Rapid Opioid Detoxification: Deaths and Adverse Events

Health Department Investigation

AAROD procedures performed in the New York City clinic included 1) administration of medications (e.g., clonidine, antiemetics, and antidiarrheal agents) that blunt withdrawal symptoms, 2) intubation and induction of general anesthesia, 3) precipitation of opioid withdrawal by intravenous infusion of high doses of the opioid antagonist naloxone or intramuscular injection of naltrexone, 4) maintenance of anesthesia until withdrawal symptoms were presumed to have subsided, and 5) extubation and monitoring during an overnight recovery. Median duration of anesthesia was 8.3 hours (range: 3.1–15.0 hours); median duration of opioid antagonist infusion was 3.9 hours (range: 2.1–14.0 hours). Median naloxone dose was 80 mg (range: 2–315 mg); median naltrexone dose was 133 mg (range: 25–300 mg). For patients with serious adverse events, the median naloxone dose was 80 mg (range: 4–88 mg) and median naltrexone dose was 150 mg (range: 0–150 mg). All patients were monitored overnight after the procedure.

A serious AAROD-associated adverse event was defined as hospitalization for any cause or death <72 hours after undergoing AAROD in New York City during September 1, 2011–September 5, 2012. DOHMH staff conducted two visits to the clinic. All four clinic staff members were interviewed, and medical records for all patients who underwent AAROD while the clinic was operational were reviewed. Records of emergency medical services calls to the clinic were obtained from the New York City Fire Department. Hospital records for all patients who were found to have made emergency department visits or been admitted to a hospital were reviewed. The practice's patient list was matched to mortality records by patient name and date of birth in New York City and the patients' usual states of residence. New York City's Poison Control Center toxicology database was searched for serious adverse events from other New York City health-care facilities.

No emergency medical services calls to the practice were reported other than those initially reported by the Poison Control Center. The mortality records and toxicology database searches yielded no additional AAROD-related serious adverse events from the implicated clinic or elsewhere. From the clinic's opening in January 26, 2012, until September 4, 2012, a total of 75 patients underwent AAROD; 62 (83%) were men (median age: 37 years; range: 20–63 years). Patient comorbidities included psychiatric disorders (55%), chronic medical conditions (23%), and polysubstance use (35%). In addition to the three adverse events reported, four additional adverse events, including one additional death, were identified during medical record review. All seven patients were men (median age: 31 years; range: 24–52 years), Four were prescription opioid users; two used both prescription opioids and heroin, and one used heroin alone. Four patients had psychiatric comorbidities, and two were polysubstance users. None of the patients had a documented chronic medical condition.