advantages of neuroadaptation? With only taking off the drug toxins (detoxification) of our body, we dont get far in the therapy of addiction. The recovery of the brain damage (neuroadaptation) is the most important because it permits the individual to think and to feel in a different way. 5. Is it a safe treatment? It is safer than using heroin, without any doubt. Thousands of persons have been treated with this procedure without any complications during or after the treatment. Even more, a lot of patients who have been treated were suffering serious physical diseases, such as AIDS, epilepsy and respiratory and hepatic disorders. 6. How does it feel after UROD? Usually fatigue even though a lot of patients feel like having dinner! You have to take into consideration that heroin and in general opiates hide the discomfort and pain of many physical diseases. During the period of addiction the patient loses weight, doesn't usually look after dental or oral higine, nor possible ulcers and they dont care whether or not they have AIDS or TB. The discomfort or pain which is caused by any of these diseases can only be perceived once heroin is out of the body. However after UROD these diseases are adequately treated. 7. How to keep away from heroine after UROD? The medication which will be given to the patient blocks the effects of heroin, methadone or any other type of opiate, like codeine or morphine. It works in the central nervous system concretely getting itself attached to little areas called receptors. To achieve its effects, heroin has to reach the same receptors, but the medication blocks this union during several days depending on the dose. The patient will have to take this medication at least for 9 months being supervised by a relative/friend/clinician. 8. Why it has to be supervised? For the patient to live without feeling attracted to drugs. 9. Is the medication addictive? Definitely not. Even after a year there is no withdrawal syndrome if it is discontinued. 10. Is it a new drug? No. It has already been used in the US for more than twenty years and in several european countries for more than five years. 11. Does it have any side effects? Even though there are minimal side effects in some cases, none of them are serious, we recommend undergoing a medical supervision every two or three months. A very small proportion of patients might experience fatigue and slight digestive problems. 12. Is a psychological treatment necessary? We highly recommend our patients to attend psychotherapy sessions three or four times per week during the first three months and once or twice a month during the following six months

OPIATE REVERSAL UNDER GENERAL ANESTHESIA

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After the patient is placed under general anesthesia, massive amounts of narcotic antagonists are administered which block all the opiate receptors in the patient's body and brain. When this occurs any opiates that may be attached to these receptors are displaced. This would ordinarily precipitate incapacitating symptoms of withdrawal such as nausea and vomiting, diarrhea, chills, fast and slow breathing, abdominal cramps, muscle aches and pains, eyes watering, stretching, fever, sweats and generalized depression, insomnia and misery symptoms. However, since the patient is asleep, he does not experience any of these symptoms nor does he even dream about it. After several hours of active withdrawal these withdrawal symptoms abate. The patient is then awakened from anesthesia. PREPARING FOR THE PROCEDURE Preparing for opiate reversal under general anesthesia is like preparing for a general anesthetic before an operation but without the actual surgery. You probably know, perhaps from personal experience, that people having a general anesthetic are asked to have no food or drink for at least eight hours before a procedure. That is to reduce the risk of vomiting during anesthesia. Once the anesthetic is established, a tube is placed into the windpipe to prevent the inhalation of vomit. Patients may continue taking their usual dose of opiates right up to the time of admission. It doesn't matter whether you reduce your medication, though it does no harm unless it causes you discomfort. The important thing is not to have a final blow-out on opiates, alcohol or other mood-altering drugs. SAFETY With respect to the risk of the treatment, it should be noted that nothing done in our medical facility carries a risk greater than the risk of illicit drug use. In general, providing effective medical treatment means giving drugs or performing operations which interfere with the chemistry or anatomy of the body. All effective drugs can cause side-effects and all operations can have complications, even if the drugs are prescribed or the operation is performed with care and skill. You cant get side-effects from a treatment that you dont have, but you cant get benefits from it either. Anesthesia has obvious benefits, but patients are more likely to die of bad anesthesia than of bad surgery. Competently performed anesthesia carries a low risk of serious complications in patients who are basically young and fit, as most opiate addicts are. Even so, it would be silly to say that nothing could ever go wrong. In contrast to alcoholics, who can get delirium tremens, which is occasionally fatal, few people, if any, have ever died from ordinary opiate withdrawal. However, some opiate addicts have previously found opiate withdrawal so unpleasant that they dont think that they could attempt it or complete it again. Others simply feel that at the dawn of the 21st Century, they shouldnt have to put up with the level of discomfort that conventional withdrawal often involves. If they have already tried the numerous alternative treatments or are skeptical of them, then anesthesia to get them through the most acute stage of withdrawal seems to be about the best we can offer. Some critics say that because there are risks in anesthesia, it shouldnt be used in opiate withdrawal. Our view is that if it is acceptable to use anesthesia to relieve the pains of childbirth (which are not in themselves fatal), or to do cosmetic surgery (which is a luxury rather than a necessity), it ought to be acceptable to use it in opiate withdrawal. If you are 80 and have arthritic hips, you can have a hip replacement, but 80 year olds are more prone to surgical and anesthetic complications than younger patients and occasional death or serious complications will occur. Nobody dies from an arthritic hip but most 80 year olds willingly accept the risks of surgery and anesthesia. We are very willing to work with physicians, counselors and treatment centers, provided they understand and accept this method of treatment. We want to give patients and their families as much help as possible. We also want to keep in touch for research purposes so that we can find out how our patients are doing. In the end, the choice is yours. We provide a range of out-patient withdrawal techniques. Each has its advantages and disadvantages. If you have any additional questions, please call our toll free number 1-800-978-0808. If you want to E-mail us, please click on the e-mail icon above on the left. ELIGIBLE PATIENTS FOR ORGA Patients with serious heart and lung problems would be unsuitable for general anesthesia. If the patients clinical condition is in question, medical clearance from a physician will be required.Patients with other serious medical conditions involving kidney and liver may be required to have medical clearance. However, ORGA has been successfully performed on patients with hepatitis, AIDS, and asthmatics without problems. Of course, general anesthesia does present some risks to patients. COST The current cost for Opiate Reversal Under General Anesthesia is $2900 for heroin and all other opiates except methadone. The cost for methadone GAD (or greater than 20 bags of heroin use per day) is $3600. A naltrexone implant is also available. This involves the injection of small pellets under the skin which gradually dissolve over a two to four week period, releasing naltrexone into the blood. This will make it unnecessary to have supervision of the administration of the oral medication, making it more convenient for everyone concerned and offering the same protection. The implants are usually put in initially at the time of the opiate reversal under general anesthesia. Additional implants can be inserted as needed. The cost of this additional procedure is $475.00. There is no additional cost for implant insertion during opiate reversal under general anesthesia. The implants are obtained from a pharmacist through a prescription for the patient. AFTER TREATMENT Most people feel reasonably well within a day or two after the procedure. They may still feel a bit tired and have a touch of diarrhea or mild back pain, but they can usually eat a meal and go for a walk. Some people will still feel withdrawal symptoms which are more than minor, but instead of getting steadily worse as they do with most standard withdrawal programs, they improve over the next few days and can be helped with appropriate medication. The patient will need to be taken home by a friend or family member. It is very important that patients are in the company of family or friends for the first day or two after the procedure. Anti-withdrawal medications are offered where necessary and when necessary. Most people are ready to return to work within a week, especially if it is not too physically demanding. The patient and his caretaker will be contacted and monitored by telephone from his home for the first forty-eight hours. There is also a doctor on call at all times in case of any subsequent clinical problems.How people recover doesn't seem to have much to do with how much heroin, methadone or other prescription pain killers they were taking, or for how long they were taking them. As with alcohol, some people just seem to have much worse (or much milder) withdrawal symptoms than the average. It is important to note that the procedure performed under general anesthesia is a detoxification, not a cure for addiction. Ultimately, it is the patient's conscious decision to stop using drugs. He is offered the services of follow-up psychological counseling by a certified psychologist. He is also provided with information regarding NA, AA and other self-help group meetings in his local community. It is important that the patient remain on Naltrexone treatment either orally or by implant. For more information on this see "Staying clean with Naltrexone".

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STAYING CLEAN WITH NALTREXONE : Continued treatment is necessary in the form of participation in 12-step recovery and the use of naltrexone. Naltrexone (trade name ReVia) is a tablet that blocks the effects of heroin, methadone and other prescription pain medications. It has been used for over 20 years. HOW DOES NALTREXONE WORK? Naltrexone is a medication that blocks the effects of heroin, methadone and other prescription pain medications. It has been used for over 20 years. There are very few side effects from naltrexone and none of them serious. It is difficult to determine whether the symptoms one experiences initially after detoxification are due to the naltrexone or remnants of the withdrawal syndrome. Naltrexone works by entering the brain and nervous system and attaching itself to small areas called receptor sites. In order for heroin and other opiates to produce their effect, it must attach to these receptor sites. However, naltrexone blocks the opiates from attaching to these receptor sites. Some people need very little support after detox but others need a great deal, which is why we offer six months of follow-up office visits and telephone support, and optional naltrexone implants. There is an additional cost for subsequent implantation procedures. The purpose of naltrexone is that it can prevent relapse. Naltrexone is not addictive. Even after several months there are no withdrawal symptoms if you stop it suddenly. LENGTH OF TREATMENT We recommend that the naltrexone therapy be continued for at least six months. Naltrexone implants are effective from four to eight weeks. Additional implantations should be performed every four weeks. The cost for the implantation procedure is $475. If a patient stops naltrexone therapy prematurely and relapses, a charge will be made for subsequent consultations until naltrexone is resumed or opiate use ceases. WHO CAN TAKE NALTREXONE? Naltrexone would be appropriate for any opiate addict who wants to stop using opiates but who has never managed for long or at all except in prison, or one who thinks that relying on will power or counseling alone will not work for them. Naltrexone is not a mood altering drug and is therefore not objectionable to most individuals who advocate abstinence. We advise all patients to seek counseling, particularly group therapy and most particularly active participation in 12-step recovery programs. We can't overemphasize the importance of living a 12-step lifestyle. Participation in a 12-step recovery program is the single most important form of follow-up care. We believe there is no substitute for the therapeutic value of one addict helping another. If an addict discontinues the use of naltrexone, he must start again either with a 10-14 day abstinence period or a repeat of his opiate reversal under general anesthesia. There are very few side effects from naltrexone and none of them serious. It is difficult to determine whether the symptoms one experiences initially after detoxification are due to the naltrexone or remnants of the withdrawal syndrome. Such symptoms generally cease within a week or two. Taking additional naltrexone is of no consequence. However, if you take naltrexone while you are physically addicted to heroin or other opiates, it will cause severe withdrawal symptoms within a few minutes. If you stop taking naltrexone and start using heroin again, you could kill yourself if you took your usual dose of heroin right away. The current price of naltrexone is approximately $4-5.00/pill. Most prescription programs cover this medication. It is recommended that patients wear a Medic-Alert tag (bracelet or necklace) that would inform a treating physician that the patient is on naltrexone maintenance therapy in the event that the patient is not able to communicate this information. The physician would obviously need to prescribe a non-opiate medication if pain relief was required. ORGA COMPARED TO TRADITIONAL DETOX PROGRAMS http://www.detoxcenter.com/compare.htm ORGA compared to traditional detoxification programs has been demonstrated to show an increased rate of success. This is undoubtedly due to the fact that the ORGA procedure greatly shortens the withdrawal period from seven to ten days or more to several hours.Details of our success rate are currently being submitted for publication and will be available soon. Copyright 1997, CITA Spain. U.S. DETOX TREATMENT FOR OPIATE ADDICTION / CARETAKER INFORMATION SHEET DESCRIPTION OF THE PROCEDURE (http://www.detox-center.com/caretak1.htm) The patient is placed under general anesthesia. It is ascertained that the airway is adequately protected and monitoring indicates that all vital signs are stable and within normal limits. After receiving additional medication to ameliorate signs and symptoms of withdrawal, the patient is administered medications that remove the opiates (narcotics) from the nervous system. This causes an immediate and sudden withdrawal. However, because the patient is unconscious, he is not aware of any withdrawal symptoms. This alleviates the two to three days it normally takes to get into withdrawal, where the patient would normally get progressively more uncomfortable. The patient is then maintained in a state where he essentially sleeps through the worst of his withdrawal symptoms over several hours. When the patient awakens, he may experience some residual withdrawal symptoms, however, they will not increase, nor will they continue at that level. They will be decreasing and the patient may expect to continually improve. The patient is provided with medications to help relieve some of these symptoms. If the patient attempts to relieve the symptoms with opiates, he will not experience any of the euphoric (high) effect of opiates as he had before detoxification. This is because of the administered pure narcotic antagonists during the procedure which will persist in the body for several days. Another advantage of this technique is that naltrexone maintenance therapy can be initiated immediately. This is done by the implantation of a pellet containing naltrexone which gradually dissolves over time, releasing the blocking agent into the bloodstream. This will protect the addict from the use of opiates while in the home environment. US DETOX INTENSIVE TREATMENT UNIT http://www.detox-center.com/clinic.htm One South Centre Street Suite 301 Merchantville, New Jersey 08109 800-978-0808 or 609-663-4447 Fax (609)-488-6380 e-mail: lgooberman@aol.com The clinic is headed by Dr Lance L. Gooberman, who is a member of the American Society of Addiction Medicine (ASAM). Dr. Gooberman has many years of medical experience and frequently appears in court as an expert witness on medical topics related to drugs and alcohol use and abuse. Dr. Gooberman is currently collecting data on the long-term outlook for patients who have Opiate Reversal (detoxification) Under General Anesthesia (ORGA), and is publishing a paper soon showing that ORGA patients are much more successful in staying off opiates than patients from traditional detox programs.Our clinic has state-of-the-art facilities for monitoring patients under anesthesia. The anesthesia is always performed under the supervision of a licensed physician.

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Our clinic is located in southern New Jersey about 15 minutes from Philadelphia. DIRECTIONS TO OUR LOCATION and MAPS OF OUR LOCATION: available on site.

CURRICULUM VITAE LANCE L. GOOBERMAN, M.D.

PERSONAL Date of birth: August 1, 1951 Married, one child Bilingual: English, Spanish EDUCATION Pennsauken High School Pennsauken, New Jersey 1966-1970 Findlay College Findlay, Ohio 1970-1971 Camden County College Blackwood, New Jersey 1972-1973 Autonomous University of Guadalajara Guadalajara, Mexico 1973-1974 University of Texas at El Paso El Paso, Texas 1977 Autonomous University of Ciudad Juarez Ciudad Juarez, Mexico 1974-1978 INTERNSHIP AND RESIDENCY TRAINING Wilmington Medical Center, Wilmington, Delaware : Rotating Internship 1978-1979 Cooper Hospital/University Medical Center, March 1980-April 1982 Residency, Internal Medicine April 1983-July 1983 MEDICAL LICENSOR New Jersey MA38191 - Issued 1980 Pennsylvania MD-038545-L - Issued 1980 EMPLOYMENT HISTORY Emergency Physician Associates Emergency Room - West Jersey Health Systems Voorhees, New Jersey April 1982 to April 1983 Cooper Hospital Pain Center Cooper Hospital, University Medical Center Camden, New Jersey Medical Consultant May 1982 to April 1983 Private Practice Internal Medicine 1982 to 1996 Addiction Medicine 1987 to present Forensic Addiction Medicine 1993 to present Merchantville, New Jersey Private Practice Occupational Medicine & Addiction Medicine 1993 to present Camden, New Jersey President, Breath Alcohol Testing, Inc. Merchantville, New Jersey 1993 to present Founder, President, Chief Medical Officer U.S. Detoxification Center Merchantville, New Jersey 1995 to present President, Forensic Medicine Associates Merchantville, New Jersey 1996 to present CONSULTING New Jersey Board of Medical Examiners 1987 to present Pennsylvania Impaired Physician Program 1987 to present New Jersey Board of Pharmacists 1991 to present Pre-Trial Intervention Program 1993 to present Amity House 1994 to present HOSPITAL APPOINTMENTS & PRIVILEGES Cooper Hospital, University Medical Center, Camden, New Jersey Staff Physician Our Lady of Lourdes Medical Center, Camden, New Jersey Staff Physician West Jersey Health Systems, Camden, Voorhees, Berlin & Marlton Divisions Staff Physician Underwood Memorial Hospital, Woodbury, New Jersey Admitting privileges-Detoxification Unit. CERTIFICATIONS Educational Commission for Foreign Medical Graduates - 1979 American Society of Addiction Medicine - 1990 American Academy of Disability Evaluating Physicians - 1991 American Academy of Pain Management - 1991 National Draeger, Inc. - Breathalyzer Operator Course 900/900A - 1993 National Draeger, Inc. - Breathalyzer Level I Trainer Instructor - 1994 SOCIETIES and COMMITTEES American Medical Association Medical Society of New Jersey Camden County Medical Society Chairman, Drug and Alcohol Abuse Committee West Jersey Medical Society American Academy of Disability Evaluating Physicians American Academy of Pain Management American College of Occupational & Environmental Medicine American Society of Addiction Medicine: Public Policy Committee Ethics Committee Pain and Addiction Disease Committee American College of Legal Medicine

CONTINUING MEDICAL EDUCATION Double Trouble for Teens: Depression and Drugs Fair Oaks Hospital Summit, New Jersey 10/87 Structured Interventions with Alcoholics and Other Chemically Dependent People Academy of Medicine Society of New Jersey Lawrenceville, New Jersey 11/19 to 11/20/87

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CITA (Center for the Investigation and Treatment of Addictions) http://www.cita1.com/who/default.htm CITA AMERICA Internal Medicine Update and Board Review Course Cooper Hospital, University Medical Center Camden, New Jersey 01/26 to 06/21/88 Treating the Addictions: Getting Off and Staying Off Harvard Medical School Boston, Massachusetts 03/04 to 03/05/88 American Medical Society on Alcohol and Other Drug Dependencies: 19th Annual Medical Scientific Conference Clinical Applications of Alcoholism Research Arlington, Virginia 04/22 to 04/24/88 American Society on Alcohol and Other Drug Dependencies: Scientific Day at the IDAA Baltimore, Maryland August 1988 American Society on Alcohol and Other Drug Dependencies: 1st National Conference on Nicotine Dependence Minneapolis, Minnesota 09/22 to 09/25/88 American Medical Society on Alcohol and Other Drug Dependencies: Review Course in Substance Abuse Disorders New Orleans, Louisiana 10/06 to 10/08/88 American Medical Society on Alcohol and Other Drug Dependencies: Review Course in Substance Abuse Disorders New York, New York 11/10 to 11/12/88 American Medical Society on Alcohol and Other Drug Dependencies: Ruth Fox Course for Physicians Atlanta, Georgia 04/27/89 American Medical Society on Alcohol and Other Drug Dependencies: 20th Annual Medical Scientific Conference Atlanta, Georgia 04/28 to 04/30/89 American Society of Addiction Medicine Ruth Fox Course for Physicians Phoenix, Arizona 04/27/90 American Society of Addiction Medicine 21st Annual Medical Scientific Conference Phoenix, Arizona 04/27 to 04/29/90 American Society of Addiction Medicine Scientific Day at the IDAA Boca Raton, Florida 08/02/90 American Society of Addiction Medicine Ruth Fox Course for Physicians Boston, Massachusetts 04/17/91 American Society of Addiction Medicine 22nd Annual Medical Scientific Conference Boston, Massachusetts 04/18 to 04/21/91 The Academy of Medicine of New Jersey Issues in Chemical Dependency New Brunswick, New Jersey 05/22/91 American Academy of Pain Medicine Regional Symposium Mt. Laurel, New Jersey 09/20/91 American Academy of Disability Evaluating Physicians Clinical Training Program in Disability Evaluation Chicago, Illinois 09/24 to 09/28/91 American Academy of Disability Evaluating Physicians Overview Course Los Angeles, California 10/12 to 10/13/91 American Society of Addiction Medicine Medical Review Officer Course Arlington, Virginia 02/14 to 02/16/92 American Society of Addiction Medicine Ruth Fox Course for Physicians Washington, DC 04/02/92 American Society of Addiction Medicine 23rd Annual Medical-Scientific Conference Washington, DC 04/03 to 04/05/92 American College of Physicians MKSAP IX Course - Part B Philadelphia, Pennsylvania 05/01 to 05/02/92 American College of Physicians San Antonio Internal Medicine Board Review Course San Antonio, Texas 06/18 to 06/21/92 American College of Physicians MKSAP IX Course - Part C Philadelphia, Pennsylvania 07/31 to 08/01/92 New Orleans Internal Medicine Board Review Course Tulane University Medical Center Extensive Review New Orleans, Louisiana 09/08 - 09/13/92 The Academy of Medicine of New Jersey Chronic Pain Management and Issues Related to Iatrogenic Addiction Voorhees, New Jersey 09/22/92 Philadelphia Pain Society Lankenau Hospital Advances in Pain Evaluation and Management Philadelphia, Pennsylvania 10/21/92 American Society of Addiction Medicine Ruth Fox Course for Physicians Los Angeles, California 04/29/93 American Society of Addiction Medicine 24th Annual Medical-Scientific Conference Los Angeles, California 04/30 to 05/02/93 American Society of Addiction Medicine Medical Review Officer Arlington, Virginia 08/27 to 08/29/93 American Society of Clinical Pathologists Ethanol and Other Alcohols: Medical and Legal Perspectives Orlando, Florida 10/21/93 Center for Studies of Law in Action Indiana University Tests for BAC in Highway Safety Programs: Supervision and Expert Testimony Bloomington, Indiana 12/04 to 12/10/93 American Society of Addiction Medicine Ruth Fox Course for Physicians New York, New York 04/14/94 American Society of Addiction Medicine 25th Annual Medical-Scientific Conference New York, New York 04/15 to 04/17/94 Drug and Alcohol Testing Training Institute Alcohol Testing - Establishing Programs for Regulated and Unregulated Workplace Testing Boston, Massachusetts 07/22 to 07/24/94 American Society of Addiction Medicine Ruth Fox Course for Physicians Chicago, Illinois 04/26/95 American Society of Addiction Medicine 26th Annual Medical-Scientific Conference Chicago, Illinois 04/27 to 04/29/95 American Society of Addiction Medicine Ruth Fox Course for Physicians Chicago, Illinois 04/18/96 American Society of Addiction Medicine 27th Annual Medical-Scientific Conference Chicago, Illinois 04/18 to 04/21/96 PRESENTATIONS Round table discussion with Governor-elect James Florio The Perils of Drug and Alcohol Addiction, Trenton, New Jersey, January 15, 1990 Panel on Safe Homes Program: Representing The Field of Addiction Medicine Bishop Eustace Preparatory School, Pennsauken, New Jersey, October 21, 1991 Chief Residents Conference Managed Care Protocol for Addictions Cooper Hospital, University Medical Center, Camden, New Jersey, November 20, 1991 The Robyn Stevens Show, Interview on Alcoholism, Channel 13 TV, Turnersville, New Jersey, January 26, 1993 Chief Rounds: Panel Discussion Participant: Alcoholism and Alcoholic Cardiomyopathy Cooper Hospital, University Medical Center, Camden, New Jersey , February 4, 1993 1993-1994 Internship Survival Lectures, Alcohol/Narcotic Withdrawal, Cooper Hospital, University Medical Center, Camden, New Jersey , August 13, 1993. Critical Care Education Day for Nurses, The Addicted Critically Ill Patient, West Jersey Health Systems, Camden, New Jersey, September 22, 1993 Lecture, Rapid Opiate Detoxification, sponsored by Ohmeda Pharmaceutical, New York City, New York, January 23, 1996. Paper Session, Rapid Opiate Detoxification, American Society of Addiction Medicine, April 19, 1996 Component Session, Rapid Opiate Detoxification, American Society of Addiction Medicine, Methadone Maintenance Committee, April 20, 1996 PUBLICATIONS CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.cita1.com/who/default.htm CITA AMERICA Rapid Opiate Detoxification, Journal of Addictive Diseases, Volume 15, No. 2, 1996, Abstract 7a, p. 117, Lance Gooberman, M.D., Thaddeus Bartter, M.D. Rapid Opiate Detoxification, American Journal of Drug and Alcohol Abuse, In Press, 1996, Lance Gooberman, M.D., Thaddeus Bartter, M.D. Rapid Opiate Detoxification and Naltrexone Induction Under General Anesthesia and Assisted Ventilation: Experience with 510 Patients in Four Countries, In Press 1996, Acta Psychiatrica Belgica, Colin Brewer, M.R.C., Psycho, Mary Laban, M.R.C.A., Charles Schmulian, F.F.A., Lance Gooberman, M.D., Yiannis Kasvikis, M.R.C. Psych., Nabil Abdel Maksoud, M.D. AWARDS Benjamin Franklin Emerging Business Award, U.S. Detox Center, Merchantville, New Jersey Most Innovative Service, Philadelphia, Pennsylvania, November 1996 REFERENCES AND LITERATURE http://www.detox-center.com/refer.htm 1. Morphine Habit of Long Standing Cured by Bromide Poisoning The British Medical Journal, July 10, 1897, pp.76-77, Neil Macleod, M.D. Edin. 2. Cure of Morphine, Chloral, and Cocaine Habits by Sodium Bromide The British Medical Journal, April 15, 1899, Neil Macleod, M.D. 3. Opiate Detoxification Under General Anesthesia By Large Doses of Naloxone Clinical Toxicology, 27 (4&5), 263-270 (1989), Otto Presslich, M.D., Norbert Loimer, M.D., Ph.D., Kurt Lenz, M.D., Rainer Schmid, Ph.D. 4. Continuous Naloxone Administration Suppresses Opiate Withdrawal Symptoms in Human Opiate Addicts During Detoxification Treatment Journal of Psychiatry, Res. Vol. 23 No. 1, pp 81-86, 1989, N. Loimer, R.W. Schmid, O. Presslich and K. Lenz 5. Naloxone Treatment for Opiate Withdrawal Syndrome Journal of Psychiatry, Dec., 153:851-852, 1989, N. Loimer, R. Schmid, O. Presslich, K. Lenz 6. Similar Efficacy of Abrupt and Gradual Opiate Detoxification American Journal of Drug and Alcohol Abuse 17 (3), pp.307-312 (1991). Norbert Loimer, M.D., Ph.D., Leopold Linzmayer, Ph.D., Rainer Schmid, Ph.D., Josef Grunberger, Ph.D. 7. Technique For Greatly Shortening The Transition From Methadone to Naltrexone Maintenance of Patients Addicted To Opiates American Journal of Psychiatry, Clinical and Research Reports 148:7, pp. 993-935, July 1991. Norbert Loimer, M.D., Ph.D., Lurt Lenz, M.D., Rainer Schmid, Ph.D., and Otto Presswich, M.D. 8. Naloxone-Precipitated Withdrawal: A Method for Rapid Induction Onto Naltrexone Clinical Pharmacology and Therapeutics, pp. 409413, (4) 1977 21 Apr. Richard B. Resnick, M.D., Richard S. Kestenbaum, Ph.D., Arnold Washton, M.A., and Doris Poole, R.N. 9. Acute Blocking of Naloxone-Precipitated Opiate Withdrawal Symptoms by Methahexitone British Journal of Psychiatry (1990), 157, 748-752, Norbert Loimer, M.D., Ph.D., Rainer Schmid, Ph.D., Kurt Lenz, M.D., Otto Presswich, M.D., Joseph Grunberger, Ph.D. 10. Respiratory Depression Following Diazepam: (Reversal with High-Dose Naloxone) The American Society of Anesthesiologists, Inc. 53: 293-298, 1980, C. Jordan, B. Tech, J.R. LeHane, M.R.C.P., F.F.A.R.C.S., J.G. Jone, M.D., F.F.A.R.C.S. 11. A Twenty-Four Inpatient Detoxification Treatment for Heroin Addicts: A Preliminary Investigation Drug and Alcohol Dependence 35 (1994) 91-93 Juan Jose Legarda, Michael Gossop 12. Rapid Opiate Detoxification Journal of Addictive Diseases, Volume 15, No.2, 1996, Abstract 7a, p.117, Lance L. Gooberman, M.D., Thaddeus Bartter, M.D. 13. Rapid Opiate Detoxification American Journal of Drug and Alcohol Abuse, In Press, 1996, Lance L. Gooberman, M.D., Thaddeus Bartter, M.D. 14. Rapid Opiate Detoxification and Naltrexone Induction under General Anesthesia and Assisted Ventilation: Experience with 510 Patients in Four Countries In Press acta Psychiatrica Belgica, 1996, Colin Brewer, MRC Psycho.:, Mary Laban, M.R.C.A., Charles Schmulian, F.F.A., Lance Gooberman, M.D., Yiannis Kasvikis, M.R.C. Psych., Nabil Abdel Maksoud, M.D.

