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To the Editor: Great Britain is in the early stages of a new heroin epidemic, often involving very young users.¹ Traditionally, treatment for heroin addiction substitutes methadone hydrochloride for heroin, often followed by gradual tapering of the methadone dose. However, this method is often unsuccessful because of high dropout and subsequent relapse rates. Furthermore, most study designs have had limited assessment of clinical outcomes.²

Methods
In a pilot study of 30 patients, we compared rapid detoxification with naltrexone under general anesthesia followed by long-term naltrexone use (rapid detoxification) with the traditional management of heroin addiction by substituting it with methadone, followed by gradual tapering of the methadone dose and long-term naltrexone (traditional methadone). After giving informed consent, the first 15 eligible patients were assigned to rapid detoxification and the next 15 to traditional methadone treatment. All patients were followed up for 3 months. During this time, treatment effectiveness was assessed by measuring metabolic levels in urine. Costs of treatment were computed both on an intent-to-treat basis (using all patients in the denominator) as well as on a cost-per-treatment success rate.

Results
The baseline characteristics of the 2 groups were similar (Table 1), except for greater duration of prior methadone use among the rapid detoxification group (P<.01). All 15 patients in the rapid detoxification group completed the 7-day rapid detoxification program, whereas only 8 patients (53%) completed the methadone tapering program. During the follow-up period, 5 patients dropped out of the rapid detoxification arm, and 3 of the remaining 8 patients dropped out of the methadone group. Thus, rapid detoxification led to a 3-month cure (abstinence) rate of 67% (95% confidence interval [CI], 38%-88%) vs 33% (95% CI, 12%-62%) in the methadone group (P = .14). The average 3-month intent-to-treat cost for rapid detoxification was $5850 (95% CI, $5625-$6040) vs $4230 (95% CI, $3075-$5350) in the methadone group. The average cost per treatment success was $8775 in the rapid detoxification group vs $12,685 in the methadone group.

View this table: [in this window] [in a new window] Table. Patient Characteristics

Comment
Given the small sample size, our pilot study had limited power to detect treatment effects. Nonetheless, rapid detoxification with naltrexone under general anesthesia, followed by long-term naltrexone therapy, may be a promising treatment strategy. It provides extra time for additional treatment to maintain abstinence from opioids. It may also prove less expensive, per success, than traditional methadone treatment. More research is clearly needed to determine how best to manage former heroin addicts following detoxification.

Robert J. F. Laheij, PhD; P. F. M. Krabbe, PhD
University of Nijmegen
Nijmegen, the Netherlands

C. A. J. de Jong, MD, PhD
Novadic
Sint Oederrode, the Netherlands

1. Dean M. Britain on the verge of a new heroin epidemic. Lancet. 1999;353:1997. 2. O'Connor PG, Kosten TR. Rapid and ultrarapid detoxification techniques. JAMA. 1998;279:229-234. FREE FULL TEXT

Letters Section Editors: Phil B. Fontanarosa, MD, Deputy Editor; Stephen J. Lurie, MD, PhD, Fishbein Fellow.

JAMA. 2000;283:1143.

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