In Reply:—
Dr. Whittington raises a valid point. The death of one patient after anesthesia-assisted rapid opioid detoxification is a significant event, and we clearly recognized it as such. However, his concern is over the decision to omit this information from the abstract and instead, to describe the patient’s death in the Results section of the manuscript. He also takes issue with our statement of “successful detoxification of 20 patients without adverse events. 1”
We gave serious thought to the construction of the abstract. We looked very closely at all the information available to determine the cause of death, but were unable to do so. Dr. Whittington believes that, because no illicit drugs were found in the patient’s blood, death was “in all likelihood” related to the effects of the procedure. Our conclusions were much less clear. We considered the patient’s history of hypertension and smoking as contributory to a possible myocardial infarction, and other causes of sudden death, for example, aneurysm or pulmonary embolus. We believe the abstract is not the place to speculate when information is not available.
Dr. Whittington mentions some well-known physiologic changes that can occur during some less widely used protocols, i.e. , increased plasma catecholamine levels and prolonged QT intervals. The issue that is not well-known or perhaps not known at all is whether any of these changes persist into the postdetoxification period and, if so, for how long. The majority of patients undergoing the procedure are discharged to home the day after the procedure; therefore, detailed collection of physiologic data has not been possible. This patient met all discharge criteria within 24 h of the procedure.
Our protocol specifically addressed the hemodynamic changes of withdrawal, and we did not see changes in heart rate, blood pressure, or the electrocardiogram. This is not to say that these types of events could not occur, but we did not see them in this patient. Furthermore, we clearly mention the potential need for postprocedure monitoring in the Discussion section; therefore, his comment concerning this “omission” is in error. We are pleased to see that Dr. Whittington has received support for a study that incorporates this type of monitoring. We look forward to his results and plan on proceeding the same way in our own program.
Finally, we used currently accepted clinical criteria in determining the end point for detoxification. These criteria were applied after the patient had emerged from anesthesia and before the patient’s discharge from the postanesthesia care unit. We repeat our conclusion from the study that all 20 patients were successfully detoxified without adverse events. We clearly describe adverse events that occurred, such as nausea or diarrhea and the death of a patient, but all were encountered in the postdetoxification period while the patients were with the rehabilitation service. We have treated 41 patients, and there have been no other deaths in our program.
Current efforts are under way to more fully explore the deaths associated with anesthesia-assisted rapid opioid detoxification worldwide. We join other practitioners and researchers in anticipating the results of those studies. There is no reason to publish a correction to our abstract.