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CITA (Center for the Investigation and Treatment of Addictions) http://www.cita1.com/who/default.htm CITA AMERICA

CITA - Center for the Investigation and Treatment of Addictions

WHO IS CITA ?
SM

http://www.cita1.com/who/default.htm

CITA , The Center for the Investigation and Treatment of Addiction, is a clinical and research-based organization specializing in the treatment of opiate dependency. Conceived in Europe, CITA now successfully treats patients in the United States, bringing new hope to opiate-dependent patients who have had repeated failures with traditional and painful withdrawal therapy. Addiction to drugs, especially opiate-based narcotics and medications, is a costly habit -- not just financially. It causes physical decay, isolation, broken families, disrupted careers and human suffering. Yet conventional rehabilitative treatments, including the "cold turkey" form of withdrawal or methadone maintenance, aren't working. CITA offers the only clinically tested and effective alternative treatment method: URODSM, or Ultra Rapid Opiate Detoxification. UROD detoxifies users of heroin, methadone, prescription painkillers and other opiate-based narcotics and medications not in days or weeks, but in 6 to 8 hours. CITA Americas is headquartered in New York City, with treatment centers throughout the United States and more opening soon. History & Philosophy CITA's philosophy is based on the safe, effective and humane treatment of individuals dependent on narcotics. Established in 1988, CITA has clinically tested The CITA Method at major medical centers throughout Europe and the United States. Today, after more than a decade of research, CITA Americas offers The CITA Method exclusively at select treatment centers in North America. CITA International operates treatment centers at additional sites worldwide, and has treated thousands of patients successfully. CITA believes, and outside experts agree, that the key issue in treating those addicted to opiates is helping them avoid relapse. The CITA Method addresses both physical and psychological needs. URODSM, Ultra-Rapid Opiate Detoxification, allows patients to achieve an opiate-free state by treating the addiction syndrome at the receptor level, in contrast to other techniques such as drug substitution therapies or tapered withdrawal. FIT, Flexible Intensity Treatment, is a comprehensive continuing aftercare program designed as an integral part of the CITA Method. This psychosocial therapeutic model utilizes individual, group and family counseling, giving patients solid support during a critical recovery stage. A non-addictive relapse-prevention medication is also administered throughout this period.

CITA's two-tier program is a major breakthrough in the struggle against addiction, providing safe and effective medical intervention in combination with intensive psycho-social services. The CITA Difference The CITA difference begins with the philosophy that Opiate Physical Dependency is a treatable medical disease, not simply a psychological or social problem. CITA believes drug-dependent individuals, like people with any medical illness, deserve to be considered as candidates for medical treatment. The CITA Method offers the most effective treatment against this disease. The CITA Method, built around UROD (Ultra Rapid Opiate Detoxification), is the only rapid detoxification method backed by years of research and a proven clinical experience. CITA and The CITA Method are unique. CITA utilizes the safest, most sophisticated, rigorously tested medical procedures and a professional and highly competent medical staff. Among more than 5,000 patients CITA has detoxified, there has been not one instance of mortality associated with The CITA Method and no significant medical complications. Other rapid detox programs cannot make this claim. This places CITA at the forefront of the rapid detoxification movement. Only The CITA Method represents a comprehensive approach to treating the physical and psychological effects of opiate addiction. This comprehensive approach is what differentiates The CITA Method from others and accounts for its unprecedented rate of success.

THE CITA METHOD

http://www.cita1.com/method/default.htm

The CITA Method is a safe and humane treatment for addiction to opiate-based drugs and medications. It minimizes the pain and suffering normally associated with drug withdrawal. This section explains the physical disorder treated by the The CITA Method as well as the treatment itself. Choose from the menu at right for more detail. For complete information, start with "About Opiate Addiction."

ABOUT OPIATE ADDICTION.

http://www.cita1.com/method/method1.htm Opiate addiction, or Opiate Physical Dependency, is a medical disease stemming from underlying physiological factors. OPD is caused by long-term narcotic use, which changes the normal activity of the brain. Normally, the human brain produces natural opiates, known as endogenous endorphins. Endorphins help the body handle pain or trauma and maintain a general feeling of well-being. When someone suffers from OPD, the natural endogenous systems stop functioning properly. Endorphin production shuts down. Without natural pain-suppression mechanisms, the addict has virtually no tolerance for discomfort. He or she becomes dependent on external, "artificial" opiates typically heroin, methadone and prescription painkillers. When the individual stops using these drugs, the body goes through a radical readjustment. For the brain to resume producing endorphins, the external opiates must first be drained from the system. The painful effects of this cleansing process are the classic symptoms of withdrawal. Withdrawal symptoms can persist for weeks or even months, causing traumatic stress and severe medical consequences. Ordinary detoxification programs fail because so many patients quit before finishing. They simply cannot endure the pain. Of the approximately half who make it through ordinary programs, research shows a strong majority relapse soon afterwards. Furthermore, some studies indicate that more than one-third of addicts, fearing withdrawal pain, refuse to enter conventional detox programs at all. Understanding this, CITA developed its unique and medically-proven approach to treating people afflicted with Opiate Physical Dependency. The cornerstone of The CITA Method, Ultra Rapid Opiate Detoxification or UROD, is administered under anesthesia. CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.cita1.com/who/default.htm CITA AMERICA All CITA patients complete detoxification quickly in 6 to 8 hours and without the painful side effects of acute withdrawal. For a full description of The CITA Method, read the Pre-Treatment Screening.

PRE-TREATMENT SCREENING

http://www.cita1.com/method/method2.htm

CITA maintains one of the most exacting patient screening processes in the field of detoxification treatment. Because CITA's high success rate is closely linked to its patients' determination to succeed, each candidate's readiness and motivation will be closely evaluated. The CITA Method is only for those who are truly ready. As a first step, candidates for treatment visit an official CITA treatment center for an initial consultation and detailed clarification of the program. All candidates must undergo a psychiatric assessment and a comprehensive physical examination. Conditions that may exclude a patient from treatment include: critical psychiatric disorders, alcohol dependency, hepatitis, cirrhosis of the liver, immune disorders, acute infections, respiratory disease and cardiac disorders as well as lack of motivation to succeed. Upon medical and psychiatric clearance, patients are given pre-treatment instructions and a date is set for Ultra Rapid Opiate Detoxification treatment. Patients are advised not to increase their intake of opiates on the eve of treatment; to avoid other drugs or alcohol for several days before UROD; and to come to the treatment center with a friend or family member. To continue this description of The CITA Method, read about UROD: The Detoxification Method.

UROD: THE DETOXIFICATION METHOD.

http://www.cita1.com/method/method3.htm UROD, Ultra Rapid Opiate Detoxification, is the cornerstone of The CITA Method. UROD is completely unlike traditional withdrawal treatments for two key reasons: Rather than cushioning the opiate addict from withdrawal pain by substituting another addictive drug, such as methadone, UROD treats the disease at the level of the brain's receptors. By inhibiting all external opiate substitutes, UROD encourages the brain to resume producing its own natural endorphins. The patient goes through detoxification under general anesthesia. As the patient feels nothing, the body is flushed clean in hours rather than days or weeks. UROD quickly cleanses the body of all opiates, thus optimizing the rehabilitation process. What The Treatment Is Like Patients admitted to the CITA treatment center for UROD receive pre-medications to prevent withdrawal while they are still awake and being prepared for the detoxification process. Monitored by a board-certified anesthesiologist (MD) and intensive care nurses, the patient is given a general anesthetic which results in deep sedation. An intravenous line (IV) is placed within the patient's vein to provide nutrients, medication and fluids. The next phase includes administration of an opiate antagonist and a formula of several other pharmaceuticals. This dramatically accelerates the natural detoxification process. As the patient's vital signs, blood pressure, heart rate, and temperature are monitored, active opiates are flushed from the body and the system is cleansed. During this time, the patient is completely asleep, feeling none of the agonizing pain normally associated with acute withdrawal. After 6 to 8 hours, detoxification is attained and the patient emerges from sedation. For the next several hours the patient is carefully monitored by medical professionals. Following a medical exam and a psychotherapeutic discharge session, patients are typically released from the treatment center within a day or two. The next, equally crucial step is the Flexible Intensity Treatment program.

FIT: FLEXIBLE INTENSITY TREATMENT.

http://www.cita1.com/method/method4.htm Ultra Rapid Opiate Detoxification is only the first step towards recovery. Following UROD each patient begins CITA's Flexible Intensity Treatment, an individualized aftercare program. FIT is customized for each patient to meet the needs of a successful, comprehensive rehabilitative process. The first component of FIT is daily oral administration of Naltrexone, an opiate antagonist which acts as the patient's first line of defense against readdiction. After detoxification, many people still feel a psychological urge cravings or social pressure to return to drug use. This frequently leads to relapse. Naltrexone insures that even if a patient gives in to temptation, opiate-based drugs will have no effect whatsoever. The second component is a psychological support system for patients and family members: a comprehensive package of therapeutic services built on recovery models from Narcotics Anonymous and other 12-step programs. The package includes: substance abuse education CITA Bridge Groups relapse prevention support groups Narcotics Anonymous individual counseling coping skills stress reduction training family unification workshops vocational activities

This comprehensive program facilitates readjustment to normal, everyday life and helps the patient resist drug-related cues in the social environment: contact with drug users, offers of drugs, familiar places, etc. Such challenging situations account for the high rate of relapse found in conventional rehabilitation programs. If the patient lives near the CITA treatment center where he or she underwent UROD, this program can be carried out there. If the patient lives elsewhere, CITA will provide the means to contact counseling sources in the patient's area; aid in setting up a customized aftercare network; refer patients to a physician or addiction specialist; and introduce patients to approved aftercare/FIT providers in the patient's own community. For more about the pharmaceutical aspect of FIT, see the next section: Naltrexone.

ABOUT NALTREXONE
http://www.cita1.com/method/method5.htm CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.cita1.com/who/default.htm CITA AMERICA Naltrexone is a non-addictive opiate antagonist and an important aspect of CITA's post-detoxification Flexible Intensity Treatment. Naltrexone works by blocking the opiate receptor cells in the body's central nervous system. This has 3 important effects: First, Naltrexone inhibits the euphoric feeling normally produced by artificial opiates. A recovering addict taking Naltrexone who readministers an addictive opiate feels no 'high'. Second, Naltrexone allows the brain's natural nerve receptors to repair themselves, regenerate quickly, and resume producing their own natural endorphins. Third, by binding at the nerve receptor sites, Naltrexone helps curb cravings for opiates induced by familiar cues in the patient's environment.

Most conventional detoxification programs employ highly addictive substitute drugs such as methadone. But methadone therapy simply swaps one harmful opiate for another. It does not stimulate the user's brain to resume producing its own endorphins. Withdrawal from methadone can be just as lengthy and painful as heroin withdrawal. In fact, some methadone patients never withdraw at all. They are destined to remain on methadone, making several treatment center visits each week, for the rest of their lives. In contrast, Naltrexone creates no new dependency in the user. Six months after undergoing UROD, patients generally cease taking Naltrexone.

COMMON QUESTIONS

http://www.cita1.com/questions/default.htm

Here are some of the questions frequently asked about CITA and The CITA Method. How do we know the CITA treatment works? The best evidence that The CITA Method works is the more than 5,000 clients worldwide who have undergone UROD at CITA facilities. All were successfully detoxified. Many had already tried numerous other treatments and failed. The CITA Method worked where others had not. The CITA Method includes Flexible Intensity Treatment (FIT), a rigorous program of addiction treatment which includes post-detoxification counseling, therapy and medication. This comprehensive approach is the main reason why 60% of CITA patients worldwide remain relapse-free for 18 months or longer following treatment. For comparison, traditional detoxification methods report an average success rate of just 7% to 17% . Is the treatment safe? CITA's Ultra Rapid Opiate Detoxification is the only rapid detox method clinically proven to be safe and effective. It is backed by more than a decade of research and endorsed by leading authorities in addiction medicine, including members of the American Society of Addiction Medicine (ASAM) and the American Society of Anesthesiologists, the principal medical bodies associated with substance abuse treatment programs and the use of anesthesia in medical procedure, respectively. The CITA UROD method is administered only at select medical facilities across the United States, by CITA-trained professionals. And only The CITA Method is subject to ongoing research, safety and improvement studies through the Scientific and Medical Advisory Committee (SAMAC) of The CITA Foundation. No addictive medications are used as opiate substitutes. After success with more than 5,000 patients worldwide, The CITA Method is the only rapid detox method with no mortality or significant instances of morbidity. What addictions can be treated? CITA has demonstrated success with clients dependent on heroin, methadone, LAAM, opium, morphine, codeine and other prescription painkillers, including Darvocet, Demerol, Dilaudid, Lorcet, Lortab, Percocet, Percodan, Tylenol with codeine and Vicodin. The CITA Method may also be appropriate for those diagnosed with AIDS, cancer, epilepsy, manic depression or other disorders who in the course of treatment develop a drug dependency. UROD is not effective against cocaine, depressants, alcohol, nicotine or benzodiazepines. But it can benefit patients who mix opiates with these drugs. By removing the opiate dependency, UROD lets such patients focus on treating remaining addictions through therapy, groups or other means. Why is The CITA Method better than traditional detoxification? There are many advantages to The CITA Method: Ultra Rapid Opiate Detoxification takes just 6 to 8 hours rather than up to 28 days. The hospital stay is reduced to a day or two. UROD is a guaranteed and 100% effective detoxification. No painful withdrawal symptoms are felt while under anesthesia. No traumatic transition between detoxification and rehabilitative treatment. No addictive medications are used as opiate substitutes. UROD accelerates repair of the body's systems and regeneration of natural opiates. UROD permits earlier return to work, home and recreation. The CITA Method reduces insurance requests for re-treatment. How is The CITA Method different from other rapid detoxification programs? The CITA Method of rapid detoxficiation is the original method. CITA is the developer and pioneer of this breakthrough course of treatment. It is the only rapid detox program affiliated with major hospitals throughout the United States and worldwide. It is the only rapid detox program that has been subjected to long-term naturalistic outcome studies. See professional journal references. The CITA Method is the only rapid detox method clinically proven safe and effective in more than a decade of research. CITA's Ultra Rapid Opiate Detoxification is the only rapid detox endorsed by leading authorities in addiction medicine, including members of the American Society of Addiction Medicine (ASAM) and the American Society of Anesthesiologists, the principal medical bodies associated with substance abuse treatment programs and the use of anesthesia in medical procedure, respectively. The CITA Method emphasizes rapid detoxification in combination with continued aftercare therapy and relapse prevention medication. This two-step approach maximizes the chances of lifetime recovery. Will there be any pain? While The CITA Method is not totally without discomfort, clients need not fear the severe pain associated with acute withdrawal. The crucial detoxification process takes place under anesthesia and lasts just 6 to 8 hours. No severe withdrawal pain is experienced. Upon waking, patients can expect the general discomfort associated with general anesthesia: fatigue, light nausea and minor aches. An opiate addiction keeps the body in a state of constant sedation. After detoxification, patients with previously undetected conditions or injuries CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.cita1.com/who/default.htm CITA AMERICA may feel related aches and pains for the first time. In some cases patients may be kept in the treatment center for a longer period or be referred by a CITA medical professional to an appropriate physician for further treatment. After UROD, some patients experience flu-like symptoms or diarrhea for a period lasting 3 to 4 days. Later, during the long-term rehabilitative process, patients can also expect some sleeplessness, fatigue and related discomfort, which will subside. Where does a person go for the CITA treatment? CITA Americas offers The CITA Method at major medical facilities in New York, Los Angeles, Chicago and Miami Beach. To schedule a consultation at the treatment center nearest you, make confidential contact now. For clients outside North America, CITA International offers The CITA Method at hospitals in Europe, Asia, and the Middle East. What medical personnel attend to CITA patients? The programs at official CITA treatment centers are directed by leaders in the fields of addiction medicine, anesthesia and psychiatry. CITAtrained and board-certified UROD anesthesiologists (MDs), nurses and therapists oversee and monitor the entire detoxification process. What happens after a CITA patient leaves the treatment center? Once detoxification is complete, the recovering client is immediately initiated into FIT (Flexible Intensity Treatment), an intensive, individualized outpatient aftercare program built on the solid foundation of a 12-step recovery model. FIT consists of personal and family counseling plus a relapse-prevention medication, Naltrexone, which prevents physical opiate cravings. FIT is an integral part of The CITA Method and accounts in large part for CITA's unprecedented success. CITA Americas will not perform Ultra Rapid Opiate Detoxification unless the client makes a good-faith commitment to FIT. Does everyone qualify for treatment? No. Every prospective client is subject to a detailed evaluation which includes a psychiatric assessment and a comprehensive physical exam. This process excludes 1 out of every 10 candidates for treatment. Among the conditions that may disqualify someone for treatment: critical psychiatric disorders, alcohol dependency, hepatitis, liver cirrhosis, immune disorders, acute infections, respiratory or cardiac disease, or lack of self-motivation for success. Does insurance pay for the treatment? At this time, the UROD procedure is covered by some union health care plans, traditional insurance companies, HMOs, and employee assistance plans (EAPs), but not by all health care plans. This situation is changing, however. CITA will contact a client's insurance company to see if they will pay for the procedure. Some insurance companies will cover the cost of FIT aftercare counseling sessions and relapse prevention medication. What does the treatment cost? The cost of CITA's comprehensive program ranges from $6,000.00 to $7,500.00: the approximate cost of maintaining a regular heroin habit for 90 days, or 8 to 10 days of traditional inpatient hospital detoxification. The fee covers: Preliminary psychological and patient history evaluations. Full physical examination and medical consultations before, during and after the UROD phase of treatment, including lab fees, urine analysis, blood work, EKG, X-ray, pregnancy and other testing, and any further required analysis. The UROD procedure and all pharmaceuticals associated with the procedure. All costs and fees for a CITA UROD-trained anesthesiologist (MD), who administers and supervises the UROD procedure and remains present throughout the detoxification process. Treatment center accommodation for the UROD procedure, including bed fees, 24-hour nursing supervision, medication, meals, phone and TV. The FIT aftercare program, including individual and group psycho-therapeutic sessions and the non-addictive anti-opiate medication Naltrexone (pre-paid for 1 month). Is there a guarantee of success? With UROD, CITA offers a guaranteed and 100% effective rapid acute detoxification. Nearly all traces of opiates are removed rapidly and painlessly. After detoxification, permanent freedom from addiction depends in part on the determination of the patient. The CITA Method includes an intensive aftercare program, Flexible Intensity Treatment (FIT), which supports the motivated patient's efforts to resume a fulfilling, drug-free life. FIT is a major reason why 60% of CITA clients worldwide remain relapse-free a full 18 months following their treatment. The CITA Method empowers the committed patient to regain control of his or her own life.

OFFICIAL CITA CENTERS

http://www.cita1.com/official/default.htm

There are currently four official CITA treatment centers in North America. Each features CITA-trained medical professionals and is equipped with the most technologically advanced medical equipment utilized before, during and after UROD. New York, New York: Metropolitan Hospital 1901 First Avenue -- Room 1183 New York, NY 10029 Phone: Toll Free: Fax: Los Angeles, California: Cedars-Sinai Medical Center Thalians Mental Health Center 8730 Alden Drive -- Suite W-153 CITA. DOC 1998 212-987-8570 888-CITA-NOW (248-2669) 212-987-0521

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CITA (Center for the Investigation and Treatment of Addictions) http://www.cita1.com/who/default.htm CITA AMERICA Los Angeles, CA 90048 Phone: Toll Free: Fax: Chicago, Illinois: University of Illinois at Chicago Medical Center 1855 West Taylor Street -- Room 1.19 Chicago, IL 60612 Phone: Toll Free: Fax: Miami Beach, Florida: Mount Sinai Medical Center 4300 Alton Road de Hirsch Meyer Building -- 6th Floor Miami Beach, FL 33140 Phone: Toll Free: Fax: 305-531-2482 888-212-CITA (2482) 305-534-8126 312-355-0746 888-996-CITA (2482) 312-355-0730 310-659-7760 888-400-CITA (2482) 310-659-7113

For further information, or to arrange a consultation at any CITA Americas treatment center, make confidential contact now.If you are outside the United States, CITA International has established additional centers in Europe, Asia, and the Middle East.

WHAT PATIENTS SAY

http://www.cita1.com/what/default.htm

To help those who suffer from Opiate Physical Dependency and their friends, some of the 5,000 clients who have undergone The CITA Method have agreed to share their stories. Names have been changed to protect confidentiality. JOHN'S STORY John, 28, is an office clerk in the Chicago area. He underwent The CITA Method in October 1996. John agreed to discuss his experience with CITA in July 1997. What drug habits did you have? I had every drug habit under the sun: heroin, methadone, painkillers, smoking and injecting cocaine, injecting amphetamines, tranquilizers, drinking, barbiturates. Did you try conventional detoxification? There were 4 or 5 failed treatment attempts. Although it was very painful, I would be successfully detoxed; the problem for me was after I got through the hell of detox. I would get these intense cravings, particularly with heroine and methadone. They have a term: the "postacute withdrawal phase." After the actual withdrawal scene of detoxing is over, you still have 6 months to a year of post-detox withdrawal. You're not sick, but there is a constant craving.By the fourth time or so, you don't have a lot of hope for traditional detox. You know you'll be facing that craving. You're like, I've seen this movie before. I know how it ends. How did you learn about The CITA Method? I heard about it through my mother. She had heard about it through relatives who lived in Europe. At the time, mid-1996, it had just become available in New York. I was on a methadone maintenance program. What was your methadone experience like? It was absolutely a disaster. The whole experience of methadone maintenance proved to be a real disaster. I guess the idea is to take away your need to be a criminal to support your drug habit, to stop anti-social behavior. But for me, all it did was allow me to prop up one habit, which was an opiate habit, and indulge all my other drug habits. Were you skeptical at first about Ultra-Rapid Opiate Detoxification? Absolutely. As a class in general, the drug addicts that I know are just skeptics by nature. When my mother told me about CITA, I said, "You're out of your mind." I had had so many bad experiences detoxing, I had no frame of reference. Did the CITA philosophy feel different to you? Yes. the people at CITA were the first I'd ever met who treated my addiction purely as a physiological disease. It was a whole different mindset. A lot of treatment facilities may embrace the disease concept, but they tend to also embrace the "psychogenic" model, which says psychosocial components are also behind addictive behavior. Well, they may play a role. But ultimately, hard experience tells you: no amount of psychobabble will help a person stay sober. What was the treatment like for you? You go in several days beforehand to consult with physicians. They do a general physical and psychological evaluation to make sure there are no serious impairments. Then, if everything checks out OK, you return a few days later. I checked in the night before the procedure. They gave me a mild sedative, because I was pretty anxious. On the morning of the procedure they prepared me, kept me mildly sedated, and then at about 2 p.m. they put me under general anesthesia. I woke at 9 p.m., 7 hours later. The only pain I felt was the removal of the nasogastric tube. It was nothing. I'll never forget it, man. I felt really tired, I felt exhausted, but I was in no physical pain. No pain whatsoever. Up until I came out of anesthesia, I was still a skeptic. I was pretty much braced for another rerun of the old, traditional detox movie. I was just stunned. What happened after that? I stayed in the hospital that night and was discharged the next day, then I convalesced for 3 or 4 days in a hotel. I was pretty weak for several weeks after that. Any other pain? CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.cita1.com/who/default.htm CITA AMERICA None whatsoever. I know other people who go through the treatment have some aches and pains afterwards. But I had nothing just fatigue. The treatment is such a jarring experience to the psyche, though, because you're used to detoxification being such a gradual process. You don't realize that you're completely drug free until several days later. Did you go through Naltrexone treatment afterwards? Yes. If you want it to be successful, you have to follow the aftercare program. Compare the Naltrexone treatment to methadone maintenance. Naltrexone is entirely different from methadone. It's not a psychoactive drug and as such doesn't alter your mood. You don't get intoxicated. It blocks the craving. It's been almost a year since you underwent The CITA Method. Any relapse? No relapse. No interest in going back. The really wonderful thing is, I've been able to get into recovery and 12-step programs and stick with them. You said drug addicts are skeptical by nature. What would you tell a skeptic about CITA? I would basically say 2 things. First, look at the experience of other people like myself. I was as skeptical as you. Second, whatever you may think of The CITA Method, consider this: it can't be any worse than what you've already gone through in terms of traditional detox. Nothing can be worse than traditional detox. And when I went through The CITA Method, I didn't feel a lot of pain. So it just really appeals.

FOR FAMILY AND FRIENDS

http://www.cita1.com/for_family/default.htm

The disease of addiction crosses all social and economic lines. You may discover it in glass office towers or back alleys, affluent suburbs or the low-rent district. Wherever it's found, addiction does terrible damage. But friends, family members, employers, clergy and others who care can make a crucial difference. You can intervene in your loved one's downward spiral, and support his or her efforts to break the addiction cycle. It will help if you know what signs to look for, how to approach the addicted individual, and, perhaps most importantly, what not to do. Drug addiction is characterized by compulsive use, loss of control and continued use despite adverse consequences. If you feel someone near you may be living with addiction, CITA salutes you for your concern. Some guidance from the CITA professionals.

TOP 10 WAYS TO KNOW IF SOMEONE IS ADDICTED

http://www.cita1.com/for_family/for_family1.htm 1. Physical Changes and Medical Problems Increasing number of physical and mental problems over the past year Decrease in appetite and weight loss Nodding off during the day Chronic pain requiring prescription medications Track marks on insides of arms Runny nose Sunken eyes, or bags under the eyes Pasty white and clammy skin Decay or loss of teeth Vomiting and diarrhea Excessive sweating Infrequent bowel movements Numerous doctor visits or hospitalizations 2. Personal Hygiene Declining interest in personal hygiene Dirty hands and nails Body odor Unkept hair 3. Personality Changes High level of anxiety and anger Inability to hold a job Need for instant gratification 4. Financial Problems Repeatedly borrowing money from family and friends Selling or pawning of personal items Credit problems Shopping binges and extravagant purchases Decline in standard of living 5. Social Problems Loss of friends Change in type of friends Loss of interest in previous hobbies or activities Isolation 6. Work Problems Inability to hold a job Lack of career ambition Excuses for poor job performance CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.cita1.com/who/default.htm CITA AMERICA 7. Behavior Changes Obsessive/compulsive behavior Lying and manipulation Stealing Excuses and rationalizations for odd behavior Denial of odd or changed behavior Poor eating habits, or increased consumption of junk food, candy, etc. More time in bed and irregular sleep patterns Lack of motivation and drive Excessive TV watching or listening to music Excessive smoking Burn marks on clothes, furniture, rugs, household items 8. Legal Problems Disorderly conduct Traffic violations or accidents DUIs or DWIs Frequent consultations with an attorney 9. Marital/Relationship Problems Poor communication Broken promises Fights and arguments Physical and verbal abuse Neglect Talk of separation or divorce 10. Family Problems Decrease in visits or phone calls to family members Change in behavior toward family Decreased family interaction due to physical capacity Family history of addiction

ENABLING BEHAVIOR: FACTS YOU SHOULD KNOW

http://www.cita1.com/for_family/for_family2.htm Enabling is any behavior by people close to the addict which, however well-intentioned, protects the addict from the consequences of his/her habit. Enabling behavior contributes to the addiction and worsens the disease in both the addict and codependents. Some common enabling behaviors include: 1) 2) 3) 4) 5) 6) 7) DENYING that the addict's drug use is a real problem. AVOIDING conflicts and confrontations which might "cause" the addict to use drugs. MINIMIZING problems associated with the addict's drug use or the amount consumed. RATIONALIZING the use excusing the addict's inappropriate behavior, or tying it to other causes. PROTECTING the addict from the natural consequences of drug use. WAITING AND HOPING that, in time, the addict will give up drugs. THE "NO TALK" RULE, which can make a taboo topic not just of drug use, but any subject threatening to a household's delicate balance: inappropriate sexual relations, destructive personal attitudes, and finances as well as addictive behavior.

HELPFUL AND UNHELPFUL BELIEFS ABOUT ADDICTION.

http://www.cita1.com/for_family/for_family3.htm Helpful Beliefs Regarding Addiction 1. Addiction is a chronic, relapsing illness. 2. Addiction is a treatable disease 3. Addiction could be genetic. 4. Addiction has definite signs and stages of progression. Look for them. 5. Treatment of addiction is often successful. 6. Help is readily available. 7. Addiction could happen to anyone. 8. AA, NA, Al-Anon and NA-Anon are effective groups for both the addict and the family. 9. The addict's spouse or parent cannot cause the problem, but can aggravate it. 10. Members of the addict's family need treatment as much as the addict does. 11. In the addict's view, alcohol or drugs are the only means of survival. 12. The recovery process is frightening, difficult and lifelong.It requires complete reordering of an addict needs complete, lifelong support. Unhelpful Beliefs Regarding Addiction CITA. DOC 1998

the addict's life. To succeed,

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CITA (Center for the Investigation and Treatment of Addictions) http://www.cita1.com/who/default.htm CITA AMERICA 1. Addiction is a self-inflicted illness. 2. Addiction is hopeless; it's not worth the effort to get an addict to stop using. 3. Recovering from addiction is simply a matter of willpower. 4. Drinking or using drugs in ANY amount is dangerous and could lead to addiction. 5. Let the poor, the sick, the unemployed and the old remain addicted to drugs and alcohol.They're better off that way. 6. Abstinence for an addict is an impossible expectation. No one can live that way. 7. Rather than trying to quit, it's more realistic for addicts to just try to limit the amount they consume. 8. Addicts are people who will not accept responsibilities as most people do. 9. Addicts are weak. They could just quit if they really wanted to.

FOR PHYSICIANS

http://www.cita1.com/for_physicians/default.htm

Professional references, further background and a list of medical authorities associated with The CITA Method are located in this area. The medical principles comprising the foundation of CITA were conceived more than ten years ago by Spanish psychologist Dr. Juan Jose Legarda, who received his Ph.D. in Psychology, specializing in substance abuse and chemical dependency, from the University of London. In 1988 Legarda began Advanced Addiction Treatment and Technologies, a Dutch-based company dedicated to the research and development of innovative techniques in treating addiction and related disorders. He studied the initial work of Charney, Kleber, Presslich, Loimer and others while developing the first anesthesia-assisted rapid detoxification method. From 1988 through 1992, through further research and treatment centeral trials, Legarda perfected the system now known as The CITA Method. In 1992, CITA International was established in Spain. And in 1996, through CITA Americas, The CITA Method became available in the United States.Here follows more information.

SCIENTIFIC AND MEDICAL ADVISORY COMMITTE

http://www.cita1.com/for_physicians/for_physicians1.htm The CITA Foundation, a non-profit charitable organization established by CITA International and CITA Americas, oversees the Scientific and Medical Advisory Committee (SAMAC), which consists of scientists, physicians and substance abuse specialists. SAMAC is helping to establish U.S. and worldwide standards of care in detoxification and rehabilitation. SAMAC's subcommittees are staffed as follows: Safety and Quality Assurance, Detoxification Chairman: Joachim S. Gravenstein, MD Members: Timothy McDonald, MD Clifford Gevirtz, MD Barry Wenig, MD Julian Gold, MD Phyllis Harrison-Ross, MD Irving Beychok, MD Safety and Quality Assurance, Aftercare Chairman: Michael Meyers, MD, ASAM Members: Norman Miller, MD, ASAM Joachim S. Gravenstein, MD Phyllis Harrison-Ross, MD Jake Epperly, CSADC Bennett Oppenheim, Ph.D. Irving Beychok, MD Clinical Research and Scientific Publications, Detoxification Co-Chairman: Timothy McDonald, MD Co-Chairman: Paul White, MD Members: Norman Miller, MD, ASAM Michael Meyers, MD, ASAM Bill Hoffman, MD Ronald Wender, MD Richard Berkowitz, MD Clifford Gevirtz, MD Francesca Cunningham, Pharm D Clinical Research and Scientific Publications, Aftercare Chairman: Bennett Oppenheim, Ph.D. Members: Anthony Albanese, MD, ASAM Joseph Flaherty, MD Michael Meyers, MD, ASAM Norman Miller, MD, ASAM Jonathan Rabinowitz, DSW Laboratory Research, Detoxification and Aftercare Chairman: Barry Wenig, MD Members: Achilles Demetriou, MD Paul White, MD CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.cita1.com/who/default.htm CITA AMERICA Nursing Committee Chairman: Donna McDonald, RN Members: Doretha Brown, RN Patricia Kittock, RN Ma.Melcha Tubianosa("Bing"), RN (pending) Lay Publication and Media Exposure Chairman: David Yerushalmi, Esq. Members: Ronald Wender, MD Bennett Oppenheim, MD Jake Epperly, CSADC Norman Miller, MD, ASAM Richard Berkowitz, MD Clifford Gevirtz, MD Pain Management Committee Chairman: Clifford Givertz, MD Members: Bennet Oppenheim, Ph.D Rick Rosenquist, MD Michael Meyers, MD Ron Wender, MD Speakers Bureau Chairman: Members: Richard Berkowitz, MD Clifford Givertz, MD Jake Epperly, CSADC Bennet Oppenheim, Ph.D Ron Wender, MD Barry Wenig, MD Timothy McDonald, MD Phyllis Harrison-Ross, MD Anthony Albanese, MD Julian Gold, MD

PROFESSIONAL JOURNALS AND PUBLICATIONS

http://www.cita1.com/for_physicians/for_physicians2.htm The CITA Foundation's Scientific and Medical Advisory Committee (SAMAC) has overseen many research projects relating to The CITA Method. Some articles have been accepted for publication by peer review journals, others are currently under review for publication, and some projects are underway at this time with reports expected to be ready for publication later in 1997. We will post the titles and publication dates of relevant articles in this space as they appear. PROFESSIONAL PEER REVIEW JOURNALS [1]Rabinowitz, J., Cohen, H., Tarrasch, R. and Kotler, M. (1997). Compliance to Naltrexone Treatment after Ultra Rapid Opiate Detoxification: An Open Label Naturalistic Study. Drug & Alcohol Depend. 47 (1997) 77-86. [2]Rabinowitz, J., Cohen, H., and Kotler, M. (1997). One Year Outcomes of Ultra Rapid Opiate Detixification Combined with Naltrexone Maintenance: An Open Label Study. Under journal review 1996. [3]Legarda, J.J. and Gossop, M. (1993). 24-Hour Inpatient Detoxification Treatment for Heroin Addicts: A Preliminary Investigation. Drug & Alcohol Depend. 35 (1994) 91-93. [4] Rabinowitz J, Cohen H, Atias S: Outcomes of Ultra Rapid Opiate Detoxification versus Intensive Inpatient Detoxification: An Open Label Naturalistic Study. Under journal review 1997. PROFESSIONAL ABSTRACTS - The following two abstracts have been submitted to the Society of Neurological Anesthesia and Critical Care Annual Meeting in October 1997 (San Diego) and to the International Society of Anesthesiology at the Annual Meeting in Orlando in March 1998. [1] Title: Respiratory and Metabolic Changes During Ultra-Rapid Opiate Detoxification (UROD) AUTHS: T McDonald, MD, W Hoffman, Ph.D., R Berkowitz, MD AFFIL: Univ of Illinois at Chicago, Chicago, Il [2]Title: Heart Rate Variability During Opiate Detoxification AUTHS: W Hoffman, Ph.D., R Berkowitz, MD, T McDonald, MD AFFIL: Univ of Illinois at Chicago, Chicago, Il CITA PUBLICATIONS [1] Oppenheim, B. and Field, J.M. (1997). Ultra Rapid Opiate Detoxification versus Methadone Maintenance.

MEDICAL LICENSURE
http://www.cita1.com/for_physicians/for_physicians3.htm CITA centers operate only in appropriately licensed and permitted hospital facilities. CITA requires that all hospital personnel and FIT Program Providers be fully licensed and certified in the designated service areas for which they are employed.

CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.cita1.com/who/default.htm CITA AMERICA

CITA FOUNDATION

http://www.cita1.com/foundation/default.htm

CITA International and CITA Americas have founded The CITA Foundation, a non-profit organization headquartered at the University of Illinois at Chicago, Illinois. The CITA Foundation is a charitable organization dedicated to: research and education in the field of detoxification and rehabilitation establishment of parameters for the standard of care in the field of rapid detoxification quality assurance and control at all CITA facilities worldwide treating addicted indigents and other individuals without means, and other humanitarian endeavors community outreach and education efforts aimed at the general public supporting the Scientific and Medical Advisory Committee (SAMAC)

The CITA Foundation is supported solely by CITA International, CITA Americas and private donations. To contact The CITA Foundation e-mail: CitaFound@aol.com

CONFIDENTIAL CONTACT
not active at the time .

http://www.cita1.com/confidential/default.htm

CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.neuroadaptation.com/ CITA SPAIN http://www.neuroadaptation.com/ Developer of UROD treatment for opiate addiction

Treatments Results

Research Faq

Online Video

Press Luinks

The Center for the Investigation and Treatment of Addiction (CITA), created in Spain by Dr. J.J. Legarda, is an entity dedicated, since 1988, to the treatment of addiction to substances like heroin, methadone, alcohol, cocaine, benzodiazepines, etc. In this centre Dr. Legarda, with a highly qualified professional staff, designed and developed a treatment for detoxification of people with opiate addiction, that he finally called UROD (UltraRapid Opiate Detoxification). The results obtained in this treatment guarantee a 100% of success rate in physical detoxification. Furthermore, 58% of patients have adapted to a life without drugs. Until May 1996 Dr. J. J. Legarda had started and presided over CITA centers in several countries in the world such as Germany, Italy, Israel, United States and Mexico, supervising more than 3500 treatments. Since then he has focused his activity in Spain, where he has developed new methodologies for addiction treatment.

1.TREATMENT
http://www.neuroadaptation.com/neuroadaptation/treatments.htm CITA Spain has developed and now offers ultra rapid treatments for: OPIATES (UROD) Heroine, methadone, ... BENZODIAZEPINES Rohipnol, Valium, ... ALCOHOL COCAINE

All of them employ a methodology based on the following premises: To accelerate the recovery (NEUROADAPTATION) of the cerebral damage caused by addictive substances. To avoid the pain of physical and psychological suffering to patients. Individualization of treatment, taking into account any kind of familiar or personal circumstance. To avoid the use of substances that generate other addictions. Treatment of patients with added problems (AIDS, hepatitis). No waiting. To ensure privacy and confidentiality To employ hospital units endowed with the most advanced human and technology resource. Before any treatment, the following procedures are performed: Detailed medical examination including Main body systems: respiratory, circulatory, digestive, ostheomuscular, metabolic and neurological. Screening tests: Blood test (haematologic cells, AIDS test, liver serology, liver and renal function...), X-rays, E.K.G., and others if necessary. Detailed psychological assessment: With a minute drug-taking history, diagnosis of existing comorbility and evaluation of personal, family, social and legal situation.

2. Video
CITA has developed a computer infography video of 30 minutes duration which allows to see the inner and outer world of the individual during addiction and treatment. Some of the contents of the video are seen in this web site. Copies of this video can be obtained by academic, governmental or other scientific institutions. The specifics of the research, the applicants name and position should be clearly stated. Address written request: to: Dr. J.J. Legarda CITA C/Roncesvalles 2 28007MADRID-SPAIN Cost: Mailing

CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.neuroadaptation.com/ CITA SPAIN

Socio-demographic characteristics of 1,037 patients treated in CITA Spain September 1992-May 1997 Age Sex Martial status 28.91 (SD = &plusmn;5.76) % of patients Male Female single married divorced or seperated widow others with parents with partner with partner / child alone others homeless Primary school GCSE /GCE Technical education Elementary Higher Illiterate Unemployed Permanent Temporary Retired / on sick leave Others 79.59 (SD = &plusmn; 49.60) 842.31 mgrs. (SD= &plusmn; 702.50) Smoked Inhaled Injected Several July 95 - May 97 85.9 14.1 60.8 28.0 10.0 0.4 0.8 58.3 16.2 15.7 6.2 3.3 0.3 32.5 25.9 18.0 12.4 10.2 0.9 45.5 36.2 9.0 4.4 4.9

Living status

Education

Working status

Daily use of heroine (months) Quantity of heroine Route of administration

37.1 3.8 25.8 33.3 17.7 23.6 23.9

Heroine use >=1,500 mgrs. Daily use of benzodiazepine Daily use of cocaine

3. RESULTS
SUCCESSFUL DETOXIFICATION

* Restrictions: amount of drugs used, time since last dose, and motivation.

SUCCESSFUL FOLLOW-UP (AFTER NINE MONTHS) ADMISSION TO TREATMENT Patients with the following illnesses have been succesfully treated: AIDS, Hepatitis, Diabetes, Epilepsia, Malnutrition, Chronic bronchitis, Psychosis, Panchreatitis, Hyperthiroidism, Long-evolution high blood pressure (220/180 mmHg) CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.neuroadaptation.com/ CITA SPAIN Patients with the following consumptions and characteristics have been succesfully treated: 400 mgr. methadone plus 1 gr. cocaine plus benzodiazepines, daily. female 28, 5 gr. white large dealer purity, daily. male 24, 20 years non-stop; last 10 years 60 mgr. methadone daily. female 40, ex-alcoholic, with chronic panchreatitis, last six months over 1,500 mgr. codeine daily, plus benzodiazepines male 58, daily. Patients with the following sociodemographic conditions successfully adapted - one year after treatment: small dealer 1.5 gr. heroin i.v., 10 years non-stop, more family members also users, living in an habitual dealing neighborhood. couple, both users, 1-2 gr. heroin, dealers, low sociodemographic status. male 28, 1 gr. heroin plus 1 gr. cocaine, 7 years non-stop, with his mother and a psychiatrist-treated sister under his care. male 24, 500 mgr. heroin plus 500 mgr. cocaine, with AIDS, two brothers also users died, another two brothers also users in prison, very low sociodemographic status. Waiting time admission to treatment: Delays due to public transport...!

4. Research
CITA constantly carries out studies and statistics to develop or improve treatments. They are published in scientific and general information magazines. The databases we have developed help us and other scientists in such a task. The video we made is also a result of our efforts to improve and help. All of them are projects of several years. Currently we are devoted to three major projects: Development of a new technology for prevention of drug use. Treatment of addicted new borns. Treatment of towns. We have been working for more than two years and now in cooperation with national and international institutions. In the new year we will be presenting our results. Databases Copies of these databases can be obtained by academic, governmental or other scientific institutions. The specifics of the research, the applicants name and position should be clearly stated. Cost: Mailing Written Request: Dr. J.J. Legarda CITA C/Roncesvalles 2 28007 MADRID-SPAIN CITA has developed the following data bases, WITHOUT PATIENTS IDENTITY DATA, for scientific and treatment improvement purposes only: LISTA'95, LISTA'96 and TASARE 1) LISTA95: UROD treated patients from September 1992 until June 1995. It includes the following variables: 1. Admission date 2. Age 3. Gender 4. Residence 5. Country 6. Education 7. Employment status 8. Reference 9. Living status 10. Psychopatholoy 11. Physical illnesses 12. Age first use of heroin 13. Age daily use of heroin 14. Daily use of heroin (months) 15. Use of heroine last 30 days 16. Route of heroine administration 17. Use of methadone 18. Use of other opiates 19. Previous detoxifications 20. Use of cocaine 21. Route of cocaine administration 22. Use of benzodiazepine 23. Use of other drugs 24. Prison 25. Psychological therapy 26. Naltrexone 27. Results

2) LISTA96: UROD treated patients form July 1995 until today. It includes the same variables as the previous database plus the following: 1. Use of heroine day before yesterday 2. Use of heroine yesterday 3. Use of heroine today 4. Frequency of alcohol use 5. Frequency of hashish use 6. Frequency of tobacco use 7. Frequency of morphine use 8. Frequency of codeine use 9. Last detoxification (date) 10. Last detoxification (days) 11. Type of detoxification 12. Drug-free (days) 13. Outcome of last detoxification 14. Relationship mother 15. Relationship father 16. Relationship brothers&sisters 17. Relationship partner 18. Relation children 19. Psychiatric records (family) 20. Living together with other addicts 21. Relations with other addicts (family) 22. Relations with other addicts (work) 23. Relations with other addicts (social) 24. Decision to treatment 25. Problems (family) last 30 days 26. Problems (social) last 30 days 27. Problems (legal) last 30 days 28. Problems (work) last 30 days 29. Support for treatment (family/friends) 30. Profession 31. Expectation for work 32. Maintenance 33. Arrest 34. Police/Legal 35. Drug traffic 36. Psychopathology (family) 37. Pharmacological treatment 38. Suicide 39. Hallucinations 40. Panic attacks 41. Convulsions 42. Loss of consciousness 43. Distortion of information 44. Patients state of mind during interview 45. Patients cheque number 46. Therapists code 47. Derivation 48. Treatment outcome

In addition, the following variables are registered 21 times during the 9 months follow-up period, by the psychologist: a. Naltrexone intake b. Sleep CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.neuroadaptation.com/ CITA SPAIN c. Drug use d. Activities e. Interpersonal relations The following variables are recorded 4 times along the 9 months follow-up period, by the physician: a. Health (clinicians appreciation) b. Health (family appreciation) c. Medical problems d. Analytical variations e. Other medications 3) TASARE: Therapists' retention rates on UROD treated patients. From 1995 until today.

4. Frequently Asked Questions

What is Ultra Rapid Opiate Detoxification (UROD)? Opiates, like heroine and methadone have their effects on specific receptors of the nerve system. When an addicted person stops consuming opiates, the withdrawal syndrome appears, which lasts five to ten days. UROD cleans the receptors of the nerve system, taking off every part of the opiates, while the person is adequately sedated. When the person wakes up, the receptors not only have been cleaned but also they are blocked so that opiates can not have any effect. What is neuroadaptation? Drugs alter the neurones of our brain. These alterations are repaired while the patient is sleeping during UROD. If the patient would only be detoxified, the illness would still persist. That is why the neuronal adaptation during UROD is so fundamental. What are the advantages of UROD? The individual does not suffer during the detoxification. He doesnt go through the withdrawal syndrome, which is the major reason for drop-out in the actual treatments. With this procedure no patient drops out during detoxification. Even further, many individuals who would never get to start a rehabilitation, can begin it without suffering. What are the advantages of neuroadaptation? With only taking off the drug toxins (detoxification) of our body, we dont get far in the therapy of addiction. The recovery of the brain damage (neuroadaptation) is the most important because it permits the individual to think and to feel in a different way. Is it a safe treatment? It is safer than using heroin, without any doubt. Thousands of persons have been treated with this procedure without any complications during or after the treatment. Even more, a lot of patients who have been treated were suffering serious physical diseases, such as AIDS, epilepsy and respiratory and hepatic disorders. How does it feel after UROD? Usually fatigue even though a lot of patients feel like having dinner! You have to take into consideration that heroin and in general opiates hide the discomfort and pain of many physical diseases. During the period of addiction the patient loses weight, doesn't usually look after dental or oral higine, nor possible ulcers and they dont care whether or not they have AIDS or TB. The discomfort or pain which is caused by any of these diseases can only be perceived once heroin is out of the body. However after UROD these diseases are adequately treated. How to keep away from heroine after UROD? The medication which will be given to the patient blocks the effects of heroin, methadone or any other type of opiate, like codeine or morphine. It works in the central nervous system concretely getting itself attached to little areas called receptors. To achieve its effects, heroin has to reach the same receptors, but the medication blocks this union during several days depending on the dose. The patient will have to take this medication at least for 9 months being supervised by a relative/friend/clinician. Why it has to be supervised? For the patient to live without feeling attracted to drugs. Is the medication addictive? Definitely not. Even after a year there is no withdrawal syndrome if it is discontinued. Is it a new drug? No. It has already been used in the US for more than twenty years and in several european countries for more than five years. Does it have any side effects? Even though there are minimal side effects in some cases, none of them are serious, we recommend undergoing a medical supervision every two or three months. A very small proportion of patients might experience fatigue and slight digestive problems. Is a psychological treatment necessary? We highly recommend our patients to attend psychotherapy sessions three or four times per week during the first three months and once or twice a month during the following six months

5. Online
It is our intention to help you You may want to hear our opinion about a case. It may be yours or a relatives or friend. You might fear that your relative or friend is addicted and you dont know how to find out or what to do. Even that she or he was treated and you fear relapse. Whatever we can do, we will. Fill out our on-line test to know if you or your friend is addicted (see : alcohol doc) OR Send a letter to us personally It may be that you want to know more about our treatments, or how to come for treatment, how much it costs, etc... Contact us at http://www.neuroadaptation.com/neuroadaptation/on-lineContact.htm Fill out this form with your question, and your e-mail for our reply. Your question will be answered by a doctor in the Cita center in Spain. Please enter your question and your e-mail:

6. Press
We have selected seven out of more than two hundred press articles from all over the world. Others are available on request. NEWSWEEK 30th of January, 1995 : " ... CITA, the Spanish-based firm that developed the treatment, claims it has detoxified 1,000 addicts since 1992..." THE INDEPENDENT 24th July, 1994 : " A drug treatment that can help to "cure" addicts within four hours could soon be available in Britain. The technique, developed in Spain, has shown a 100 percent succes rate on more than 100 heroin users. Drug specialist considering setting up a similar programme in London." THE JERUSALEM POST 21th of September, 1994: "A painless one-day drug treatment, pioneered in Seville, enables addicts to go through withdrawal symptoms avoiding the dreaded "cold turkey". Psychologist Juan Jose Legarda, the man behind the breakthrough, says the accelerated detoxification method can help even hardened heroin and cocaine users to give up drugs" CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.neuroadaptation.com/ CITA SPAIN EL PAIS 13th of January, 1994 : "...The withdrawal syndrome is the most difficult part of drug detoxification. The fastest method requires between four and seven days. Now it can be reduced to 12 hours with the method developed by psychologist Juan Jose Legarda..." BN Brabants Niewsblad 6th of may, 1995 : " ... The miracle of Seville. ... The salvation came through the TV. At the begining of the year NCRV showed a documentary about psychologist Juan Jose Legarda and his treatment method for drug addicts..." IL GIORNALE 29th of June, 1995 : " ... the method developed ten years ago by psychiatrist Juan Jose Legarda. The treatment called UROD (Ultra Rapid Opiate Detoxification) has been ex[ported to Mexico, Holland, Greece and soon will be available in United States, in cooperation with universities and local authorities."

7. LINKS
With the following links to the best sites we hope we help you yo get good information about addictions and related fields INDEX OF LINKS : Organizations Scientific Journals Databases Indexes & Search Engines ORGANIZATIONS Addiction Research Foundation http://www.arf.org/ The ARF is one of the most active northamerican entities in the research and investigation of problems caused by the addiction to alcohol, tobacco and other drugs. The main aim of this foundation is the prevention and reduction of consumption of these substances in Ontario (Canada). American Psychological Association http://www.apa.org/ FUNDACIN DE AYUDA CONTRA LA DROGADICCIN http://www.fad.es/ La Fundacin de Ayuda contra la Drogadiccin lleva 10 aos trabajando para la prevencin de los consumos de drogas. Ahora, con su presencia en Internet, abre una nueva etapa con la pretensin de dar continuidad lgica a nuestras intervenciones de prevencin. Indiana Prevention Resource Center http://www.drugs.indiana.edu/prevention/ Indiana Prevention Resource Center Website is designed to provide technical support for prevention professionals. Institute for the Study of Drug Dependence http://www.isdd.co.uk/frameset.html ISDD is an independent organisation founded in 1968 to provide objective, accurate and current information on all aspects of drug misuse for professionals, policy makers and researchers. ISDD is the UK link with the European Monitoring Centre on Drugs and Drug Addiction (EMCDDA) and our work is now carried out in a European context. National Institute on Drug Abuse (NIDA) http://www.nida.nih.gov/ The NIDA is an institute wich main aim is to promove and to eject scientific researchs that allow to resolve drug abuse & drug addiction problem. Another aim, not less important, is to use the information got to improve this problem by prevention, treatment and consulting in the application of politics about the matter. PREVLINE http://www.health.org/ Prevention On Line. Spain: National Drug Plan Information http://www.mir.es/plandrog/index.htm about the National Drug Plan of Spain Government. Society for Neuroscience http://www.sfn.org/ The Society for Neuroscience is the world's largest organization of scientists and physicians dedicated to understanding the brain, spinal cord and peripheral nervous system. Neuroscientists investigate the molecular and cellular levels of the nervous system; the systems within the brain, such as vision and hearing; and behavior produced by the brain. This research provides the basis for understanding the medical fields concerned with treating nervous system disorders. These medical specialties include neurology, neurosurgery, psychiatry and opthalmology. United Nations International Drug Control Programme http://undcp.or.at/ The United Nations International Drug Control Programme is the United Nations agency responsible for coordinating activities relating to the international control of narcotic drugs and psychotropic substances. The Office of Minority Health Resource Center http://www.omhrc.gov/Welcome.htm A Nationwide Service of the Office of Minority Health Public Health Service. U.S. Department of Health and Human Services. National Institute on Alcohol Abuse and Alcoholism (NIAAA) CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.neuroadaptation.com/ CITA SPAIN http://www.niaaa.nih.gov/ This organization supports and conducts biomedical and behavioral research on the causes, consequences, treatment, and prevention of alcoholism and alcohol-related problems. NIAAA also provides leadership in the national effort to reduce the severe and often fatal consequences of these problems National Clearinghouse for Alcohol and Drug Information ?? The National Clearinghouse for Alcohol and Drug Information (NCADI) is the information service of the Center for Substance Abuse Prevention of the Substance Abuse and Mental Health Services Administration in the U.S. Department of Health & Human Services. NCADI is the world's largest resource for current information and materials concerning substance abuse. Drug Enforcement Administration (U.S. Department of Justice) http://www.usdoj.gov/dea/ The mission of the Drug Enforcement Administration is to enforce the controlled substances laws and regulations of the United States and to bring to the criminal and civil justice system of the United States or any other competent jurisdiction, those organizations, and principal members of organizations, involved in the growing, manufacture, or distribution of controlled substances appearing in or destined for illicit traffic in the United States; and to recommend and support nonenforcement programs aimed at reducing the availability of illicit controlled substances on the domestic and international markets. In carrying out its mission, DEA is the lead agency responsible for the development of overall Federal drug enforcement strategy, programs, planning, and evaluation. The National Center on Addiction and Substance Abuse at Columbia University (CASA) http://www.casacolumbia.org/ The National Center on Addiction and Substance Abuse at Columbia University (CASA) is a unique think/action tank that brings together under one roof all of the professional disciplines (health policy, medicine and nursing, communications, economics, sociology and anthropology, law and law enforcement, business, religion and education) needed to study and combat all forms of substance abuse - illegal drugs, pills, alcohol and tobacco - as they affect all aspects of society. Project Cork Institute http://www.dartmouth.edu/dms/cork/ The Project Cork Institute at Dartmouth Medical School promotes locally, regionally and nationally, the education and training of health care and human service professionals in issues related to substance abuse. The Institute supports educational efforts through its online database of substance abuse information, the preparation of curriculum materials, and involvement in curriculum development efforts. The Society for Prevention Research http://www.pitt.edu/~cedarspr/spr.html The Society for Prevention Research consists of scientists, practitioners and administrators committed to the improvement of prevention intervention through empirical investigation. The focus of the society is broadly defined and concerned with the problems pertaining to the prevention of drug and alcohol abuse, and associated social maladjustment, crime, and behavior disorders. World Health Organization http://www.who.ch/ The objective of WHO is the attainment by all peoples of the highest possible level of health. Health, as defined in the WHO Constitution, is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. In support of its main objective, the Organization has a wide range of functions. The American Psychiatric Association http://www.thebody.com/apa/apapage.html This is a national medical specialty society whose 39,500 physician members specialize in the diagnosis and treatment of mental and emotional disorders and substance abuse. The APA's organizational objectives include the advancement and improvement of care for persons with mental illnesses through nationwide public information, education, and awareness programs and materials. SCIENTIFIC JOURNALS The Addictions Newsletter Pages about The Addictions from the American Psychological Association. http://www.kumc.edu/addictions_newsletter/ Psychological Bulletin http://www.apa.org/journals/bul.html Links to Psychological Journals http://www.shef.ac.uk/~psysc/journals/journals.html An Index of 1,000+ Psychology and Social Science Journals Online DATABASES Web of Addictions http://www.well.com/user/woa/ The Web of Addictions is dedicated to providing accurate information about alcohol and other drug addictions. We developed the Web of Addictions for several reasons. We are concerned about the pro drug use messages in some Web sites and in some use groups. We are concerned about the appalling extent of misinformation about abused drugs on the internet, particularly on some usenet news groups. Finally, we wanted to provide a resource for teachers, students and others who needed factual information about abused drugs. DRCNet Online Library of Drug Policy http://druglibrary.org/ CITA. DOC 1998

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CITA (Center for the Investigation and Treatment of Addictions) http://www.neuroadaptation.com/ CITA SPAIN The world's largest online library of drug policy. The Internet Public Library: Substance Abuse http://www.ipl.org/cgi/teen/teen.db.out.pl?id=he5000 The Internet Public Library is the first public library of the Internet. As librarians, we are committed to providing valuable services to that world. We do so for many reasons: to provide library services to the Internet community, to learn and teach what librarians have to contribute in a digital environment, to promote librarianship and the importance of libraries, and to share interesting ideas and techniques with other librarians. MEDLINE MEDLINE http://www.health.org/database/medline/medline.htm One of the major data bases of the National Library of Medicine, contains over 6.5 million bibliographic records covering the fields of medicine, nursing, dentistry, veterinary medicine, and the preclinical sciences. MEDLINE refers to articles from more than 3,600 international biomedical journals. There are approximately 30,000 new citations added each month. Hyperreal Drugs Archive http://www.hyperreal.org/drugs/ Links to a large collection of posts to Usenet or submissions from other computer users. Psychopharmacology Tips http://uhs.bsd.uchicago.edu/dr-bob/tips/tips.html This site offers a large amount of tips on medication. It is of interest for those who prescribe and those who take. Written by the Assistant Professor of Clinical Psychiatry from the University of Chicago The Drug Discrimination Bibliography http://www.arf.org/dd/ Drug Discrimination is widely recognised as one of the major methods for studying the behavioral and neuropharmacological effects of drugs and plays an important role in drug discovery and investigations of drug abuse. This WWW page provides access to Dr. Ian Stolerman's ongoing Comprehensive Bibliograpy of Drug Discrimination Research. INDEXES & SEARCH ENGINES Internet Search Nodes : http://www.cdmgroup.com/cewg/SearchSys.htm The Internet search nodes listed here are a few of the starting points that can be of use to researchers when beginning an investigation on the Internet. Internet Mental Health - Links http://www.mentalhealth.com/fr13.html This site provides links to web sites providing more than 10 pages of free, scientifically sound mental health information. Yahoo - Substance Abuse http://www.yahoo.com/Health/Mental_Health/Diseases_and_Conditions/Substance_Abuse/ The National Substance Abuse Web Index (NSAWI) http://nsawi.health.org/cgi-bin/intro.cgi This site was developed as a convenience to the substance abuse prevention and treatment communities to assist in obtaining relevant, authoritative information available on the World Wide Web. It is indexed from multiple government and private web sites maintained by different organizations. Heroin -- nobody says you have to do it http://web2.airmail.net/bhate/heroin.htm This page offers links to well known organizations to know and answer some questions you may have about drugs.

Copyright 1997, CITA Spain. All Rights reserved.

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy.

CEDRO (Centre for Drug Research) & Fondazione Exodus

Links to other drug related sites. Exodus Foundation is not responsible for the contents of any "off-site" Internet information referenced by or linked to this Internet site. http://www.exodus.it/ http://www.frw.uva.nl/cedro Australia

ADF, Australian Drug Foundation http://www.vicnet.net.au/vicnet/health/adf/adf.htm Australia's Commonwealth Department Department of Human Services and Health http://www.health.gov.au/hfs/depthome.htm The Australian Institute of Criminology http://www.aic.gov.au/ CEIDA, Centre for Education and Information on Drugs and Alcohol http://www.merlin.com.au/druglinks/ceida/ Connexions, The Journal of Drug and Alcohol Issues, published bimonthly by CEIDA (the Centre for Education and Information on Drugs and Alcohol). http://www.merlin.com.au/druglinks/conn/ CEIDA DrugLinks, Australia http://www.merlin.com.au/druglinks/ Austria http://undcp.or.at/ http://undcp.or.at/cnd.html http://undcp.or.at/incb_hp.html

UNDCP, United Nations International Drug Control Programme CND, Commision on Narcotic Drugs INCB, International Narcotics Control Board Canada

ARF, The Addiction Research Foundation, Ontario, Canada Canadian Centre on Substance Abuse Canadian Foundation for Drug Policy Europe

http://www.arf.org/ http://www.ccsa.ca/ http://fox.nstn.ca/~eoscapel/cfdp/cfdp.html

ITACA, European Association of Professionals working with Drug Abuse Finland

http://www.itaca-europe.org/ http://www.mclink.it/com/itaca/index.htm

FCA, The Finnish Cannabis Association University of Turku, "LSD - My Problem Child" by Albert Hofmann France

http://www.kaapeli.fi/~sky/english_SKY.html http://www.utu.fi/~jounsmed/asc/drugs/Hofmann/Hofmann.html

CIRC, Collectif d'Information et de Recherche Cannabique Reitox France, Observatoire Franais des drogues et des toxicomanies Germany

http://www.magic.fr/indie-musique/circ/circ1.htm http://dgldt.dgldt.fr/

Grow! HanfBlatt, Das Magazin Fr Hanfkultur Hanfmuseum Berlin Institur fr Psychologie, Bayerische Julius-Maximilians-Universitt Wrzburg, Projekt: Medikamente und Drogen im Straenverkehr, Forschung im Bereich Methodenlehre / Verkehrspsychologie / Alkoholtoleranz Kawumm Head Shop, Saarbrcken NID, Nichtraucher-Initiative Deutschland e.V. Greece

http://141.100.102.88/grow/ http://www.hanfblatt.de/ http://userpage.fu-berlin.de/~dawn/hemp/ http://wy3x01.psychologie.uni-wuerzburg.de/ http://wy3x01.psychologie.uni-wuerzburg.de/drogen.html http://wy3x01.psychologie.uni-wuerzburg.de/methff.html http://www.kawumm.com/ http://www.ip.cubenet.de/NID/index.html

NRC, Narcotics Reference Centre, Aristotle University of Thessaloniki, Macedonia, Greece Hong Kong

http://nrc.med.auth.gr/

DARU, Drug Addiction Research Unit, Social Sciences Research Centre, University of Hong Kong Israel

http://www.ssrc.hku.hk/daru/

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Ultra Rapid Opiate Detoxification (UROD ) Italy http://www.opiates.com/

TRAPEZIO Exodus Foundation Centro ricerche sulla droga ed argomenti correlati. http://www.exodus.it/banner.htm Associazione Papa Giovanni XXIII http://www.exodus.it/ASSOCIAZIONI/APG23/default.htm Fondazione Villa Maraini http://www.fnc.net/maraini/ Ce.I.S. Centro Italiano di Solidariet http://www.metro.it/ceis/ceis.htm C.N.C.A. Coordinamento Nazionale Comunit di Accoglienza http://www.sapienza.it/html-doc/fermo/assoc/cnca.htm Gruppo Sims http://versilia.toscana.it/pietrasanta/sims.html CORA Coordinamento Radicale Antiproibizionista http://www.agora.stm.it/coranet/ Federazione Italiana delle Comunit Terapeutiche http://www.fict.it/ Medicina delle Tossicodipendenze, Italian Journal of the Addictions http://www.vol.it/IT/IT/SCIENZA/MEDICINA/POLSCIENCE/cov-meds.htm Gruppo Abele http://services.csi.it/~abele/gruppo.htm CBFT, Centre of Behavioural and Forensic Toxicology, University of Padova http://apf.cbft.unipd.it/ TIAFT, The International Association of Forensic Toxicologists http://www.cbft.unipd.it/tiaft/ San Patrignano http://www.vol.it/IT/IT/ASSOC/SAMPA/ Netherlands http://www.euro.net/5thworld/market/ http://users.bnc.nl/~aagroningen http://www.channels.nl/bluebird.html http://www.nedernet.nl/nonprof/bouman.html http://web.inter.nl.net/users/Broekman.Beta/ http://www.fsw.ruu.nl/cvo/ http://neturl.nl/codreams/ http://huizen.dds.nl/~jeroenw http://www.xs4all.nl/~mlap/drugtext.html

The Amsterdam HighMarket Anonieme Alcoholisten Werkgroep Groningen Coffeeshop Bluebird, Amsterdam Boumanhuis, Centrum Verslavingszorg Zuid-Holland-Zuid Bureau Bta, a research firm specialized in evaluation research in the mental health field Centrum voor Verslavingsonderzoek (Addiction Research Institute), Universiteit Utrecht Conscious Dreams Psychedelicatessen The Digital Coffeeshop DrugText Netherlands The Flow Magazine, All things Hemp related from the world of Hemp coming from Holland, Who's Who & Where? online directory of Hollands Coffeeshop's, Headshop's, Growshop's, Seed Suppliers, Grote Handles, Medicale & Publications. GG&GD Amsterdam GVC, Gelders Centrum voor Verslavingszorg The Ibogaine Dossier Interpolm Amsterdam Homegrow Shop IVV, Corporation Information Systems on Addiction Care and Treatment (Stichting Informatievoorziening Verslavingszorg) Buro Jansen en Janssen LVGGD, Landelijke Vereniging voor GGD'en The Mind's High Ministry of Health, Welfare and Sport, Central Directorate Public Relations, Documentation and Library. NIAD, Netherlands Institute for Alcohol and Drugs NIPO, het marktonderzoekinstituut, "Ruim de helft van de Nederlanders vindt Franse kritiek op Nederlands drugsbeleid onterecht" Positronics, Amsterdam, dedicated to the positive promotion of Cannabis through its many uses ranging from consumption for Medical and Personal use through to its future as a renewable reusable resource saving natural resources. CEDRO, Centre for Drug Research, UvA The Stanton Peele Addiction Web Site Norway

http://www.theflow.nl/ http://www.gggd.amsterdam.nl/ http://www.bart.nl/~gcv/ http://desk.nl/~ibogaine http://www.interpolm.nl/ http://www.ivv.nl/ http://www.xs4all.nl/~respub/ http://www.ggd.nl/ http://www.xs4all.nl/~4david/index.html http://www.minvws.nl/home.htm http://www.niad.nl/index.html http://www.nipo.nl/ http://www.nipo.nl/result/pers/f2723.htm http://www.positronics.nl/

http://peele/Welcome.html

FMR, Forbundet Mot Rusgift (League Against Intoxicants) http://www.nettinfo.no/fmr/ RusInfo, Agency for the Prevention and Treatment of Alcohol http://www.rusinfo.no/rusinfo/english.htm and Drug Problems, The Municipality of Oslo. This site contains the book "The Psychology of Getting High" by Hans Olav Fekjr. http://www.rusinfo.no/rusinfo/high.htm Organization of American States (OAS) CITA. DOC Friday 27 February 54 1998

CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Inter-American Drug Abuse Control Commission Singapore http://www.gov.sg/mha/mhahq/cnb/ http://www.gov.sg/mha/mhahq/sps/ http://www.oas.org/EN/PROG/cicad.htm

Central Narcotics Bureau Prison Service Singapore Spain

The Penal Lexicon (UK), Spain - Drugs, Prisons, And Treatment. Sweden

http://www.penlex.org.uk/ http://www.penlex.org.uk/spain.html

Bgen Local Welfare Department, Hssleholm Flashback, The Scandinavian home of Underground Hasela Nordic Network, a politically and religiously independent network for international exchange of theoretical ideas and suggestions for practical action to maintain a restrictive drugs policy and prevent the legalisation of illicit drugs. PNI, Projekt Narkotika Information RFV, Riksfrskringsverket Enheten fr lkemedelsfrgor (The National Social Insurance Board, Division for Drug Affairs) RNS, Riksfrbundet Narkotikafritt Samhlle (The Swedish National Association for a Drug Free Society) . UNF, Ungdomens Nykterhetsfrbund (The Swedish Youth Temperance Organization). Switzerland

http://www.algonet.se/~bagen/ http://www.flashback.se/

http://www.hassela.se/hassela/ http://www.lysator.liu.se/pni/ http://www.pharmasoft.se/rfv/eng/index.html http://www.algonet.se/~rns/ http://www.etek.chalmers.se/~toby/UNF/index.html

WHO, World Health Organization Taiwan

http://www.who.ch/

Government Information Office, R.O.C. United Kingdom

http://www.gio.gov.tw/

Brixton Drug Project CIA, UK Cannabis Internet Activists ISDD, The Institute for the Study of Drug Dependency, UK The Penal Lexicon (UK) United Nations

http://www.cynapse.com/bdp.html http://www.foobar.co.uk/users/ukcia/index.html http://www.globalnews.com/isdd/home.html http://www.penlex.org.uk/

CND, Commision on Narcotic Drugs INCB, International Narcotics Control Board UNDCP, United Nations International Drug Control Programme WHO, World Health Organization United States of America http://solar.rtd.utk.edu/~al-anon/ http://www.alcoholics-anonymous.org/ http://www.iugm.org/iugm/av/main.html http://center.butler.brown.edu/index.html http://www.capitalresearch.org/ http://www.capitalresearch.org/crc/trends/ot-0596.html http://www.bsos.umd.edu/cesar/cesar.html http://www.goshen.net/cir/ http://www.ca.org/ http://www.cris.com/~kenr1/commonsense/ http://www.cris.com/~kenr1/commonsense/12steps/index.shtml http://www.usdoj.gov/dea/deahome.htm http://drcnet.org/ http://itsa.ucsf.edu/~ddrc/ http://www.druglibrary.org/ http://www.cp.duluth.mn.us/~brandonc/reform.html

Al-Anon / Alateen Alcoholics Anonymous Alcoholics Victorious CAAS, The Center for Alcohol and Addiction Studies Capital Research Center, The Movement to Legalize Drugs in the United States: Who's Behind It? CESAR, Center for Substance Abuse Research, University of Maryland Christians in Recovery Cocaine Anonymous Common Sense 2000, contains the book "More Revealed, A Critical Analysis of Alcoholics Anonymous and the Twelve Step Movement" by Ken Ragge. DEA, Drug Enforcement Administration DRCNet, Drug Reform Coordination Network Drug Dependance Research Center, Langley Porter Psychiatric Institute, the University of California, San Francisco Drug Library, Drug Reform Coordination Network Library The Drug Policy Reform Page CITA. DOC 1998

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. DrugText USA http://www.drugtext.org/drugtext.html DrugWatch International http://www.lec.org/Drug_Watch/ Ecstasy.org, site by Nicholas Saunders, http://ecstasy.org/ author of "E for Ecstasy" http://hyperreal.com/drugs/e4x/ Family Research Council, Legalization of Drugs: http://www.frc.org/townhall/FRC/ The Myths and the Facts http://www.frc.org/townhall/FRC/insight/is95c2dr.htm Food Addicts Anonymous http://www.shore.net/~tcfraser/faa.htm HabitSmart's Harm Reduction Site http://www.cts.com/~habtsmrt/hrmtitle.html Hazelden Foundation, Nonprofit organization providing rehabilitation, education, prevention, and professional services and publications in chemical dependency and related disorders. http://www.hazelden.com/ The Heffter Research Institute, Santa Fe http://www.heffter.org/ Hyperreal Drug Archive http://hyperreal.com/drugs/ IDAP, Institute for Drug Abuse Prevention, Indiana University http://www.indiana.edu/~idap/index.html IPRC, Indiana Prevention Resource Center, Indiana University http://www.drugs.indiana.edu/ JACS, Jews in Recovery from Alcoholism and Drug Abuse http://www.jacsweb.org/ Join Together Online http://www.jointogether.org/jointogether.html The Life Education Network, http://www.lec.org/ DrugSearch http://www.lec.org/DrugSearch/ The Lindesmith Center http://www.lindesmith.org/ The Fritz Hugh Ludlow hypertext library http://www.lycaeum.org/~sputnik/Ludlow/index.html MAPS Multidisciplinary Association for Psychedelic Studies http://www.maps.org/ Marijuana Policy Project http://www.mpp.org/ Massachusetts Cannabis Reform Coalition / NORML http://www.crocker.com/~anderson/mc/index.htm Marijuana Anonymous http://www.primenet.com/~bundle/ NAMA, National Alliance of Methadone Advocates http://www.interport.net/~clueless/nama1.html National Clearinghouse for Alcohol and Drug Information http://www.health.org/ NCJRS, The National Criminal Justice Reference Service's http://ncjrs.aspensys.com:81/0/ncjrshome.html National Institutes of Health http://www.nih.gov/ National Library of Medicine http://www.nlm.nih.gov/ Nicotine Anonymous http://rampages.onramp.net/~nica/ NIDA, National Institute on Drug Abuse http://www.nida.nih.gov/NIDAHome.html NORML, National Organization for the Reform of Marijuana Laws http://www.norml.org/ Carl E. Olsen's Marijuana Archive http://www.calyx.net/~olsen/ Paranoia Drug Archive http://www.paranoia.com/drugs The Psychoactives Archive http://www1.usa1.com/~debaser/drugs/ RAND, a nonprofit institution dedicated to improving public policy through research and analysis. They have conducted many influential studies of alcohol and other drug policies over the years. Some of their recent work is now available online. http://www.rand.org/ RIA, Research Institute on Addictions, Buffalo, NY http://www.ria.org/ RWJF, The Robert Wood Johnson Foundation, U.S. largest substance abuse philanthropy. The site includes current calls for proposals, guidelines, and other health care related information. http://www.rwjf.org/ Jim Rosenfield's Site http://turnpike.net/~jnr/ Rutgers Center of Alcohol Studies, Rutgers State University, New Jersey http://www.rci.rutgers.edu/~shaver/ SAVE, Substance Abuse Volunteer Efforts http://www.nicoh.com/heritage/SAVE/ Sex, Drugs, and Democracy http://www.cc.columbia.edu/~arb33/ SMART, Self-Management And Recovery Training http://www.netwizards.net/recovery/smart.html SOS, Secular Organizations For Sobriety http://www.codesh.org/sos/ Cliff Schaffer's Home Page http://www.calyx.com/~schaffer/ Steve's Syberscience Secrets, http://www.wdc.net/~smd/ "Delta 1-tetrahydrocannabinol, a fat-soluble "vitamin M" fram marijuana" http://www.wdc.net/~smd/vitaminm.htm Virginia Addiction Training Center http://freenet.vcu.edu/health/vatc/vatc.html Web of Addictions http://www.well.com/user/woa/ Journals, magazines Connexions, The Journal of Drug and Alcohol Issues, published http://www.ceida.net.au/connexions/index.html bimonthly by CEIDA (Centre for Education and Information on Drugs and Alcohol). DRUGSedition http://www.xs4all.nl/~mlap/release/edition.html The Flow Magazine, All things Hemp related from the world of Hemp coming from Holland, Who's Who & Where? online directory of Hollands Coffeeshop's, Headshop's, Growshop's, Seed Suppliers, Grote Handles, Medicale & Publications. Grow! HanfBlatt, Das Magazin Fr Hanfkultur International Journal of Drug Policy http://www.xs4all.nl/~mlap/ijdp.html The Journal, published by the Addiction Research Foundation http://www.arf.org/Intropage.html Journal of Applied Behavior Analysis http://www.envmed.rochester.edu/wwwrap/behavior/jaba/jabahome.htm Journal of the Experimental Analysis of Behavior http://www.envmed.rochester.edu/wwwrap/behavior/jeab/jeabhome.htm CITA. DOC 1998

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Copyright 1996, Fondazione Exodus - Viale Marotta 18/20 Milano By WDL Tel.+39.2.2150428 0338/6781221 http://www.exodus.it/fon.htm Know of a link we should include? Please let us know! Volete segnalarci nuovi links? Informateci!!! 02/1997 Questo lavoro di archiviazione, catalogazione e linkaggio dei siti nazionali ed internazionali sulla droga realizzato dal C.E.D. Exodus. Chiunque fosse interessato ad utilizzare questa pagina invitato a contattare i responsabili di Trapezio

CITA. DOC 1998

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy.

The Israeli Institute of Advanced Treatment and Research for Opiate Dependency

Mission Statement by Dr. Andre Waismann

In this age of violence, when death is a legitimate commodity, when policies on management of famine, disease and ignorance are determined by political lobbies, when one person's tragedy becomes another's evening of entertainment, in this time of rage, we must seek grace and find a place where each one of us can still make a difference. Millions of people throughout the world suffer from the disease of Opiate Dependency. Society has judged, condemned them and found them guilty for crimes they may not have committed. Moral prejudice and theories on addictive personalities and psychological disorders are preventing these people from the medical care they urgently need. Throughout history mankind has always looked for different ways of self healing and shelters from everyday reality. For decades, our society has been victim to opiate abuse. Opiate abuse is wide spread with no effective treatment available. Its victims are not viewed as patients, but more commonly - as outlaws. Society has pushed them to the gutters and the dark alleys of life, and then, discovered the urgent need to protect itself from them. Some of the choices, until now, have been remedies such as addictive opiate replacements and long term isolation from society. Rehabilitation centers throughout the world offer individuals suffering from opiate dependency procedures based on suffering from a long, tormenting withdrawal syndrome. While failing to provide a better solution, the suffering is then justified for it's so called therapeutic value. This process stands in the way of many addicts from seeking treatment, and among those who do seek treatment, many drop out. Worse of all, the minority that does complete the treatment is likely to relapse and is then even more reluctant then ever to seek treatment again. Opiate Dependency has been treated by social workers, psychologists, psychiatrists, and law enforcement personnel. In reality, it is a central nervous system disorder. Abrupt abstinence causes a traumatic disorder involving sever consequences to the central nervous system. This disorder should be given appropriate medical care. We can never undo the tragic losses that have resulted from this historical misjudgment. But, times have changed, and Opiate Dependency has finally been recognized as a central nervous system disorder caused by continuous opiate intake. Therefore, we must not judge, punish, or morally confront those with opiate dependency. Rather, we should provide them with appropriate medical care. We invite you to join us in the fight against human suffering, and to witness the birth of a new era. Dr. Andre Waismann Founder director of the Israeli Institute of advanced treatment and research for opiate dependency. Please follow me.

Understanding the Treatment - Rapid Opiate Detoxification

1. Background 2. The Rational 3. The Process 4. Results 5. Summary 1. Background In the last decade Rapid Opiate Detoxification is being attempted by many different physicians and institutions throughout the United States and Europe. Some of these attempts were described in several scientific and medical publications. Based on the positive clinical results of Dr. J.J. Legarda in Seville, Dr. Andre Waismann founded his Institute in Tel-Aviv. New steps were achieved in bringing to reality the aspirations of doctors and patients throughout the world. Since then, thousands of opiate physically dependent patients were freed from their disease and effectively relived of their craving. As of January 1997 in Dr. Waismann's Institute in Tel Aviv, over two thousand patients (from sixteen to sixty two years of age) have successfully undergone the procedure, among them pure heroin users, methadone, codeine or morphine users, even cases with secondary diseases (such as AIDS). With over three years of follow-up our center in Israel under the medical direction of Dr. Waismann and the psychological supervision of Dr. Michael Reiter became a reference point for doctors throughout the global medical community. With that we do understand that it will take sometime until our work and experience will be properly learned by others, but we do positively believe that the new era in combating opiate dependency is already a reality where patients can be treated in an effective, safe and humane way. With the unique personal experience of over 3000 cases treated, Dr. Waismann decide to found the Israeli Institute Of Advanced Treatment And Research For Opiate Dependency (MEGAMA) 1997. Apart of treating patients from all over the world we encourage the scientific community and any governmental agency to come, learn and join efforts to make the treatment available as part of the several basic public health treatments offered in the different countries; this could change drastically the "almost" ridiculous situation where for so many years not much was achieved by the scientific community on this field, while in so many others, medicine, has embraced advanced technology resulting in huge achievements. 2. The Rational The procedure we provide requires one to two days of hospitalization including a four hours procedure in an intensive care unit (ICU). The success of the program is attributed to the absence of physiological discomfort to the patient during the neuro-regulation phase and the rapidity with which patients enter the rehabiliation process effectively protected from craving.

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. "Detoxification", (we would prefer to call it neuroregulation) programs require a minimum of 10 days and up to several weeks to complete neuroregulation, and usually imply substantial discomfort to patients during withdrawal. This typically results in an extremely high drop-out rate, as high as 30 to 50 percent for in patient procedures and 70% in out patient clinics. Our approach is critically different. OD is a central nervous system disorder caused by continuous opiate intake. As a result, a physical dependency state occurs. This is represented at the symptom level by what is traditionally conceptualized in terms of withdrawal syndrome that is experienced in the absence of continuous opiate intake. In order to achieve an opiate free state without withdrawal syndrome for OD individuals, we use an active technique for neuro-regulation, in place of a passive one. Instead of using a classical model for OD, we treat it at the receptor level rather than just the symptom level. This results in an effective new adaptation of the previous affected systems that were compromised by the continuous opiate intake; at the same time we block the opiate receptors which eliminates craving thus enabling an immediate continuity to social and psychological rehabilitaion. 3. The Process Patients undergo comprehensive psychological and medical examination prior to the commencement of the procedure. Before the treatment the patient is prepared with a six hours pre-medication program. The procedure is carried out in an ICU. Patients are hospitalized for a full 24 to 36 hours treatment protocol. Utilizing deep sedation during the procedure enables patients to undergo the treatment without conscious suffering. The patient spends the remaining time in the hospital under supervision and is usually discharged in the following morning. The patients embark on an out-patient Naltrexone, non-addictive, non mood affection substance regime within 24 hours of completion of the process. We emphasize counselling when it is necessary. 4. Results Our data shows 100% success rate as demonstrated by no withdrawal syndrome observed following Naltrexone administration on patient's discharge. The procedure enables patients to set forth an opiate antagonist program with no relapse between the procedure and the beginning of the rehabilitation phase. In addition, there is no relapse as long as the patient is on the Naltrexone regimen. The present procedure should also be viewed in contrast to the traditional "detoxification" procedures in which a long and costly in-patient hospitalization is required. Also, one should take into account the drop out rate of these procedures - 30% to 50% for in-patient procedures and 70% for out-patient clinics. The process allowes patients to return to their occupations within a few days following the treatment. 5. Summary Megama detoxification procedure is unique in four major points: 1. 100% success in releasing the patients from Opiate dependency. 2. No conscious suffering is experienced by patients undergoing withdrawal process. 3. Immediate induction of opiate antagonist treatment, (Naltrexone) optimizing the efficiency of the rehabilitation process. 4. Effective pharmacological managing of "craving".

Operation Hope
Curing more than 500 patients in Italy, over one day. What the world is saying about Megama, Dr. Waismann and Dr. Reiter

Quotes from the Press. "A revoulutionary medical treatment is achieving astound success." The Jerusalem Report, July 13, 1995 "I woke up with no withdrawal symptoms, no pain." Eldad Niv, Former Patient "A miracle cure for opiate addicted people." Dan Rather, CBS Evening News "What we do is not a miracle, it's a medical solution." Brian Zavell, Former Patient & Director of Admissions "I couldn't believe it. I was reborn. Thank you!" AB, Former Patient. "Instead of shaking, sweating, and retching for 10 days or more, the patients purportedly go home clean the next day." Newsweek, Jan 30, 1995 "My son has come back to us, to life... In our home, we have learned to laugh again." Mother of Former Patient.
Frequently Asked Questions
Question: Is the treatment dangerous? Answer: Extensive studies, (several by various government agencies) have clearly determined that not a single incident of major medical complication or mortally has occurred. Question: Aids and other illnesses? Answer: For aids patients, the treatment is profound. The physical drain opiate dependency puts on the body is tremendous and continual. Now, overnight, aids patients can be 100% freed from their physical enslavement to the substance. Now the body turns its whole attention to battling the virus. Question: Is the Treatment Guaranteed? Answer: Neuroregulation with minimal discomfort, is absolutely guaranteed.

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Question: Craving? After detoxification, will I experience craving? Answer: No. A daily dose of Naltrexone (a non-addictive, non-narcotic opiate antagonist) in pill form satisfies cravings, then caps the brain's receptors, blocking the ability of the opiates to take hold. In example, if the patient breaks discipline and attempts an opiate "fix", he will not feel its effects. The patient is given a sober chance to reflect on the "stumble". This greatly enhances the patient's motivation to remain opiate free. Question: Is confidentiality guaranteed? Answer: YES. Privacy and confidentiality are professionally guaranteed. Question: What about rehabilitation? Answer: Depending on the current life status of the patient and his history, a rehabilitation process may be recommended. The same applies to follow-up counseling, therapy, etc. With that, over exposure of a former dependent patient to issues as craving and dependency, when he had already been armacologically treated, causes neuro exitation that is counter productive to the patient. According to our experience of over 2000 patients, rehabilitation should deal primarily with the patient's life problems, (i.e. employment), family relations, leisure time etc. Question: Are there any side effects to the medications used? Answer: All the medications used in the treatment are FDA approved. The patient will be on a regimen of Naltrexone for a year following the procedure. Naltrexone is FDA approved and is in use for about 20 years and has no known serious side effects. Question: How long will I take the medication after the procedure? Answer: The patient will be taking Naltrexone for one year after the procedure is performed. The main reason for the maintenance dose is to keep the patient blocked against the impact of opiates (i.e, Heroin, Methadone etc.), to eliminate the craving and to create a situation where the patients without opiate use and without craving can resume his life. Question: How is this treatment different from traditional treatments? Answer: The technique deals approaches the problem from a totally different angle. In effect, this technique actively deals with the central nervous system to influence decisively and fast the euroadaptive process. Traditionally we let the patient go through withdrawal and at best, try to ease the discomfort with some medications. The technique precipitates withdrawal and completes the process within a few hours under sedation with minimal discomfort to thepatient. The advantages are : 1.No drop out from "deoxification." 2.No significant discomfort in the process. 3.The patient is blocked against opiates immediately. (Heroin, Methadone, Morphine etc.) 4.No craving. 5.Maintenance on Naltrexone for a whole year. 6.Opiate addiction is dealt with as an illness - and not as a character flow, i.e. medical approach which is both humane and effective. 7.The patient, after the procedure (being blocked and without craving) can devote a lot of free psychic energy towards his/her rehabilitation.

Contact Megama
Megama is located in Tel Aviv, Israel. Our mailing address is:

http://www.megama.com/pages/contact.html

Megama Institute Ltd. 144 Hayarkon Street Tel Aviv, Israel 63451 Phone: +972.3.527-3616 Fax: +972.3.527-3767
We are affiliated with the North American Megama Institute located in Ensenada, Baha California, and on the web at http://www.urod.com. We can also be reached by email at the following addresses: Dr. Andre Waismann: Dr. Michael Reiter: General Inquiries: waismann@megama.com reiter@megama.com contact@megama.com

Contact Name (or alias) Contact Email (Click here to learn how to obtain an anonymous email address) Add Address to Mailing List City State Country Comments

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Biography Andre Waismann M.D. Dr. Waismann completed his training in Tereropolis University, Rio De Janeiro and taught cardiology and propedeurics. In 1982 he immigrated to Israel where he joined the Department Of Surgery of Naharya Hospital. During the Lebanon War he joined the army and became the physician in charge for an infantry unit. In his military service received honors for actions as a doctor and officer by the former Minister of defense and Prime Minister Itzhak Rabin and by the former Israeli President Haim Herzog. After the military service he worked in the Department Of Surgery of Ashkelon Hospital and on the Trauma Center of Ashdod. In 1988 he was the MD in charge of the Jerusalem district for the Israeli police, he had the medical responsibility of all the prisoners of the district and started researching Opiate Dependency in order to improve the level of care of inmate patients. In 1990 was the M.D in charge of the Israeli counter terrorism unit and was honored with a medal from the minister of police for treating a wounded soldier under enemy fire. In 1994 he founded the Cita Institute of Israel. In 1995 he organized and directed Operation Hope in Milano where in 3 days his team successfully detoxified 273 patients. Dr. Waismann appeared on several television, press and radio interviews in Israel, U.S.A., Brazil and Europe. He lectured on the topic of Opiate dependency in several countries and consults physicians and practioners from many countries. Today Dr. Wasimann directs his Institute in Tel Aviv and is engaged in research and treatment of O.D patients that arrive in Israel from all the world. He is a consultant on Opiate Dependency supervises and collaborates with the Cita Center of Ensenada, with offices in Beverly Hills, CA. The world wide unique experience of over 3000 patients treated place Dr. Waismann on heading the scientifical community to a new era. "Opiate dependency is no longer the almost, unbeatable enemy". Biography Michael Reiter Ph.D. Dr. Reiter received his Ph. D. in clinical Psychology from the University of Texas at Austin Texas in 1966. He interned at Mclean Hospital, a teaching hospital of Harvard Medical school. He held the position of Chief Psychologist of the Brown Schools and was senior staff Psychologist at the Counseling Center of the University of Texas from 1967 to 1970. From 1970 to 1975 Dr. Reiter served as the chief Psychologist and Director of the Tel-Aviv-Jaffa Community Mental Health Center and in 1975 he founded and directed the Tel-Aviv Drug Abuse Rehabilitation Center. The Center included a Methadone Clinic, a detox inpatient ward and day Hospital program. Dr. Reiter directed the Center for 20 years and in 1994 he was Co-Founder and CoOrdinator of Megama-Israel. Between 1976 and 1983 Dr. Reiter served as National Director of Drug Abuse services in the Ministry of Health. Dr. Reiter serves as a member of the National Council of Mental Health (from 1994), board Member of the National Drug Authority, Chairman of the Attorney General's Committee on Treatment and Rehabilitation, and the Ministry of Health Commission of Drug Abuse policy. Dr. Reiter taught at the University of Texas at Austin Texas; He was the Director of Social Science Sequence, school of continuation studies in Medicine, the University of Tel-Aviv; Director Drug Abuse Treatment studies, Dept. of Criminology, Bar Ilan University. (1989-1990). In addition Dr. Reiter was Lecturer at Bar Ilan University School of Social Work and Tel-Aviv University Dept. of Psychology. Among his publications Dr. Reiter wrote extensively on the Drug Scene in Israel. (1994 - Israel Anthology on Drug Abuse: "Drug Abuse Treatment in Israel"; 1978 - in the Israel Journal of Public Health "The Israel Drug Scene"; in 1986 - Caruzi & Schneider "Drugs and Alcohol, socialization into Addict subculture and resocialization into wide society". Dr. Reiter appeared on several television forums as an expert on drug abuse treatment and related issues in Israel, Germany and the U.S.A. He was interviewed extensively on these issues on radio and in the press and lectured on Drug Abuse Treatment in Israel, Italy, the U.S.A. and Germany. Currently as Co-Founder and Co-Director of Megama-Israel he devotes his full time to the treatment of heroin addicts, using the newly developed and well proven technique developed by Dr. Waismann.

NOTES:
1.Naltrexone in Alcohol Dependence PETER M. HARTMANN, M.D. York Hospital, York, Pennsylvania American Family Physician http://www.aafp.org/family/afp/970400ap/abs_18.html This is an Abstract from the April 1997 edition of American Family Physician.

Naltrexone is a narcotic antagonist that has been shown to reduce alcohol craving and alcohol use in patients with alcohol dependence. It should not be used as exclusive treatment but only as an adjunct to a comprehensive program that includes psychologic and social treatment approaches such as those in Alcoholics Anonymous or professional programs. The two most serious complications of naltrexone therapy are the precipitation of narcotic withdrawal in patients taking narcotics, and hepatotoxicity. The latter complication occurs only at dosages much higher than the 50 mg per day recommended for treatment of alcohol dependence. Alcohol is known to enhance opioid receptors. Evidently, naltrexone blockade of these receptors results in reduced craving for alcohol, less of a "high" while drinking and less alcohol use. April 09, 1997. American Academy of Family
Physicians 2. CURBING THE CRAVING By Jennifer Baldino From Penn Health Magazine, July/August 1995. Reprinted with permission. http://www.med.upenn.edu/~recovery/pros/pnhealth.html

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. For the first time in 50 years, the federal government has approved a new drug treatment for alcoholism. The treatment is based on the research of a psychiatrist at the University of Pennsylvania Medical Center. For more than a decade, Joseph R. Volpicelli, M.D., PhD., worked to show the medical community that naltrexone, a drug used since the 1980s to treat heroin addiction, can also curb the craving for alcohol. Last December, the U.S. Food and Drug Administration approved the use of naltrexone specifically to treat alcohol addiction. The drug, manufactured by DuPont Pharma and formerly sold under the name Trexan as a heroin-addiction treatment, will now be sold as ReVia. Volpicelli first recognized naltrexone's potential to treat alcoholism 15 years ago as a graduate student in Penn's Department of Psychology. What prompted his study of naltrexone was his suspicion that the drug might work in alcoholics the same was it did in heroin addicts. He discovered that rats had a higher preference for alcohol following stressful events, what Volpicelli calls the "weekends-were-made-forMichelob" effect. He also found that the rats taking naltrexone didn't increase their intake of alcohol. In 1981, he began publishing his findings on the drug. But the research was met with skepticism. As Volpicelli told Penn Health: "Everybody--academics, the drug company-thought it was a pretty wild idea." The exception was Charles P. O'Brien, M.D., PhD. A professor and vice chair of psychiatry at Penn and chief of psychiatry at Philadelphia's Veterans Administration Center, he says he was won over by Volpicelli's naltrexone research on rats. Volpicelli in turn credits O'Brien with giving him the financial and moral support and time to continue his research on naltrexone. "We did it without any outside funding," says O'Brien. "We got it started against pretty great odds." According to O'Brien, the researchers even had difficulty recruiting subjects for their studies in the 1980s because treating alcoholism with medication was not common. Volpicelli, O'Brien, and their colleagues Arthur I. Alterman, PhD., and Motoi Hayashida, D.Sc., started a naltrexone study using volunteers at the Veterans Administration Hospital in 1985. They tracked 70 men for 12 weeks following their outpatient detoxification program. Half received naltrexone, half a placebo. The researchers found that while 23 percent of the volunteers who took naltrexone experienced a drinking relapse, 54 percent of those who received a placebo reverted to drinking. During the study period, half the participants in both groups took at least one drink each (an act known among alcoholics as "slipping"). But when those who took naltrexone slipped, they were able to stop drinking after a few drinks, avoiding a total relapse. "Ordinarily in alcoholics even one or two drinks stimulates the body's craving for more," Volpicelli told The New York Times. But with naltrexone, "the cycle of craving was broken. This made it easier for them to stop drinking again and continue their treatment." In 1991, researchers at Yale University School of Medicine tested the effects of naltrexone in conjunction with psychological therapy in 104 alcohol-dependent men and women. The Yale study found that patients who took naltrexone were nearly twice as successful in their clinical outcomes, including abstinence and avoiding a relapse, as those who took a placebo. The corroborating results gave Volpicelli's research the credibility it needed in the eyes of those in academe and the pharmaceutical industry. As Volpicelli puts it, they realized that "the findings were real, not just an accident." The Penn and Yale studies were published in the Archives of General Psychiatry in November of 1992. DuPont Pharma showed interest in manufacturing the drug. (DuPont Pharma, a partnership between DuPont and Merck & Co., Inc., is a research-based pharmaceutical company. DuPont Pharma receives the profits from the sale of ReVia and has provided Volpicelli with funding for educational programs.) Last summer, the drug was presented to the FDA for approval. Controversial because of its lengthy approval process, the FDA surprised the researchers by authorizing naltrexone's use in alcoholism treatment in just six months. According to Volpicelli, the FDA was "pretty confident" that the drug was safe: It had been under research for 20 years and on the market for 10 as a treatment for heroin addiction. "It's very rewarding for us to see that the research we've been doing for the past decade or so has found a niche," says Volpicelli. Only one other medication, Antabuse, known generically as disulfiram, has been widely used to treat alcoholism. The drug is designed to cause vomiting and severe nausea when mixed with alcohol but it does little to stop the alcoholic's craving. Volpicelli reports that his patients who take naltrexone have been happy with the results. They've told him that "they went to a bar, had a drink, and didn't get anything from it. They didn't get that buzz." And several did something they had never done before: "They left half their drink on the bar." In speaking to the media about the effects of naltrexone, however, Volpicelli and O'Brien warned that the drug is not a "magic bullet." Naltrexone does not cure the addiction; it eliminates the pleasurable "high" of drinking alcohol and reduces the craving for more. Volpicelli calls naltrexone an "antipsychoactive drug" because it works by blocking the effects of drugs like heroin or alcohol on the mind and behavior. While people may turn to such drugs as alcohol to "escape," naltrexone blocks their psychoactive effects so people can learn to cope with life without drugs. Naltrexone actually works in the brain, blocking the pleasurable effects of alcohol on nerve cells known as opioid receptors, which help dull emotional and physical pain and lead to feeling high. Naltrexone's critics argue that is was not very effective when used to treat heroin abuse; some have called taking a pill to curb alcoholism a "quick fix"; others have wondered if naltrexone can help people who abuse more than one substance or if naltrexone fits into the "drug-free" philosophy of many addiction treatment centers. Volpicelli uses two words--they are quite a mouthful--to respond to their criticisms: Biopsychosocial support. To recover fully from addiction to alcohol or any drug, he explains, most people need what he calls a "tripod" of support: medication, counseling, and support from family, friends, or other addicts. In Volpicelli's view, a pill alone won't help an addict. But without medication, he says, neither will psychotherapy and social support. "If you have two legs of the tripod," he says, "you're going to tip over. If you have three legs, you have a good foundation." Volpicelli feels so strongly that naltrexone works well only in combination with psychosocial treatment that, with the support of the national alcohol research community, he successfully urged the FDA to approve naltrexone only as an adjunct to conventional treatments. "Our results show that naltrexone, when used with a 12-step or other recovery program, may be effective--particularly in the early stages of treatment," says Volpicelli. "But it is essential that recovering alcoholics also undergo a comprehensive treatment program which helps them cope with the social, legal, family, physical, and psychological problems that occur as a result of their drinking behavior." Naltrexone is taken orally once a day. Its most common side effects, reported in approximately 10 percent of patients, are nausea, difficulty in sleeping, anxiety, nervousness, abdominal pain or cramps, vomiting, low energy, joint and muscle pain, and headaches. The National Institute on Alcohol Abuse and Alcoholism, which funded the Penn and Yale studies, is supporting nine clinical trials to determine the patient type, dose, therapy combinations, and treatment duration with which naltrexone works best. At Penn's Treatment Research Center in September, Volpicelli will begin clinical trials on whether a three- or nine-month course of treatment with naltrexone works better. He is also studying the effects of giving naltrexone to people at risk for alcoholism because of their family history. In other research, Volpicelli and his team are studying a comprehensive treatment program or, as the psychiatrist puts it, "one-stop shopping," for women addicted to cocaine. According to the Department of Health and Human Services, alcohol abuse and dependence affect about 15.3 million adult Americans and approximately 38 percent of adult Americans have experienced alcoholism or alcohol abuse in their families. An article in Alcohol, Health, and Research World includes the estimate that alcoholism and alcohol abuse cost $98.6 billion in 1990; some 70 percent of that total is attributed to lost earnings and decreased productivity because of alcohol-related illness and early death. The immediate physical effects of alcohol include decreased motor coordination and respiratory capacity. Long-term alcohol abuse can cause the liver and other organs to degenerate, a point Volpicelli underscores in presentations with a slide of Promethues Bound, a painting by Peter Paul Rubens depicting a mythical titan doomed to have his liver plucked out again and again. According to Volpicelli, the recent findings on naltrexone reinforce the little-appreciated theory that alcoholism is biochemically based addiction and not a personal flaw; studies have proven that alcoholism runs in families and that alcohol triggers the release of natural opioids in the body. The proof of biochemical motivation for alcohol dependence, says Volpicelli, may help alcoholics "overcome their shame, come out of hiding, and get treatment." Volpicelli also sees

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. approval of naltrexone as another step in educating the public and the medical community about alcoholism. He says patients unable to control their drinking through conventional programs have told him they'd been blaming themselves and asking, "What's the matter with me?" Now, he says, there is proof that their drinking has a physiological base. Naltrexone, says Volpicelli, "has given them hope." To refer a patient or volunteer for the clinical trials on naltrexone, call Volpicelli at the Treatment Research Center at (215) 222-3200, ext. 170. The published findings of the research studies mentioned in the above article are available as: An Overview of Naltrexone in the Treatment of Alcohol Dependence. Naltrexone Therapy: Natlextrone in the Treatment of Alcoholism: Predicting Response to Naltrexone. Reprint requests to: Joseph R. Volpicelli, MD, PhD, Treatment Research Center, University of Pennsylvania, 3900 Chestnut Street, Philadelphia, PA 19104-6178; Telephone: (215) 222-3200, Fax : (215) 386-6770, E-mail: volp@cattell.psych.upenn.edu. Naltrexone in the Treatment of Alcoholism: A Clinical Review. Reprint requests to: Charles O'Brien, M.D., Ph.D., Center for the Study of Addiction, University of Pennsylvania, 3900 Chestnut Street, Philadelphia, PA 19104-6178; Telephone: (215) 222-3200, Fax: (215) 386-6770. Opioids and Alcohol Self-administration in Animals. Reprint requests to: Ronald R. Ulm, Ph.D., Psychology Department, Salisbury State University, Salisbury, MD 21801.

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy.

Revia and Alcohol addiction

Addiction Research Foundation Library 33 Russell Street Toronto, Ontario Canada M5S 2S1 Tel: (416) 595-6144 Internet: isd.arf.org Nouveau mdicament pour traiter l'alcoolisme est toujours boud PAR ANITA DUBEY http://www.arf.org/f-naltrexone.html Cet article est paru la page 5 du numro (nov.-dc. 1996). Bien que les centres de traitement de la toxicomanie montrent un intrt marqu pour le naltrxone dans le traitement de l'alcoolisme, ce mdicament ne jouit pas encore d'une grande popularit en Ontario. C'est en janvier que Sant Canada a donn son aval au naltrxone. Le mdicament est le premier traitement pharmacologique contre l'alcoolisme a voir le jour en 50 ans. L'action du mdicament, vendu sous le nom de ReVia, est de refouler les envies de boire et de rprimer les effets agrables de l'alcool. Lors d'tudes contrles, il a grandement rduit le taux de rechute et les envies irrsistibles lorsqu'il tait accompagn de sances de counseling. Mais, la poussire est maintenant retombe aprs l'agitation qui a suivi son homologation. Jusqu' maintenant, la demande n'est pas crasante, signale Nady El-Guebaly, prsident de la Socit mdicale canadienne sur l'alcool et autres drogues. Selon Janice Martin, chef du projet ReVia chez Dupont Pharma, compagnie qui met le mdicament en march au Canada, jusqu'ici, 47 p. 100 de la demande provient de l'Ontario. Nous le voyons comme une option viable, dclare Bonnie Madonik, directrice des services mdicaux l'institut Donwood de Toronto. Mais nous agissons avec circonspection. En effet, le personnel se familiarise petit petit avec le mdicament et quelques clients du Donwood sont, l'heure actuelle, traits au naltrxone. Shelley Gorman, directrice des services de counseling en toxicomanie de Peel Mississauga, prcise que le mdicament doit tre prescrit par un mdecin. Cette condition reprsente un obstacle pour les nombreux centres de traitement qui n'ont pas de mdecin sur les lieux. Nous distribuons de la documentation sur le naltrxone aux clients afin qu'ils la remette leur mdecin. Mais souvent, les mdecins ne voient jamais cette documentation, ou dcident simplement de ne pas utiliser le naltrxone. Elle ajoute que les services entre les mdecins traitant et les centres de traitement se doivent d'tre bien intgrs afin d'assurer l'efficacit du traitement au naltrxone. Plusieurs intervenants sont d'avis qu'il faut renseigner davantage les mdecins et le public sur le naltrxone, si ce n'est que pour ressusciter le concept du traitement pharmacologique dans le domaine. Je pense qu'on devrait le prescrire un peu plus que a, affirme Peter Selby, conseiller mdical la Fondation de la recherche sur la toxicomanie (ARF). Selon Jim Hanna, coordonnateur de la programmation au centre New Port Port Colborne, la perception gnrale consiste ce que le client en traitement arrte compltement de consommer. L'ide de prendre un mdicament pour y arriver semble donc un peu incongrue. M. Selby a eu une cliente qui a d interrompre sa consommation de naltrxone afin de satisfaire aux conditions d'admission dans un centre de traitement.On a grand besoin de rduquer les intervenants, reconnat M. El-Guebaly. Mme Martin signale que DuPont Pharma a rejoint plus de 1 000 mdecins l'aide de confrences ou de prsentations audiovisuelles. Pour les mdecins qui ont prescrit le naltrxone, les preuves non scientifiques ressemblent aux rsultats des tudes scientifiques. Pour certains, il est extraordinairement efficace, commente George Davidson, un mdecin de Port Colborne spcialis en toxicomanie. Il renverse compltement le dsir de boire chez les buveurs. Quelques-uns de ses clients ont arrt le naltrxone aprs quelques mois et vont toujours bien. Chez certains autres clients, cependant, le naltrxone n'a aucun effet. J'ai l'impression qu'il est trs efficace pour un sous-ensemble de personnes, mais nous ne savons pas encore lequel. M. El-Guebaly, galement directeur du centre de toxicomanie de l'Hpital Foothills Calgary, fait observer que le naltrxone semble tre efficace dans les cas o le dsir de boire est un problme grave, ou lorsqu'il y a antcdents de rechute. M. Selby, quant lui a remarqu que les clients qui n'taient pas dsintoxiqus de manire adquate continuent de boire lorsqu'ils prennent le naltrxone. Mais quand le mdicament agit, les clients sont en mesure de bien fonctionner. En raison du cot du naltrxone, M. Davidson a refus d'adopter une attitude gnraliste et de le prescrire tous ses clients qui ont un problme li l'alcool. Chaque comprim cote 5,50 $; ce qui peut se traduire par 165 $ par mois. Les clients qui ne sont pas assurs doivent en assumer les frais. C'est le mme prix qu'un verre d'alcool, mais les clients ne le voient pas comme a, poursuit-il. Il ajoute que certains patients sont horrifis par le prix. C'est un bon investissement long terme, mais ce n'est pas l'opinion de certains. M. El-Guebaly est d'avis que le naltrxone sera de plus en plus souvent prescrit mesure que les intervenants se familiarisent avec le mdicament. Il replace le rle du mdecin sa juste place dans le domaine. NALTREXONE AND ALCOHOL http://www.arf.org/ Selected BibliographyLast Updated:02/96 This bibliography lists recent articles on naltrexone and alcohol. Materials are available from the ARF Library, or consult your local library and information services. Additional resources are available. Journal Articles Alcohol-Related Disorders: Treatment Principles and Alternatives. American Journal of Psychiatry 152 (11, Nov.suppl): 28-35 (1995). Naltrexone in the Treatment of Alcohol Dependence. The Annals of Pharmacotherapy 28:210 (1994) NIAA Media Advisory: Naltrexone Approved for Alcoholism Treatment. A/B/M/R/F Journal. 5 (1):39 (1995). O'Malley, Stephanie S. et al. Naltrexone and Coping Skills Therapy for Alcohol Dependence: a Controlled Study. Archives of General Psychiatry 49: 881-87 (1992). Swift, Robert M. Effect of Naltrexone on Human Alcohol Consumption. Journal of Clinical Psychiatry 56 (suppl 7): 24-29 (1995).

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Volpicelli, Joseph R. et al. Effect of Naltrexone on Alcohol "High" in Alcoholics. American Journal of Psychiatry 152 (4): 613-15 (1995). Volpicelli, Joseph R. et al. Naltrexone in the Treatment of Alcoholism: Predicting Response to Naltrexone. Journal of Clinical Psychiatry 1995: 56 (suppl 7) 39-44 (1995). Volpicelli, Joseph R. et al. Naltrexone and the Treatment of Alcohol Dependence. Alcohol Health and Research World 18 (4): 272-78 (1994). Volpicelli, Joseph R. et al. Naltrexone in the Treatment of Alcohol Dependence. Archives of General Psychiatry 49: 876-80 (1992).

Newsletters Dubey, Anita. Pleasure Blocker. The Journal. May/June 1995. Addiction Research Foundation FDA-Approved Heroin Drug To Be Sold as Treatment for Alcohol Dependency. The National Report on Substance Abuse 9(4):1-2 (1885). Far from 'Magic Bullet,' Is Naltrexone Even on Radar Screen? Alcoholism & Drug Abuse Weekly 8(4):1-2 (1996) New Drug Approved for Alcoholism Treatment. Research in Brief 95(3):1-2 (1995) Newly approved Naltrexone can help reduce craving and prevent relapse. The Addiction Letter 11(2):1-2 (1995). Fact Sheet Fast Fax Facts on Naltrexone. Addiction Research Foundation Contact the ARF Information Centre, 1-800-463-6273 (In Toronto, 5956111) and listen to taped message #71 or request that Fast Fax Facts on Naltrexone be either faxed or mailed to you. http://www.arf.org/isd/pim/naltrex.html. This will also be available on the ARF web site: http://www.arf.org and SANO (telnet: sano.arf.org). WWW sites: DATNet (Drugs and Alcohol Treatment Net) by Haight Ashbury Free Clinics: http://www.datnet.com/wesson/revia.htm Publications For Counselors From DuPont Pharma: Answers to frequently asked questions about ReVia as part of a comprehensive treatment program for alcohol dependence. DuPont Pharma. 1995. On the climb toward sobriety... give them tools to make counseling more effective: A Guide for Counselors. DuPont Pharma. 1995.

ReVia is on the loose. Wed, 18 Jan 95 (http://www.dmu.ac.uk/ln/pme/q1-1995/0017.html) Many individuals, professional and lay, have been calling to ask about the new drug for alcoholism. Naltrexone has been formulated into a tablet to be used for this indication, as well as others. If you would like more information on this subject or have people flanking you for this info, have them call Dupont Pharma at 1-800-4-PHARMA. The Medical Affairs people are handling these requests.

Copyright 1998 source: http://www.med.upenn.edu Date: Wednesday 11 March 1998 http://www.med.upenn.edu/~recovery/cons/pnhealth.html CURBING THE CRAVING By Jennifer Baldino From Penn Health Magazine, July/August 1995. Reprinted with permission. For the first time in 50 years, the federal government has approved a new drug treatment for alcoholism. The treatment is based on the research of a psychiatrist at the University of Pennsylvania Medical Center. For more than a decade, Joseph R. Volpicelli, M.D., PhD., worked to show the medical community that naltrexone, a drug used since the 1980s to treat heroin addiction, can also curb the craving for alcohol. Last December, the U.S. Food and Drug Administration approved the use of naltrexone specifically to treat alcohol addiction. The drug, manufactured by DuPont Pharma and formerly sold under the name Trexan as a heroin-addiction treatment, will now be sold as ReVia. Volpicelli first recognized naltrexone's potential to treat alcoholism 15 years ago as a graduate student in Penn's Department of Psychology. What prompted his study of naltrexone was his suspicion that the drug might work in alcoholics the same was it did in heroin addicts. He discovered that rats had a higher preference for alcohol following stressful events, what Volpicelli calls the "weekends-were-made-forMichelob" effect. He also found that the rats taking naltrexone didn't increase their intake of alcohol. In 1981, he began publishing his findings on the drug. But the research was met with skepticism. As Volpicelli told Penn Health: "Everybody--academics, the drug company-thought it was a pretty wild idea." The exception was Charles P. O'Brien, M.D., PhD. A professor and vice chair of psychiatry at Penn and chief of psychiatry at Philadelphia's Veterans Administration Center, he says he was won over by Volpicelli's naltrexone research on rats. Volpicelli in turn credits O'Brien with giving him the financial and moral support and time to continue his research on naltrexone. "We did it without any outside funding," says O'Brien. "We got it started against pretty great odds." According to O'Brien, the researchers even had difficulty recruiting subjects for their studies in the 1980s because treating alcoholism with medication was not common. Volpicelli, O'Brien, and their colleagues Arthur I. Alterman, PhD., and Motoi Hayashida, D.Sc., started a naltrexone study using volunteers at the Veterans Administration Hospital in 1985. They tracked 70 men for 12 weeks following their outpatient detoxification program. Half received naltrexone, half a placebo. The researchers found that while 23 percent of the volunteers who took naltrexone experienced a drinking relapse, 54 percent of those who received a placebo reverted to drinking. During the study period, half the participants in both groups took at least one drink each (an act known among alcoholics as "slipping"). But when those who took naltrexone slipped, they were able to stop drinking after a few drinks, avoiding a total relapse. "Ordinarily in alcoholics even one or two drinks stimulates the body's craving for more," Volpicelli told The New York Times. But with naltrexone, "the cycle of craving was broken. This made it easier for them to stop drinking again and continue their treatment." In 1991, researchers at Yale University School of Medicine tested the effects of naltrexone in conjunction with psychological therapy in 104 alcohol-dependent men and women. The Yale study found that patients who took naltrexone were nearly twice as successful in their clinical outcomes, including abstinence and avoiding a relapse, as those who took a placebo.

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. The corroborating results gave Volpicelli's research the credibility it needed in the eyes of those in academe and the pharmaceutical industry. As Volpicelli puts it, they realized that "the findings were real, not just an accident." The Penn and Yale studies were published in the Archives of General Psychiatry in November of 1992. DuPont Pharma showed interest in manufacturing the drug. (DuPont Pharma, a partnership between DuPont and Merck & Co., Inc., is a research-based pharmaceutical company. DuPont Pharma receives the profits from the sale of ReVia and has provided Volpicelli with funding for educational programs.) Last summer, the drug was presented to the FDA for approval. Controversial because of its lengthy approval process, the FDA surprised the researchers by authorizing naltrexone's use in alcoholism treatment in just six months. According to Volpicelli, the FDA was "pretty confident" that the drug was safe: It had been under research for 20 years and on the market for 10 as a treatment for heroin addiction. "It's very rewarding for us to see that the research we've been doing for the past decade or so has found a niche," says Volpicelli. Only one other medication, Antabuse, known generically as disulfiram, has been widely used to treat alcoholism. The drug is designed to cause vomiting and severe nausea when mixed with alcohol but it does little to stop the alcoholic's craving. Volpicelli reports that his patients who take naltrexone have been happy with the results. They've told him that "they went to a bar, had a drink, and didn't get anything from it. They didn't get that buzz." And several did something they had never done before: "They left half their drink on the bar." In speaking to the media about the effects of naltrexone, however, Volpicelli and O'Brien warned that the drug is not a "magic bullet." Naltrexone does not cure the addiction; it eliminates the pleasurable "high" of drinking alcohol and reduces the craving for more. Volpicelli calls naltrexone an "antipsychoactive drug" because it works by blocking the effects of drugs like heroin or alcohol on the mind and behavior. While people may turn to such drugs as alcohol to "escape," naltrexone blocks their psychoactive effects so people can learn to cope with life without drugs. Naltrexone actually works in the brain, blocking the pleasurable effects of alcohol on nerve cells known as opioid receptors, which help dull emotional and physical pain and lead to feeling high. Naltrexone's critics argue that is was not very effective when used to treat heroin abuse; some have called taking a pill to curb alcoholism a "quick fix"; others have wondered if naltrexone can help people who abuse more than one substance or if naltrexone fits into the "drug-free" philosophy of many addiction treatment centers. Volpicelli uses two words--they are quite a mouthful--to respond to their criticisms: Biopsychosocial support. To recover fully from addiction to alcohol or any drug, he explains, most people need what he calls a "tripod" of support: medication, counseling, and support from family, friends, or other addicts. In Volpicelli's view, a pill alone won't help an addict. But without medication, he says, neither will psychotherapy and social support. "If you have two legs of the tripod," he says, "you're going to tip over. If you have three legs, you have a good foundation." Volpicelli feels so strongly that naltrexone works well only in combination with psychosocial treatment that, with the support of the national alcohol research community, he successfully urged the FDA to approve naltrexone only as an adjunct to conventional treatments. "Our results show that naltrexone, when used with a 12-step or other recovery program, may be effective--particularly in the early stages of treatment," says Volpicelli. "But it is essential that recovering alcoholics also undergo a comprehensive treatment program which helps them cope with the social, legal, family, physical, and psychological problems that occur as a result of their drinking behavior." Naltrexone is taken orally once a day. Its most common side effects, reported in approximately 10 percent of patients, are nausea, difficulty in sleeping, anxiety, nervousness, abdominal pain or cramps, vomiting, low energy, joint and muscle pain, and headaches. The National Institute on Alcohol Abuse and Alcoholism, which funded the Penn and Yale studies, is supporting nine clinical trials to determine the patient type, dose, therapy combinations, and treatment duration with which naltrexone works best. At Penn's Treatment Research Center in September, Volpicelli will begin clinical trials on whether a three- or nine-month course of treatment with naltrexone works better. He is also studying the effects of giving naltrexone to people at risk for alcoholism because of their family history. In other research, Volpicelli and his team are studying a comprehensive treatment program or, as the psychiatrist puts it, "one-stop shopping," for women addicted to cocaine. According to the Department of Health and Human Services, alcohol abuse and dependence affect about 15.3 million adult Americans and approximately 38 percent of adult Americans have experienced alcoholism or alcohol abuse in their families. An article in Alcohol, Health, and Research World includes the estimate that alcoholism and alcohol abuse cost $98.6 billion in 1990; some 70 percent of that total is attributed to lost earnings and decreased productivity because of alcohol-related illness and early death. The immediate physical effects of alcohol include decreased motor coordination and respiratory capacity. Long-term alcohol abuse can cause the liver and other organs to degenerate, a point Volpicelli underscores in presentations with a slide of Promethues Bound, a painting by Peter Paul Rubens depicting a mythical titan doomed to have his liver plucked out again and again. According to Volpicelli, the recent findings on naltrexone reinforce the little-appreciated theory that alcoholism is biochemically based addiction and not a personal flaw; studies have proven that alcoholism runs in families and that alcohol triggers the release of natural opioids in the body. The proof of biochemical motivation for alcohol dependence, says Volpicelli, may help alcoholics "overcome their shame, come out of hiding, and get treatment." Volpicelli also sees approval of naltrexone as another step in educating the public and the medical community about alcoholism. He says patients unable to control their drinking through conventional programs have told him they'd been blaming themselves and asking, "What's the matter with me?" Now, he says, there is proof that their drinking has a physiological base. Naltrexone, says Volpicelli, "has given them hope." To refer a patient or volunteer for the clinical trials on naltrexone, call Volpicelli at the Treatment Research Center at (215) 222-3200, ext. 170. The published findings of the research studies mentioned in the above article are available as: An Overview of Naltrexone in the Treatment of Alcohol Dependence. Naltrexone Therapy: Natlextrone in the Treatment of Alcoholism: Predicting Response to Naltrexone. Naltrexone in the Treatment of Alcoholism: A Clinical Review. Reprint requests to: Joseph R. Volpicelli, MD, PhD, Treatment Research Center, University of Pennsylvania, 3900 Chestnut Street, Philadelphia, PA 19104-6178; telephone (215) 222-3200, fax (215) 386-6770, email volp@cattell.psych.upenn.edu. Opioids and Alcohol Self-administration in Animals. Reprint requests to: Charles O'Brien, M.D., Ph.D., Center for the Study of Addiction, University of Pennsylvania, 3900 Chestnut Street, Philadelphia, PA 19104-6178; telephone (215) 222-3200, fax (215) 3866770.. Reprint requests to: Ronald R. Ulm, Ph.D., Psychology Department, Salisbury State University, Salisbury, MD 21801.

A 'quick fix' is not always the answer. Psychologists find themselves battling the American penchant for the 'magic pill.'
By Scott Sleek source: http://www.apa.org/monitor/may95/prozac.html When Cleveland psychologist Gary DeNelsky, PhD, first meets patients who want to quit smoking, many of them already have a treatment in mind: Instead of behavioral therapy, patients expect a quick cure via the highly marketed nicotine patch. 'One of my biggest jobs is to get

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. people to realize that the patch won't do everything,' said DeNelsky, noting that the product alleviates physical withdrawal symptoms but has no effect on psychological dependence. 'When used as directed, it has a limited effect. People come in with high expectations and end up disillusioned.' DeNelsky, head of psychology at the Cleveland Clinic Foundation and an expert on smoking cessation, is among countless psychologists who find that their therapeutic techniques clash with the quest for the quick cure. Americans expect a swift solution to depression, addiction and other mental disorders and life problems, therapists say. The insurance industry's push for short-term treatment reinforces that standard, they add. And as science uncovers the biological components of mental disorders and emotional characteristics, drug manufacturers develop medications to treat them, and patients expect overnight cures. No patience The push for fast psychological relief proliferates despite admonitions from the most respected voices in the mental health field. In his bestselling book, The Road Less Traveled, psychiatrist M. Scott Peck, MD, warns that people who seek treatment for depression or anxiety never view their problems as a healthy growth process. They either look for instant solutions or avoid solving the problems in the hope that they will eventually go away, he said. Pharmaceutical advances seem to foster those tendencies. People are demanding quick cures for everything from insomnia to obesity. Drug companies advertise products that can suppress sleeplessness, melancholy, a voracious appetite and chemical addictions. Sandra Haber, PhD, a New York City psychologist who treats eating disorders, says her patients have always looked for easy solutions to their weight problems. While they once sought the latest fad diet, they now look for pills like the antidepressant Prozac-also prescribed to attack obesity. In essence, they prefer to find a quick way to suppress their appetites rather than look at their compulsive relationship with food, she said. 'People want to have their cake and eat it, too,' Haber said. 'They want to be able to have as little pain, and as much pleasure, as possible. Taking a pill sounds easy. They don't have to deal with their feelings. It feels like a shortcut and that's attractive.' Many psychologists view psychopharmacology, when used appropriately, as a necessary part of mental health care. In fact, some are pushing for legislation that would give them prescription privileges, and are emphasizing the importance of combining drug treatment with psychological treatment when appropriate. But others, like DeNelsky, oppose the concept of psychologists prescribing medications, and contend that psychotropic drugs have overshadowed the clear, lasting benefits of psychotherapy-even for serious disorders. For example, studies show that schizophrenics achieve a more lasting recovery from effective psychotherapy than from continuous use of medications such as Thorazine (chlorpro-mazine), said Bertram P. Karon, PhD, a Michigan State University psychology professor. Karon's own work shows that schizo-phrenics who receive psychotherapy are better able to work, relate, take responsibility, free themselves from the symptoms of the disorder and avoid rehospitalization. Medication should be seen as a temporary adjunct for schizophrenics, he says. Some caution The quick-fix mindset is by no means universal, psychologists say. Many patients remain adverse to any kind of psychotropic medication. And the public seems to be growing wise to the commercial interests underlying the promotion of such drugs, they add. On National Depression Awareness Day last year, Eli Lilly & Co., the manufacturers of Prozac, went to a suburban Washington, D.C., high school, passed out brochures and other materials promoting the antidepressant. Students complained about being a captive audience to what they regarded as a one-sided view of depression and its remedies.'This might be an example of society no longer seeing psychotropic drugs as a panacea,' said Russ Newman, PhD, JD, the American Psychological Association's executive director for practice. 'That search for the magical cure is starting to turn around.' Still, health experts feel compelled to warn the public not to expect miracle cures. When the National Institute on Alcohol Abuse and Alcoholism announced the release of naltrexone, a new drug treatment for alcoholism, it stressed that the product was an adjunct, not a 'magic-bullet' replacement, for conventional treatment programs.The Dupont Merck Pharmaceutical Co., which manufactures naltrexone and markets it under the trade name ReVia, issued a similar caveat when it announced that the Food and Drug Administration approved the drug. William R. Miller, PhD, a University of New Mexico psychology professor and an expert in alcoholism treatment, said he believes ReVia is being marketed responsibly. 'In this field, we need every tool we can get,' Miller said. 'I'm glad to see the research on naltrexone, and I don't think anyone sees it as a stand-alone treatment.' But responsible marketing is only so successful. Alan Marlatt, PhD, psychology professor at the University of Washington and an expert on alcohol abuse, said many people have failed to hear the full message about naltrexone. 'When all the publicity about naltrexone came out, we got calls from people in Seattle wanting to know where to get the pill,' Marlatt said. 'But these were people who are still drinking. They thought this would do it all for them. When I told them the realities, they got less interested.' Therapists need to be direct with new patients who hope for a purely pharmacological solution, said Haber. Patients usually come to realize that their problems have deep roots and need more than medicine, she said. Most of her patients have tried a variety of 'miracle' diets to lose weight, to no avail, and she immediately douses their hope for a quick remedy in therapy. 'I'm like a splash of cold water,' she said. 'They don't really want to hear what I have to say. But it rings true, so they stay.'

"Drinking got me into my share of problems.Now I've got a chance to put all that behind me." --Chuck T. http://www.dupontmerck.com/disease/alcohol1.htm Now you can improve your chances of quitting drinking with a treatment program and a medication called REVIA. Deciding to quit drinking is never easy, and sticking with that decision can be even harder. But quitting drinking isn't an impossible task. All you may need is some extra help. You can get extra help with a treatment program and REVIA (naltrexone HCl tablets). REVIA is a tablet you take once a day. It's not habit-forming. If you have a drink, it won't make you sick or sober you up. In clinical studies, over half the people in treatment programs that included REVIA were able to quit drinking. In the same 12-week studies, only about a third of the people were able to quit without REVIA. Most people tolerate REVIA very well. However, some people experience side effects. The most frequent side effects are difficulty sleeping, nervousness, abdominal pain, nausea and/or vomiting, low energy, joint and muscle pain, or headache. REVIA is not right for everyone. People who are currently using narcotics should not take REVIA. If you have liver problems, please consult your doctor before using REVIA. (See warnings below.) If you're serious about quitting drinking, now there's another reason to try. Ask your doctor about REVIA. Combined with the right treatment program, it just might be the extra help you need to really do it. WARNING:You must not take REVIA if you have acute hepatitis, liver failure or active liver disease, as it could cause further damage. Do not take more than the amount prescribed by your doctor because REVIA can cause liver damage when more than the recommended dose is taken. (The recommended dose is one tablet every day for 12 weeks.) If you experience symptoms of acute hepatitis (abdominal pain, yellowing of the skin or eyes, dark urine), stop taking REVIA immediately and see your doctor. 1996 The DuPont Merck Pharmaceutical Co. RV 31989-WP REVIA is a registered trademark of The DuPont Merck Pharmaceutical Company.

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Please click here to see full prescribing information and discuss it with your healthcare provider.

Alcohol Use Disorders Identification Test source CITA SPAIN : http://www.neuroadaptation.com/neuroadaptation/on-line.htm Since it is our intention to help you, we have selected, from the myriad of questionnaires, the best reserched for our purpose.In this case, the questionnaire will tell you whether you should seek specialised advice. Of course, this result will never substitute for the opinion of your physician or mental health specialist. "Now I am going to ask you some questions about your use of alcoholic beverages during the past year." Alcoholic beverages = beer, wine, liquor (vodka, whiskey,brandy, etc.. Tag the right answers A) How often do you have a drink containing alcohol? 0Never 1Monthly or less 22-4 times a month 32-3 times a week 44 or more times a week B) How many drinks containing alcohol do you have on a typical day when you are drinking? 0None 11 or 2 23 or 4 35 or 6 47 or 9 510 or more C) How often do you have six or more drinks on one occasion? 0Never 1Less than monthly 2Monthly 3Weekly 4Daily or almost daily D) How often during the last year have you found that you were unable to stop drinking once you had started? 0Never 1Less than monthly 2Monthly 3Weekly 4Daily or almost daily E) How often during the last year have you failed to do what was normally expected from you because of drinking? 0Never 1Less than monthly 2Monthly 3Weekly 4Daily or almost daily F) How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 0Never 1Less than monthly 2Monthly 3Weekly 4Daily or almost daily G) How often during the last year have you had a feeling of guilt or remorse after drinking? 0Never 1Less than monthly 2Monthly 3Weekly 4Daily or almost daily H) How often during the last year have you been unable to remember what happened the night before because you had been drinking? 0Never 1Less than monthly 2Monthly 3Weekly 4Daily or almost daily I) Have you or someone else been injured as the result of your drinking? 0Never 1Less than monthly 2Monthly 3Weekly 4Daily or almost daily J) Has a relative, friend, doctor, or other health worker been concerned about your drinking or suggested you cut down? 0Never 1Less than monthly 3Monthly 4Weekly 5Daily or almost daily

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Record the total of the specific items.A score of 8 or greater may indicate the need for a more in-depth assessment by your specialist. Note: SOURCE: Developed by the World Health Organization, AMETHYST Project. 1987

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy.

LISTE DES SUBSTANCES PSYCHOTROPES COMPILES.

http://fra.drugtext.nl/miroir/meducation/produits/ixsubs2.html A Actone Arosols (bombes...) Acide Alcool Amanita muscaria Amphtamines Angel Dust Antabuse Apo-chlordiazpoxyde Apo-diazpam Apo-lorazpam Apo-oxazpam Apo-triazo Ativan Atropine B Bire Belladone Benzodiazpines Benzne Bromazpam Buspar C Caf Cafine Cannabis sativa Centrax Champignons magiques Chlordiazpoxyde Cigarette Cocane Codine Coca-Cola Colas Colles Correcteur liquide papier Cristal Cylert Crack D Dalmane Datura Demerol Diethylpropion Dilaudid Dimethyltryptamine 222 (Frosst) DMT Disulfiram DOM Doxpine E Ecstasy Empracet-30 et Empracet60 Emtec-30 phdrine Essence moteurs Estazolam thanol F Fiorinal Fluoxtine Flurazpam Fluvoxamine Freebase G Gloire du matin H Habitrol Halazepam Halcion Haschich Havlane (France) Hyoscyamine I Ibogamine Ibotinique (acide ...) Ionamin J Joint Jusquiame K Ketalar Ketamine L Lectopam Lexomil (France) Librium Lithane Lorazpam LSD Luvox Lysanxia M Ma Huang Mandragore Marijuana MDMA MDA Metamphtamine Mthanol Mescaline (PCP vendu sous le nom de...) Mescaline (vritable) Mthylphnidate Morphine MOS MS-Contin Muscade (noix de ...) Mushrooms Myristicine N Nicoderm Nicotrol Nicorette Nitrazpam Noctec Nordaz (France) Noriel (France) Normisson (France) Novazam (France) Novo- Dipam Novo- Lorazem Novo- Triolam Nu- Alpraz Nuctalon (France) O Opium P Paxil PCP Pmoline Pepsi-Cola Percocet Percodan Peyolt (cactus ...) Phencyclidine Phenobarbital Phentermine Placidyl PMS- Chloral hydrate PMS- Methylphnidate Poppers Pot Praxadium (France) Prazepam ProSom Prozac Psilocybine Q Quazepam R Rsine Restoril ReVia Ritalin Rohypnol Roofies S Scopolamine Seconal Serax Seresta (France) Smack Solium Speed STP T Tabac Temesta (France) Tetrachlorure de carbone Tetrahydrocannabinol TH THC Th Tolune U V Valium Veratran (France) Versed Vin Vivol W Wake-Up (vendus en pharmacie au Qubec) X X Xanax XTC Y Z Zoloft

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Phencyclidine (PCP) http://fra.drugtext.nl/miroir/meducation/produits/Perturbateurs/PCP/general.html

Nom gnrique: Phencyclidine Dnominations communes (march illgal): (PCP,Acide, Angel Dust, Crystal, Supergrass) Attention: Au Qubec, la plupart des produits vendus sous le nom de TH ou de Mescaline contiennent du PCP. Demi-vie d'limination: moyenne de 18 h ( varie selon le pH urinaire... excrtion plus rapide en urine acide) Effet maximal: En quelques minutes Dose moyenne: 5 10 mg. Dure des effets: 6 heures ( mais la littrature scientifique rapporte que squelles psychiques peuvent persister plusieurs jours) Historique La phencyclidine a t synthtise en 1963 pour usage anesthsique. Ses effets secondaires ont provoqu son retrait de la mdecine humaine. Le produit est toujours utilis, certains endroits, en mdecine vtrinaire. Apparence Le plus souvent, la substance se prsente sous forme de poudre cristalline, qui peut tre ajoute du tabac, du persil ou de la marihuana et fum. On peut aussi l'injecter ou l'inhaler ( &laqno sniffer ). On peut en faire des capsules ou des comprims. Hallucinognes http://fra.drugtext.nl/miroir/meducation/produits/Perturbateurs/Hallucinogenes/general.html

Hallucinognes apparents la srotonine Lysergic acid diethylamide (LSD), Psilocybine (Champignons magiques) Dimethyltryptamine (DMT), Lysergic acid amide (Gloire du matin), Buftonine, Ibogamine. Pharmacologie : Modifient les rseaux nerveux qui font usage de srotonine. Le blocage de la srotonine est malgr tout une condition essentielle mais qui ne suffit pas expliquer l'apparition des hallucinations. Les mcanismes d'action prcis sont encore l'tude. Dure des effets LSD: effets ressentis en moins de 1 heure, dure moyenne de 2 12 heures. DMT: effets immdiats , dure moyenne 30 60 minutes. Lysergic acid amide: effets ressentis en 30 90 minutes avec la consommation de graines de Gloire du matin. Hallucinognes apparents la norpinphrine. Mescaline, (vritable mescaline... extraite du cactus Peyotl) 2,5-dimethoxy-4-methylamphtamine (DOM ou STP), 3,4- mthylnedioxyamphtamine (MDMA ou Ecstasy), 3-mthoxyoxy-4,5-mthylne-dioxyamphtamine (MDA), Myristicine (noix de muscade) Pharmacologie Identique aux substances apparentes la srotonine Dure des effets Mescaline: effets d'apparition lente, d'une dure moyenne de 10 18 heures. MDMA: les concentrations sanguines maximales sont atteintes en 2 heures. DOM: les effets sont ressentis pendant 16 24 heures. Hallucinognes apparents l'actylcholine Anticholinergiques Atropine, Hyoscyamine, Scopolamine. Substances prsentes dans les plantes de la famille des solanaces: la mandragore, la belladone, la jusquiame, la datura. Attention: les plantes mdicinales mentionnes dans cette liste sont des POISONS VIOLENTS connus depuis des sicles. On les sait responsables de la mort de plusieurs personnes. Les doses mortelles sont trs proches des doses ventuellement hallucinognes. Il s'agit de produits dont l'usage rcratif ou exprimental doit tre vit. L'ingestion de ces plantes exige une intervention mdicale d'urgence. Pharmacologie Les hallucinations sont produites par le blocage de la transmission dans les synapses cholinergiques. Autres hallucinognes Acide ibotinique (dans Amanita muscaria), Phencyclidine (PCP), Ktamine (Ketalar ) Pharmacologie Mcanismes trs complexes. Impliquent la norpinphrine, la dopamine, l'actylcholine et la srotonine. L'action globale des produits comme le PCP est aussi lie au blocage de acides amins comme le glutamate et l'aspartame qui auraient un rle de transmetteurs dans certaines rgions du cortex. Dure des effets PCP: Effets en moins de 30 minutes, peuvent persister plusieurs jours. Demi-vie de 18 heures . limination influence par pH urinaire. Acide ibotinique: excrt inchang dans urine. Effets Modification des perceptions de soi et de l'environnement, difficults de concentration, troubles de la mmoire, dpersonnalisation, euphorie, expriences mystiques ou religieuses intenses, panique, comportement dsordonn, agression. Augmentation de la pression sanguine, tachycardie, mydriase, frissons, hyperventilation, incoordination, engourdissement. Comparaison la toxicit de ces produits: Attention: dans le cas des hallucinognes, les ractions des utilisateurs constituent souvent la principale source de danger. La faible toxicit de certaines molcules n'implique pas que leur consommation ne comporte aucun danger. Faibles dangers: LSD, psilocybine, mescaline. Dangers modrs: MDA, DOM Risques levs: anticholinergiques. Notez la toxicit trs leve du PCP qui distingue ce produit (dose mortelle peine 10 15 fois la dose efficace, multiplie par l'alcool et les autres dpresseurs du SNC). Le PCP interagit aussi avec le Prozac : risque de convulsions. Effets (gnraux) Les effets des hallucinognes disparaissent lorsque les substances sont limines. Le bad-trip peut tre contrl grce la technique du talk-down, qui consiste formuler la personne en crise des suggestions de calme et de rtablissement. Sauf dans le cas du PCP o cette technique n'est pas oprante, la talk-down, profitant de l'extrme suggestibilit des personnes sous hallucinognes, est une mthode eficace et sans danger. Les flashbacks sont des pisodes qui peuvent survenir plusieurs annes aprs la consommation, et ne durer que quelques secondes. Plus souvent diffus, voquant l'exprience hallucinogne plus que ne la recrant, ils peuvent se prsenter sous la forme de sensations ou de perceptions dj connues sous intoxication. On ne leur connat pas d'explication satisfaisante. Ils ne prsentent aucun danger. Attention: ces phnomnes, s"ils semblent s'intensifier dans les annes qui suivent l'arrt de consommation d'hallucinognes, pourraient avoir une autre origine. Une consultation mdicale s'imposerait alors. Le PCP prsente un profil distinct.

Cannabis

http://fra.drugtext.nl/miroir/meducation/produits/Perturbateurs/Cannabis/general.html

Tableau des principales substances de ce groupe: Nom gnrique: Delta-9 tetrahydrocannabinol (THC) Sources connues: Marijuana (cannabis sativa), Herbe, Pot, Grass, H, Haschich, Shit, Rsine, Huile de Hasch Demi-vie d'limination: En 2 tapes: un premier stade, plus rapide de 30 minutes, suivi d'un processus de 50-60 heures (demi-vie). Dans certains cas, des traces de THC dans le sang ont t dcouvertes 30 jusqu' 30 jours aprs l'arrt de la consommation.

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Effet maximum: 30 60 minutes aprs la consommation. Dose moyenne: variable. Dure des effets: variable et subjective. Les personnes fortement dpendantes commencent ressentir un inconfort 6 heures aprs l'arrt de la consommation. Marijuana: Mlange de fleurs, tiges, feuilles sches du plant de cannabis. Couleurs: brun, vert, gristre, beige Habituellement fum dans des cigarettes (joints). Concentrations en THC varient ( 5 11% ) selon la varit, la culture et les conditions d'entreposage. Haschich: Masse rsineuse compacte et ferme, obtenue partir des plants de cannabis. Couleurs: brun, beige, noir. Habituellement fume dans des cigarettes , des pipes, et divers dispositifs permettant d'en inhaler la fume de combustion. Concentrations en THC (2028%) varient selon la varit et les conditions de fabrication ou d'entreposage. Rsine ( ou Huile ) : Liquide marron, jaune ou incolore. Obtenu en laissant bouillir le haschich dans un solvant, tel l'thanol. habituellement fum en le rpandant sur le papier d'une cigarette. Possde une teneur en THC 15 30 fois plus importante que la mari et 3 6 fois plus importante que le Hachish. Nicotine http://fra.drugtext.nl/miroir/meducation/produits/Stimulants/Nicotine/general.html

Tableau des principales substances de ce groupe: Nom gnrique: Nicotine Dnominations communes: 1. Dnominations commerciales (vente lgale) : Tabac (cigares; cigarettes; tabac priser, chiquer , pipe) Une cigarette contient ( en moyenne) de 8 9 mg de nicotine. Seule une fraction ( 20%) est inhale par le fumeur. La dose rsiduelle se retrouve dans la fume de combustion libre dans l'environnement. 2. Prparations vendues en pharmacie et destines rduire les manifestations de sevrage du fumeur (adjuvants au sevrage tabagique): Habitrol: Dispositifs transdermiques (pansements, patches) librant 7 mg/jour, 14 mg/jour ou 21 mg/jour. Nicorette: Disponible en gommes mcher de 2 mg (vente libre en pharmacie) et de 4 mg (vente sur ordonnance en pharmacie). Nicotrol: Dispositifs transdermiques (pansements, patches) librant 15 mg/16 hres, 10 mg/16 hrs ou 5 mg/16 hres. Indications mdicales Seuls les adjuvants au sevrage (produits utiliss pour rduire les ,alaises du toxicomane qui cherche arrter) ont une utilisation mdicale. Un usage qui ressemble l'utilisation que l'on fait de la mthadone dans le sevrage des narcomanes. De nombreux sites consacrs au tabagisme existent sur le Web. En anglais: Nicotine Blair's Quitting Smoking Resources Page http://www.aarc.org/tips/quitsmok.html http://www.quitnet.org/ Counselling to Prevent Tobacco Use Eric Krieg's smoking page Smoking and Pregnancy Cocane http://fra.drugtext.nl/miroir/meducation/produits/Stimulants/Cocaine/general.html

Principales substances de ce groupe: Nom gnrique: cocane Dnominations communes (march illgal): coke, crack, base, freebase Demi-vie d'limination: approximativement de 40 minutes (pH de l'urine affecte la vitesse d'limination) Concentrations sanguines maximales: dlai varie selon la mthode d'administration. Voie nasale: 10 20 minutes Voie parentrale et fume: quelques minutes ( 1 3 minutes ?) Dure des effets: variable et subjective. Moyene de 20 30 minutes ( la perception des effets par l'utilisateur n'est pas toujours relie aux concentrations plasmatiques). Origine: Le chlorhydrate de cocane est obtenu partir des feuilles de l'Erythroxylon Coca, un arbuste d'Amrique du Sud. Il se prsente sous forme d'une poudre blanche, qui est habituellement inhale (sniffe) ou injecte. La chaleur provoque une importante destruction du sel de cocane qu'on tenterait de fumer. Le crack et la freebase rsultent du traitement que l'on fait subir au chlorhydrate de cocane ( l'aide de solvants volatils ou d'une base lgre comme le bicarbonate de soude). On obtient alors une prparation de cocane qui supporte la vaporisation, et permet la consommation par voie respiratoire (on peut fumer du crack ou de la freebase).Peu importe la mthode d'administration utilise, les toxicomanes utilisateurs de crack, de freebase ou de chlorhydrate de cocane sont tous des cocanomanes. Historique: Utilise depuis des sicles par les populations vivant en Amrique du Sud. On a retrouv des feuilles de coca dans des tombes pruviennes datant de 2500 ans av. J-C. Les travaux de Sigmund Freud sur les effets toniques du produit sont clbres. En 1863, Angelo Mariani a brevet la formule de son vin de coca. Vers cette poque, un pharmacien amricain nomm John Pemberton a aussi produit une boisson de ce type. Sous la pression des groupes prohibitionnistes amricains, il a retir en 1886 l'alcool de sa liqueur, et l'a remplac par un extrait de noix de kola. Il y ajouta ensuite du soda... le Coca-Cola tait n ! (Ce produit tait, ses dbuts, considr comme un tonique et vendu en pharmacie). En 1906, la cocane a t officiellement retire de la formule. La cocane est un anesthsique local ( application topique) et un stimulant du systme nerveux central. Solvants volatils http://fra.drugtext.nl/miroir/meducation/produits/Depresseurs/Solvants/general.html

Tableau des principales substances de ce groupe: Nom gnriques: Plusieurs substances peuvent tre regroups sous le vocable de solvants volatils. Le plus souvent, en toxicomanie, on rencontre: tolune, tetrachlorure de carbone, actone, benzne Les dnominations commerciales varient selon les produits. Les principales sources de solvants volatils sont: essence moteurs, certaines colles, solutions netoyantes, dcapants, vernis ongle, liquide correcteur pour papier, bombes arosol. Les nitrites volatils (< poppers) ne sont pas des psychotropes. Ils agissent sur le systme cardiovasculaire, et ne causent pas de dpendance. Attention ! Mme si l'usage de solvants est souvent associ aux jeunes et aux enfants, on retrouve des utilisateurs adultes ou gs. C'est une pratique retrouve galement chez les deux sexes.

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy.

THANOL (alcool)

http://fra.drugtext.nl/miroir/meducation/produits/Depresseurs/Ethanol/ethanol.html

L'thanol est une molcule psychotrope, range selon la nomenclature chimique dans le groupe des alcools. Le produit est comestible, et ne doit pas tre confondu avec le mthanol, qui est toxique. Alcool et thanol sont, dans l'usage quotidien, devenus synonymes, et dsignent le principe actif de la bire (teneur thylique: 2% 10% v/v), du vin (teneur thylique de 10-14% v/v) et des spiritueux (teneur thylique: 30 60% v/v). Selon les pays, d,autres normes pourraient tre rencontres. L'thanol est un psychotrope naturel, produit par la fermentation de certains sucres. Il est aussi possible de l'obtenir synthtiquement. Disponible: Au Qubec, on peut l'acheter librement dans les boutiques autorises, si on a plus de 18 ans. La vente d'thanol est un monopole d'tat rgi par la Socit des alcools du Qubec. Indications mdicales: Dsinfectant . Antidote l'intoxication l'alcool de bois (ou mthanol.) Pharmacologie : Effets directs, Effets indirects , Utilisation pendant la grossesse, Recherche mdicale et alcoolisme PHARMACOLOGIE ABSORPTION : L'thanol est rapidement et compltement absorb dans la partie suprieure du tractus gastro-intestinal. La prsence de nourriture en retarde l'assimilation. L'thanol provenant de la bire semble pntrer moins rapidement dans la circulation, ce qui ferait de la bire un produit moins intoxiquant (mme concentrations alcooliques quivalentes).Par contre, le prsente de gaz carbonique (comme dans le Champagne ou les vins ross) pourrait faciliter le passage de l'thanol dans la circulation. L'thanol contenu dans des liquides forte concentration (spiritueux purs) passe plus rapidement dans la circulation que l'thanol provenant de boissons forte dilution (cocktails). On peut mesurer les concentrations sanguines d'thanol. Les donnes quantitatives sont formules en &laqnox milligrammes d'alcool par 100 ml de sang.Comme 100 ml de sang a un poids de 100 grammes, on peut transposer notre mesure en pourcentage de poids/poids. Exemple: le seuil lgal de l'intoxication criminelle, au Canada, est de 80 mg par 100 ml de sang. Soit 80 mg pour 100,000 mg de sang. Le rapport serait donc de 80/100,000 soit 0.08/100. Le seuil lgal canadien est de 0.08. Cette norme varie selon les pays. DISTRIBUTION : L'thanol est soluble dans l'eau et les lipides. Il passe facilement la barrire hmato-encphalique. Plus de 90% de l'thanol en circulation dans le sang parvient ainsi au cerveau. L'thanol traverse aussi la barrire placentaire, et les concentrations plasmatiques ftales sont identiques aux concentrations maternelles. LIMINATION : L'thanol est limin inchang 5 % (par les poumons, la sueur et l'urine). Le mtabolisme de l'alcool prsente une caractristique inusite: sa courbe d'limination est linaire, et le produit est limin un rythme constant: le corps limine en moyenne 15 mg d'thanol pur l'heure. Ce mtabolisme s'effectue en deux temps: L'enzyme alcool dhydrognase convertit l'thanol en actaldhyde, puis, L'actaldhyde est transforme, via l'enzyme aldhyde dhydrognase, en actyl-CoA, puis en gaz carbonique et en eau (avec libration d'nergies (calories). MCANISME D'ACTION : L'thanol agit sur la membrane du neurone et provoque une fluidisation de la membrane lipidique. La dformation de la membrane amne une chute de l'efficacit de la transmission dans l'axone, rduisant l'amplitude de l'influx qui atteint la synapse et la libration de neurotransmetteurs. EFFETS : Lgre stimulation INITIALE ( aprs le premier verre), suivie rapidement d'une dpression progressive du S.N.C. L'thanol lve les inhibitions. C'est une substance qui peut favoriser les comportements risque (conduite avec facults affaiblies, rapports sexuels non protgs,...)On lui connat aussi une action apritive.L'thanol modifie les HDL (lipoprotines haute densit) et pourrait ainsi diminuer les risques d'accidents cardio-vasculaires chez l'individu sain. Systme nerveux La consommation prolonge d'alcool cause des dommages crbraux: atrophie crbrale et destruction cellulaire dans des rgions lies la mmoire (Butters et Cermak 1983). Les dommages crbraux sont de deux types: la dmence alcoolique et le syndrome de Wernicke et Korsakoff. La dmence, rsultant de l'action toxique directe de l'thanol, consiste en une dtrioration des fonctions intellectuelles totales, avec des dficiences dans la pense abstraite et la rsolution de problmes, de la dysphagie, des difficults manipuler des objets, des anomalies l'lectrncphalogramme, une atrophie crbrale et une dilatation des ventricules crbraux. Le Wernicke consiste en perturbations oculaires, ataxie et confusion. Associ la dficience en thiamine, on peut le corriger par une administration de cette vitamine. (Martin et al, 1968). On estime que 80% des patients qui survivent au Wernicke dveloppent la psychose de Korsakoff (Reuler et al, 1985). Le Korsakoff, quelquefois considr comme le stade chronique du Wernicke, est un dficit permanent des fonctions cognitives, accompagn de l'impossibilit de se souvenir d'vnements rcents ou de nouvelles informations. La mortalit du Wernicke est de 10 20% (Reuler et al, 1985), ce qui en fait une maladie grave ncessitant un traitement. Dficiences neurologiques chez l'alcoolique: de 50 75% des alcooliques dsintoxiqus ayant consomm pendant une longue priode vont prouver des difficults lors des tests de rsolution de problmes, de perception et de mmoire. Les pathologies hpatiques de 45% des alcooliques pourraient suggrer un lien entre des dficits cognitifs et l'hpatite. L'action du lactulose, qui corrige partiellement les dficiences, semble confirmer cette thse (Tarter et Edwards 1986). Le comportement L'thanol diminue le sommeil REM et perturbe les rythme du sommeil, favorisant les veils rpts pendant la nuit, un symptme pouvant subsister jusqu' 200 semaines aprs le sevrage. (Mendelson 1979) Diminue de l'acuit visuelle partir de doses de 70 mg par 100 ml. Diminue de 10% le temps de raction des concentrations sanguines de 80 mg par 100 ml. Diminue le score aux tests d'intelligence et modifie la perception du temps coul ( 50 mg par 100 ml, une priode de 5 minutes semble durer 8 minutes)(McKim, 1990) Note: une grande partie des informations qui suivent sont traduites librement de: " Hasselblad, J. Alcohol Abuse Curriculum Guide for Nurse Practitioner Faculty, U.S. Departement of Health and Human Services, Public Health Service, National Institue on Alcohol Abuse and Alcoholism, USA, 1984." Systme digestif Bouche : Risque accru de cancer du pharynx, Inflammation de la langue, Hypertrophie de la parotide Oesophage : a. Risque accru de cancer. b. Lsions des tissus de recouvrement, par irritation directe ou vomissements. c. Syndromes lis l'thanol: Syndrome de Mallory-Weiss:

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Lacrations de la muqueuse. Se manifeste par vomissements de sang indolores aprs prise d'alcool et vomissements svres. Diagnostic par endoscopie. Cause frquente de vomissements avec sang. Syndrome de Boerhaave Rupture de la section infrieure de l'oesophage accompagne d'panchement de liquide gastrique. Se manifeste par des vomissements avec sang douloureux, prcds de toux, convulsions et vomissements violents. Mort possible. Varices oesophagiennes Consquences de dommages hpatiques produisant une hypertension portale. Sujettes rupture. Possibilit d'hmorragie et de dcs. Cause frquente de vomissements avec sang.

Estomac Gastrite : Se manifeste par des malaises gastriques, nauses, vomissements et saignements. Cause peu frquente de sang dans les vomissements. Rsulte de la destruction de cellules de la muqueuse gastrique par l'thanol. Intestins Destruction de la muqueuse cause malabsorption. Se manifeste par des dsordres inflammatoires (colite, entrite) lis la consommation d'alcool. Hmorrodes causes par hypertension portale. Foie Statose hpatique : Rsulte de l'accumulation d'acides gras dans les cellules hpatiques, produisant des dpts de graisse. Possible chez le buveur modr non dpendant. Se manifeste par douleurs abdominales aigus et violentes, ainsi que par le jaunisse chez les buveurs " cuite". Diagnostic: Hpatomgalie et tests de laboratoire. Hpatite alcoolique Conscutive la ncrose des cellules hpatiques, qui occasionne une fibrose. Risque pour la survie. Diagnostic: Hpatomgalie, jaunisse, douleur au foie, tests de laboratoire. Peut tre rversible, selon le stade: 30% mortalit, peu de chances de recouvrement si stade avanc de destruction. Cirrhose : Ncrose cellulaire avance avec cicatrices, formation de nodules et modifications de la structure de l'organe. Irrversible. Diagnostic: dme, ascite, hypertension portale, foie ferme avec nodules et possible augmentation de volume, tests de laboratoire. Aux stades terminaux: varices sophagiennes, encphalopathie (insuffisance hpatique produit niveaux d'ammoniaque levs, troubles neuromoteurs, mentaux et comportementaux), coma. Pancras Alcool impliqu dans prs de 50% des pancratites. Pancratite aigu. Aprs 24 48 heures de consommation abondante. Diagnostic: Douleur abdominale trs svre, irradiant vers le dos, nauses, vomissements, fivre. Tests de laboratoire. Pancratite chronique Systme cardio-vasculaire Effets directs: thanol dprime muscle cardiaque en grandes quantits: Diminution de l'output cardiaque, Dilatation vasculaire, Tachycardie compensatoire Cardiomyopathie a. Si consommation soutenue pendant plus de 5 ans. b. Dommages irrversibles l'organe: Accumulation de triglycrides, Inflammation, Fibrose. Diagnostic: Dyspne nocturne et l'effort, hypertension et pouls acclr, puis TROUBLES DU RYTHME: FIBRILLATION, TACHYCARDIE : Insuffisance cardiaque: cardiomgalie, toux, douleur thoracique, souffle court, ascite, dme pulmonaire et priphrique, ascite TROUBLES DE LA CONDUCTION CARDIAQUE : Dficience de magnsium, potassium, sodium et chlore secondaire la consommation d'thanol. Arythmie rsultant du dsquilibre lectrolytique. TROUBLES LIS AU SEVRAGE : Stress cardiaque pouvant favoriser accident (infarctus, fibrillation, ) BRIBRI : Nvropathies priphriques. Caus par dficience en thiamine. Diminution de la rsistance vasculaire priphrique, associe output cardiaque augment et circulation diminue. Possibilit de dcs. HYPOTHERMIE : Rsulte de vasodilatation priphrique causant perte de chaleur. Se prsente si l'individu est expos des froids importants, intoxiqu. Systme respiratoire Effets directs : Diminution des mcanismes de dfense pulmonaires. Augmentation des risques d'infection et d'obstruction des voies respiratoires. Effets indirects : RDUCTION DES DFENSES IMMUNITAIRES; AUGMENTATION DES RISQUES LIS AU TABAGISME. Systme urognital HOMME : Rduction des niveaux de testostrone, avec atrophie testiculaire , infertilit et apparition de caractres sexuels secondaires fminins. Diagnostic: impuissance, rduction de la libido, diminution de la croissance pileuse, atrophie de la prostate. Si prsence en plus d'hyperstrognisme, on a: gyncomastie, redistribution des graisses selon le modle fminin. FEMME : Probablement problmes gyncologiques: irrgularits menstruelles, avortements spontans Systme locomoteur Effets directs : Destruction musculaire. Effets indirects : Frquents traumatismes musculaires ou osseux. Ostoporose Secondaire au manque de calcium, la malnutrition et l'absence d'activit physique. Ostoncrose de la hanche: Rare pathologie secondaire hyperlipidmie (embolie bloquant irrigation de la tte du fmur et causant ncrose). Diagnostic: douleur svre la hanche, bilatrale souvent. Pas de prsence d'arthrite. GROSSESSE Syndrome alcoolique foetal (SAF) Dcrit en 1973 pour la premire fois (Jones et Smith; 1973): Dficiences prnatales ou postnatales (retard de croissance, poids infrieur la moyenne) Anomalies anatomiques (facis caractristique) Atteinte nerveuse (retard mental chez 50% des enfants)Rosett; 1980) En outre, la consommation d'alcool pendant la grossesse peut provoquer: Retard de croissance Anomalies cardiaques

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Anomalies urognitales Dsordres ophtalmiques (myopie, strabisme,) Dsordres auditifs (surdit partielle,) Problmes de comportement (dficit attentionnel, faible rflexe de succion, insomnie,) SAF: Prvalence varie de 26% (Seidenberg et Majewski; 1978) 2% (Sokol et al,; 1980). Seuil scuritaire voisine 30 40 mg d'thanol par jour. (bien au-dessus du seuil considr comme "modr"). Caractristiques maternelles identifies comme relies au SAF: Statut socio-conomique: bas, Pas de soins prnataux, Antcdents d'enfants avec SAF, Risques augmentent avec l'ge, Usage de cafine et de tabac. Caractristiques paternelles: L'influence de la consommation paternelle repose sur les proprits mutagnes (et non tratognes) du produit. On a rapport des malformations cardiaques (SAVITS et al.; 1991), des problmes de poids insuffisant (SOKOL et al.; 1993) et des modifications du comportement et des fonctions immunitaires chez des modles animaux. LA RECHERCHE MDICALE ET L'ALCOOLISME. Cette piste de recherche fut appuye par Gerard Cohen et Michael Collins , en 1970. Ils dmontrrent que, chez le rat, l'actaldhyde se transformait bel et bien en tetrahydroisoquinolines (THIQ). Au hasard de la recherche sur les effets du stress sur des rats, Geller et Blum constatrent que leurs animaux buvaient plus d'alcool la fin de semaine, alors qu'aucune exprimentation n'tait effectue. Ils conclurent (1971) que c'tait l'obscurit qui affectait le comportement. Or, les rats tenus dans l'obscurit (les lumires du laboratoire tant fermes le samedi et dimanche) avaient comme caractristique de fabriquer plus de mlatonine, un produit synthtis partir du neurotransmetteur "srotonine". Ce phnomne survenait dans l'hypophyse, qui a donc un rle jouer dans les penchants vers l'alcool. En 1973, Carlsson dmontra que l'alcool rduisait la concentration de norpinphrine et de dopamine dans le cerveau, deux neurotransmetteurs impliqus dans les processus d'excitation neuronale. Au mme moment, Sutton et Simmonds, Londres, dmontraient que l'administration sur une longue priode d'thanol augmentait d'au moins 50% la concentration de GABA, neurotransmetteur actif dans les processus d'inhibition neuronale. La formation de THIQ dans l'organisme humain fut dmontre en 1973 par Sandler, Londres. Ils confirmrent que les THIQ taient normalement prsents chez l'humain, que l'augmentation du niveau de dopamine augmentait les THIQ retrouvs dans l'urine, et que l'alcool augmentait enfin lui-mme de beaucoup les THIQ retrouvs. Autour des annes 1975, plusieurs chercheurs tudirent un compos identifi dans l'organisme humain, nomm tantt "substance X", "enkephaline", "morphine-like factor" ou "morphine-like substance". Les recherches dmontraient que cette substance avait t retrouve dans le cerveau aux sites ayant la plus forte densit de rcepteurs opiacs (Snyder). On rapporta encore (Goldstein) que l'effet du produit pouvait tre antagonis par la naloxone, un antagoniste des opiacs. Il s'agissait des endorphines, une famille de produits regroupant des substances proches des opiacs: on connat prsent les alpha , beta et gammaendorphines, 2 varits d'enkphalines et la dynorphine. Les chercheurs ont dcouvert ce moment que c'tait dans la rgion du systme limbique, associe aux phnomnes de gratification, qu'on retrouvait la plus grande concentration de rcepteurs opiacs (Simon). Que la morphine rduisait la prfrence de souris noires l'alcool, tmoignant que la morphine en remplissant les rcepteurs opiacs stoppait le besoin de consommer de l'alcool. Blume rapporta aussi que l'administration de morphine aux souris alcooliques rduisaient leurs symptmes de sevrage, de la mme faon que de petites doses de THIQ. Vers 1977, Myers, cit par Blume, crivait: "Nous savions dj que le cerveau produit, suite la consommation d'alcool, des THIQ. Nous avions prsent dmontr que de grandes quantits de THIQ injects direcement au cerveau stimulaient une prise exagre d'alcool. Il semblait donc vident que ce que nous avions accompli, c'tait d'augmenter la surproduction de THIQ au cerveau, tel qu'on le voit chez l'alcoolique. Nous pouvions conclure que si les THIQ sont formes en quantit suffisante dans les sites stratgiques du cerveau, elles pouvaient induire des modifications de la chimie crbrale dbouchant sur un besoin pathologique d'alcool, en dpit de consquences ngatives. Ce pourrait bien tre le schma qui donne naissance l'alcoolisme". L'intrt pour les THIQ amena plusieurs tudes. En 1978, on savait dj que: De fortes doses de THIQ provoquaient un besoin intense et permanent d'alcool chez le rat qui pourtant prfrait l'eau pure. Des injections rptes provoquaient, si on les cessait brusquement, un syndrme de sevrage chez les rats (Myers,1978) Les endorphines et les THIQ bloquent la liaison du calcium ses sites crbraux, comme le font les opiacs (Ross, 1978) Au dbut des annes 1980, on a dcouvert que la dopamine tait aussi implique dans les phnomnes alcooliques. Par exemple, quand on injectait une dose intoxiquante d'alcool aux souris alcooliques, leur mtabolisme de la dopamine augmentait, tmoignant de l'augmentation dans la libration de dopamine. On a aussi dcouvert que l'alcool ou son mtabolite THIQ amenaient une augmentation de la libration de dopamine, via l'activation de rcepteurs opiacs. Un modle biologique de "craving" : La recherche mdicale sur l'alcoolisme bnficie d'un modle animal: la souche C57 de souris noires. que Lonora Mirone (1952) a identifi comme prfrant boire une solution d'eau 5% en thanol plutt que de l'eau pure. McClearn (1959) , qui a tudi cette souche de souris, a dtermin avec certitude leur prdisposition boire de l'alcool. Avec ces souris alcooliques, dbutait l'tude mdicale scientifique de l'alcoolisme gntique. Les bases biochimiques de la dpendance : Virginia Davis et Michael Walsh ont caus une commotion dans le monde scientifique en publiant en 1970 dans la revue Science leurs travaux. Leur hypothse, telle que rsume par Blum et Payne, est la suivante: 1. Dans le cerveau, la dopamine est convertie en aldhyde de dopamine et finalement en acide dopaminique. 2. La conversion finale s'effectue via un enzyme, l'actaldhyde dhydrognase. 3.Quand l'alcool est absorb, il est tout d'abord mtabolis en actaldhyde, puis en CO2 et H20 grce encore l'actaldhyde dhydrognase. 4. Il est vident que l'aldhyde de dopamine, prsent l'tat naturel dans le neurone, entre en comptition avec l'actaldhyde, rsultant du mtabolisme de l'alcool, pour les services de l'enzyme actaldhyde dhydrognase. 5. Cependant, l'actaldhyde est plus fortement attir vers l'enzyme que ne l'est l'aldhyde de dopamine. En consquence, il y a beaucoup plus d'actaldhyde qui entre en contact avec l'enzyme et est dtruit. Un excs d'aldhyde de dopamine se forme dans le cerveau. 6. Cet excs d'aldhyde de dopamine peut se combiner des molcules intactes de dopamine pour former un alcalode du nom de tetrahydropapavroline (THP) . Or la THP a une structure trs proche de la morphine. Blum dessine un modle simplifi du "craving", son "motivational model of alcohol craving". En gros, le modle qu'il propose compte 3 phases: la mise en place, la substitution et la destruction. Mise en place : La personne possdant une prdisposition gntique l'alcoolisme a un stock d'enkphalines insuffisant, ou subit une libration rduite de ce neurotransmetteur dans les rgions de son cerveau o sigent les motions. Le taux de srotonine est bas cet endroit, il y a augmentation du nombres de rcepteur opiacs et diminution du nombre de rcepteurs D2. Enfin, il y a renforcement du lien du GABA ses sites rcepteurs. Il rsulte de tout ceci que la personne ne peut, en situation normale, jouir pleinement de sensations de bien-tre, n'ayant pas assez de dopamine libre, et ne pouvant avoir suffisamment de dopamine en contact avec les rcepteurs D2 de la gratification. En raison de cette dficience, une supra-sensibilit se dveloppe au cerveau. Tout ce qui pourrait amener une libration de dopamine-mme les plus petites quantits d'alcool-dclenche de fortes sensations de mieux-tre.

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Substitution : En buvant pour la premire fois de l'alcool, la personne prdispose exprimente un plaisir et une satisfaction marque, et rsiste mieux la fatigue, la nause et aux difficults motrices. L'alcool provoque une libration de dopamine, annulant temporairement la dficience gntique. Destruction : Les problmes naissent si la personne augmente sa consommation une baisse des enkphalines et de la srotonine dans l'hypothalamus. une augmentation des rcepteurs l'enkphaline. une baisse du nombre de rcepteurs la dopamine. une augmentation du taux de mtabolisation de la dopamine. une augmentation du pouvoir liant des rcepteurs D2. une augmentation des enzymes dtruisant les enkphalines. une modification dans la structure des enkphalines aboutissant leur inactivation. une augmentation de la transmission du rseau GABA dans la substantia nigra. une diminution de la libration de dopamine et une diminution de l'activit de l'AMP cyclique et une diminution gnrale de la neurotransmission dans le SNC. Le tout provoque une diminution de l'activit aux sites de gratification. Plus la personne boit, plus l'effet diminue et plus les dommages sont importants dans les centres de gratification. Ce qui amne un plus grand besoin de boire, en cercle vicieux. La prdisposition hrditaire En 1972, Schuckit constata que chez les sujets de son tude, les personnes dont un parent tait alcoolique avait plus de risques de la devenir. Cette constatation subsistait que l'enfant ait eu ou non contact avec son parent biologique. En 1973, Goodwin a tudi un chantillon de 5,483 Danois, adopts tt dans leur enfance, et levs loin des parents biologiques. Il dcouvrit que les fils d'alcooliques adopts avaient prs de 4 fois plus de chances de devenir alcooliques que ceux dont le pre n'tait pas alcooliques, et ce, un ge plus prcoce.En 1978, c'est Bohman (Sude) qui compara le taux d'alcoolisme chez 2,324 enfants adopts et leurs parents. Il dcouvrit que les fils de pres alcooliques avaient 3 fois plus de risques de devenir alcooliques que les autres. Les fils de mres alcooliques avaient 2 fois plus de chances. Le traitement pharmacologique de l'alcoolisme On ne possde aucun traitement universel de l'alcoolisme. Parmi les interventions possibles, certaines utilisent des agents pharmacologiques, tels l'Antabuse pour renforcer la motivation viter la consommation d'thanol.Depuis quelques mois, le Revia a t autoris, au Qubec, comme adjuvant du sevrage alcoolique. Agissant uniquement en rduisant certains facteurs biologiques lis au craving, ce produit n'est pas une antidote l'alcoolisme. Son efficacit maximale exige un suivi psychothrapeutique parallle. ATTENTION aux extrapolations htives ! Des donnes pondrer... Les informations qui prcdent justifient l'intrt pour une tude mdicale de l'alcoolisme. L'internaute peu familier avec les thories contemporaines de l'alcoolisme ou des toxicomanies devra cependant viter d'y voir LA seule explication aux problmes alcooliques. Les thories actuelles de la dpendance intgrent diverses considrations psychologiques et sociales aux lments mdicaux. La sociologie, la psychosociologie, la psychanalyse, l'histoire et les sciences politiques doivent tre mises contribution pour complter la vision que la pharmacologie, la psychiatrie et la mdecine gnrale proposent des problmes toxicomanes. Amphtamines et stimulants. http://fra.drugtext.nl/miroir/meducation/produits/Stimulants/Amphet/general.html

Tableau des principales substances de ce groupe: Les amphtamines sont une famille de plusieurs drogues synthtiques dont l'utilisation mdicale est rare ou inexistante. On les retrouve principalement sur le march illgal ( Au Qubec). On peut identifier: Nom gnrique: d-amphtamine Dnomination commune: ( Dexdrine) demi-vie d'limination : 6-8 heures (enfant), 11.5 heures (adulte) Nom gnrique: mtamphtamine Dnomination commune: ( Mthdrine, speed, cristal) demi-vie d'limination : approx. 4 heures On utilise mdicalement certains produits apparents aux amphtamines dans le traitement du dficite attentionnel. Nom gnrique: mthylphnidate Dnominations commerciales: (Ritalin) demi-vie d'limination : 1 7 heures Nom gnrique: pmoline de magnsium Dnominations commerciales: (Cylert) demi-vie d'limination : 7.2 heures (enfant), 12 heures (adulte) On utilise dans le traitement de l'obsit exogne, comme adjuvants, des mdicaments tels le Tenuate et le Sanorex. Nom gnrique: diethylpropion Dnominations commerciales: (Tenuate) demi-vie d'limination : Nom gnrique: phentermine Dnominations commerciales: (Ionamin) demi-vie d'limination : L'phdrine, un psychotrope naturel retrouv dans les plants d'phedra (dont une varit est le Ma Huang, herbe utilise en Chine depuis plus de 5000 ans.) BENZODIAZPINES http://fra.drugtext.nl/miroir/meducation/produits/Depresseurs/Benzos/general.html

Tableau des principales substances de ce groupe Nom gnrique: Alprazolam Dnominations commerciales: (Xanax, Apo-alpraz, Novo-alprazol ,Nu-alpraz) demi-vie d'limination: 1219h dose quivalente ( effet comparable 1 mg de Ativan): 0,5 mg Nom gnrique: Bromazpam Dnominations commerciales: (Lectopam) demi-vie d'limination: 10-20h dose quivalente ( effet comparable 1 mg de Ativan): 3 mg Nom gnrique: Chlordiazpoxyde Dnominations commerciales: (Librium, Solium, Apo-chlordiazpoxyde) demi-vie d'limination: 6-30h dose quivalente ( effet comparable 1 mg de Ativan): 25 mg Nom gnrique: Clonazpam Dnominations commerciales: (Rivotril) demi-vie d'limination: 16-20h dose quivalente ( effet comparable 1 mg de Ativan): 0,25 mg Nom gnrique: Diazpam Dnominations commerciales: (Valium, Apo-diazpam, PMS-diazpam, Vivol) demi-vie d'limination: 20-80h dose quivalente ( effet comparable 1 mg de Ativan): 5 mg Nom gnrique: Estazolam Dnominations commerciales: ( Prosom) demi-vie d'limination: 8-24h dose quivalente ( effet comparable 1 mg de Ativan): 1 mg Nom gnrique: Flunitrazpam Dnominations commerciales: ( Rohypnol) demi-vie d'limination: 15-20 h dose quivalente ( effet comparable 1 mg de Ativan): ?? Nom gnrique: Flurazpam Dnominations commerciales: (Dalmane, Apo-flurazepam) demi-vie d'limination: 40-250 h (mtabolites) dose quivalente ( effet comparable 1 mg de Ativan): 30 mg

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Nom gnrique: Halazepam Dnominations commerciales : (non-disponible au Qubec) demi-vie d'limination: 39-96h dose quivalente ( effet comparable 1 mg de Ativan): 40 mg Nom gnrique: Lorazpam Dnominations commerciales au Qubec: (Ativan, Apo-lorazepam, Novo-lorazem, Nu-loraz) Dnomination commerciale en France et en Belgique: (Temesta) demi-vie d'limination: 10-20h dose quivalente ( effet comparable 1 mg de Ativan): 1 mg Nom gnrique: Nitrazpam Dnominations commerciales (Qubec et France): (Mogadon) demi-vie d'limination: 30-60h dose quivalente ( effet comparable 1 mg de Ativan): 2.5 mg Nom gnrique: Oxazpam Dnominations commerciales: (Srax, Apo-oxazepam ) demi-vie d'limination: 5-10h dose quivalente ( effet comparable 1 mg de Ativan): 15 mg Nom gnrique: Prazpam Dnominations commerciales: Centrax (non-disponible au Qubec) demi-vie d'limination: 30-100h dose quivalente ( effet comparable 1 mg de Ativan): 10 mg Nom gnrique: Quazpam Dnominations commerciales: (non-disponible au Qubec) demi-vie d'limination: 39-120h (mtabolites) dose quivalente ( effet comparable 1 mg de Ativan): 7.5 mg Nom gnrique: Tmazpam Dnomination commerciale (Qubec) : (Restoril ) demi-vie d'limination: 3-25h dose quivalente ( effet comparable 1 mg de Ativan): 10 mg Nom gnrique: Triazolam Dnominations commerciales: (Halcion, Apo-triazo, Gen-triazolam, Novo-triolam, Nu-triazo) demi-vie d'limination: 1.5-5h dose quivalente ( effet comparable 1 mg de Ativan): 0,25 mg

Indications mdicales les plus frquentes: Rduction de l'anxit , Traitement temporaire de l'insomnie , Certaines benzodiazpines peuvent tre utilises pour accompagner le sevrage l'thanol. Les benzodiazpines diminuent l'anxit et rduisent l'activit de certains centres nerveux associs avec aux motions (hippocampe, hypothalamus, rgion du septum). Ces produits agissent aussi sur seuil convulsif et modifient configuration des ondes crbrales. Utilisation mdicale (Au Qubec) Les benzodiazpines peuvent tre utilises comme adjuvant lors d'interventions psychothrapeutiques, sur une courte priode, dans le traitement de l'anxit et/ou de l'insomnie. L'usage constant et rgulier, sur des priodes de plus de 6 mois est rarement justifi.Le diazpam peut aussi tre utilis comme relaxant musculaire. On peut utiliser certaines benzodiazpines lors du sevrage alcoolique pour en rduire la mortalit et la morbidit.Les benzodiazpines sont frquemment utilises en mdication pr-anesthsique. Cafine http://fra.drugtext.nl/miroir/meducation/produits/Stimulants/Xanthines/general.html

Principales substances : Nom gnrique: cafine Nom rel : 1,3,7-trimethylxanthine La cafine est un psychotrope naturel de la famille des xanthines. On retrouve la cafine ou des substances voisines dans plus de 60 plantes diffrentes. Sources de cafine ( attention: ces concentrations sont approximatives et peuvent varier selon la dure ou le mode de prparation): Tasse de caf filtre: 64-150 mg Tasse de caf dca: 2-5 mg Tasse de caf instant: 40-108 mg Tasse de th (sachet): 28-48 mg Format rgulier de cola: 45 mg Chocolat (30g): 20 mg. Il est important de considrer les quantits totales des produits ingres ! Un <mug > de caf quivaut plus d'une tasse de caf ! Ajustez les calculs en fonction de la consommation totale quotidienne pour obtenir un portrait rel. Opiacs http://fra.drugtext.nl/miroir/meducation/produits/Depresseurs/Opiaces/general.html

Tableau des principales substances de ce groupe: Opiacs d'origine naturelle Nom gnrique: Codine Dnominations commerciales: ( Codine, Empracet-30, 222, Atasol-130, Fiorinal avec codine, sirops codins ) demi-vie d'limination de la codine: Nom gnrique: Morphine Dnominations commerciales: ( MOS, MS-Contin,...) demi-vie d'limination: Nom gnrique: Opium Dnominations commerciales: (Opium camphre et tanin) demi-vie d'limination: Principaux opiacs d'origine semi-synthtique Nom gnrique: Diactylmorphine Dnominations commerciales: (Hrone) demi-vie d'limination: Nom gnrique: Hydrocodone Dnominations commerciales: (Hycodan, Robidone,...) demi-vie d'limination: Nom gnrique: Hydromorphone Dnominations commerciales: (Dilaudid) demi-vie d'limination: Nom gnrique: Oxycodone Dnominations commerciales: (Percodan, Percocet) demi-vie d'limination: Principaux opiacs d'origine synthtique Nom gnrique: Mpridine Dnominations commerciales: (Dmerol) demi-vie d'limination: Nom gnrique: Mthadone Dnominations commerciales: idem demi-vie d'limination: Nom gnrique: Propoxyphne Dnominations commerciales: (Darvon, 642 (Frosst)) demi-vie d'limination: Utilisation mdicale (Au Qubec) : Soulagement de la douleur, Traitement de la diarrhe profuse, Rduction de la toux Sevrage ou entretien des narcomanes (mthadone seulement) Les inhibiteurs slectifs de la recapture de la srotonine (ISRS) http://fra.drugtext.nl/miroir/meducation/produits/Stimulants/Antidepresseurs/ISRS.html Nom gnrique Fluoxtine Fluvoxamine Paroxtine Sertraline Nom commercial au Qubec Prozac Luvox Paxil Zoloft

Indications mdicales Dpression majeure;prvention des la dpression secondaire dans certains troubles psychiatriques (tels la schizophrnie ou la dmence);boulimie et troubles obsessifs-compulsifs (pour Prozac). On les utilise parfois pour le traitement (non approuv au Canada) de: panique, comportement agressif, syndrome de la fatigue chronique.

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CEDRO (Center for Drug Research - Netherland) http://www.exodus.it/LINK.HTM Drug links listed by Country. - Foundation Exodus Italy. Pharmacologie Mcanisme peu connu. Pourraient agir directement sur les neurones la srotonine qui agiraient, en second, sur d'autres systmes neuronaux. Effets secondaires: Leur profil varie selon leur affinit et leur action avec les neurotransmetteurs. Habituellement, les effets secondaires diminuent avec la poursuite des traitements sur priode prolonge. Systme nerveux : Stimulation ou sdation avec le Prozac, Tremblements fins, Tinnitus Systme cardio-vasculaire: Palpitations, tachycardie; Peut produire vasoconstriction ...attention chez les patients angineux! Systme gastro-intestinal : Anorexie, Nauses, vomissements; Diarrhe Urognital : Rduction de la libido, Impuissance, Difficults jaculatoires, Anorgasmie Sevrage : L'arrt brusque du traitement doses leves pourrait produire de l'anxit, irritabilit, insomnie, fivre, sueurs, cphale, incoordination.Priode critique: 24 48 heures aprs arrt. MTHANOL http://fra.drugtext.nl/miroir/meducation/produits/Depresseurs/Autres/Methanol.html

Substance liquide, incolore, inodore, au got agrable. Trs toxique: Dose toxique adulte: 60 240 ml ; Dose toxique enfant: 1 gorge (5-10 ml). Synonymes: alcool de bois, hydrate de mthyle Au Qubec, on le retrouve dans: Antigel pour essence 100% , Combustible fondue 100%, Dgivreurs serrure 60-100%, Lavevitres d'auto 45-55%, Alcool frelat variable Effets : Une priode de latence allant jusqu' 12 heures a t signale. Il est donc possible que les effets ne soient perceptibles que plusieurs heures aprs la consommation. Intoxication modre: vomissements; nauses; cphales; Intoxication grave: dpression du systme nerveux central; cyanose; mydriase; coma; acidose grave; troubles visuels (mouvements douloureux, sensibles la pression). Traitement: Si il y a eu consommation d'une dose importante ou si la dose relle est inconnue et que le traitement mdical semble impossible dans les 60 minutes qui suivent la prise de mthanol, on peut procder une thanolisation "artisanale" avec: 1 ml/kg d'thanol pur (i.e.: 95%) ou 2 ml/kg d'alcool 40%(scotch, vodka, gin, .. Pour un homme de 70 kg, approximativement 150 ml..Par la suite, il faudra maintenir le niveau sanguin obtenu avec l'addition de 7 15 ml ( par heure ) d'alcool 95% ou 15 30 ml ( par heure ) d'alcool 40%. ATTENTION: IL S'AGIT D'UNE SITUATION D'URGENCE, ET UN TRAITEMENT HOSPITALIER EST REQUIS DANS LES PLUS BREFS DLAIS. Retour au menu gnral des substances Retour au menu principal de MDUCation MDUCation,1996

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