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Date Printed: August 23, 2017: 06:07 AM

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07-00007-13

Original Effective Date: 08/15/05

Reviewed: 08/25/11

Revised: 11/01/15

Subject: Opioid Antagonists under General Anesthesia or Heavy Sedation as a Technique for Opioid Detoxification

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Update  

DESCRIPTION:

The traditional treatment of opioid addiction involves substituting the opiate (i.e., heroin) with an equivalent dose of a longer acting opioid antagonist (i.e., methadone) followed by tapering to a maintenance dose. Methadone maintenance therapy does not resolve opioid addiction, but has been shown to result in improved general health, retention of patients in treatment, and a decrease in the risk of transmitting HIV or hepatitis. However, critics of methadone maintenance point out that this strategy substitutes one drug of dependence for the indefinite use of another.

Detoxification followed by abstinence is another treatment option, which can be used as the initial treatment of opioid addiction, or offered as a final treatment strategy for patients on methadone maintenance. Detoxification is associated with acute symptoms followed by a longer period of protracted symptoms (i.e., 6 months) of withdrawal. Although typically not life threatening, acute detoxification symptoms include irritability, anxiety, apprehension, muscular and abdominal pains, chills, nausea, diarrhea, yawning, lacrimation, sweating, sneezing, rhinorrhea, general weakness, and insomnia. Protracted withdrawal symptoms include a general feeling of reduced well-being and drug craving. Relapse is common during this period.

Detoxification may be initiated with tapering doses of methadone or buprenophrine (an opioid agonist-antagonist), treatment with a combination of buprenophrine and naloxene (an opioid antagonist), or discontinuation of opioids and administration of oral clonidine and other medications to relieve acute symptoms. However, no matter what type of patient support and oral medications are offered, detoxification is associated with patient discomfort, and many patients may be unwilling to attempt detoxification. In addition, detoxification is only the first stage of treatment. Without continued medication and psychosocial support after detoxification, the probability is low that any detoxification procedure alone will result in lasting abstinence. Opioid antagonists, such as naltrexone, may also be used as maintenance therapy to reduce drug craving and thus reduce the risk of relapse.

Dissatisfaction with current approaches to detoxification has led to interest in using relatively high doses of opioid antagonists, such as naltrexone, naloxene, or nalmefene under deep sedation with benzodiazepine or general anesthesia. This strategy has been referred to as "ultra-rapid," "anesthesia assisted “or” one-day" detoxification. The use of opioid antagonists accelerates the acute phase of detoxification, which can be completed within 24 – 48 hours. Since the patient is under anesthesia, the patient has no discomfort or memory of the symptoms of acute withdrawal. Various other drugs are also administered to control acute withdrawal symptoms, such as clonidine (to attenuate sympathetic and hemodynamic effects of withdrawal), ondansetron (to control nausea and vomiting), and somatostatin (to control diarrhea).

Hospital admission is required if general anesthesia is used. If heavy sedation is used, the program can potentially be offered on an outpatient basis. Initial detoxification is then followed by ongoing support for the protracted symptoms of withdrawal. In addition, naltrexone may be continued to discourage relapse. Ultra-rapid detoxification may be offered by specialized facilities. Neuraad™ Treatment Centers, Nutmeg Intensive Rehabilitation, and Center for Research and Treatment of Addiction (CITA) are examples. These programs typically consist of 3 phases: a comprehensive evaluation, inpatient detoxification under anesthesia, and finally, mandatory post-detoxification care and follow-up. The program may be offered to patients addicted to opioid or narcotic drugs such as opium, heroin, methadone, morphine, demerol, dilaudid, fentanyl, oxycodone, hydrocodone, or butorphanol. Once acute detoxification is complete, the opioid antagonist naltrexone is often continued to decrease drug craving, with the hope of reducing the incidence of relapse.

POSITION STATEMENT:

Opioid antagonists under anesthesia or heavy sedation as a technique for opioid detoxification is considered experimental or investigational, as the lack of controlled trials and the lack of standardized approach to this technique does not permit scientific conclusions regarding its safety or efficacy when compared to other approaches that do not involve deep sedation or general anesthesia.

BILLING/CODING INFORMATION:

There is no specific CPT or HCPCS code that describes opioid antagonists under anesthesia or heavy sedation.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Inpatient Hospital Stays for Treatment of Alcoholism (130.1), Outpatient Hospital Services for Treatment of Alcoholism (130.2), Chemical Aversion Therapy for Treatment of Alcoholism (130.3), Electrical Aversion Therapy for Treatment of Alcoholism (130.4), Treatment of Alcoholism and Drug Abuse in a Freestanding Clinic (130.5), Treatment of Drug Abuse (Chemical Dependency) (130.6), and Withdrawal Treatments for Narcotic Addictions (130.7). located at cms.gov.

DEFINITIONS:

Lacrimation: excessive secretion of tears.

Opioid antagonist: agents such as naloxone and naltrexone that have high affinity for opiate receptors but do not activate these receptors. These agents block the effects of opiods such as morphine, heroin, meperidine, and methadone.

Opioid: narcotic substance, either natural or synthetic.

Rhinorrhea: discharge from the nasal mucous membrane.

RELATED GUIDELINES:

None applicable.

OTHER:

Other indexing terms for this therapy:

ultra-rapid detoxification
anesthesia assisted detoxification
one-day detoxification

REFERENCES:

  1. American Society of Addiction Medicine, Inc.; Public Policy Statement on Rapid and Ultra Rapid Opioid Detoxification (Formerly Public Policy Statement on Opioid Antagonist Agent Detoxification under Sedation or Anesthesia (OADUSA), updated 04/05.
  2. Blue Cross and Blue Shield Association Medical Reference Policy Manual 3.01.02, Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid Detoxification, (12/09/10).
  3. Centers for Medicare and Medicare Services NCD 130.1 for Inpatient Hospital Stays for Treatment of Alcoholism
  4. Centers for Medicare and Medicare Services NCD 130.2 for Outpatient Hospital Services for Treatment of Alcoholism. Accessed - 7/20/11.
  5. Centers for Medicare and Medicare Services NCD 130.3 for Chemical Aversion Therapy for Treatment of Alcoholism. Accessed - 7/20/11.
  6. Centers for Medicare and Medicare Services NCD 130.4 for Electrical Aversion Therapy for Treatment of Alcoholism. Accessed - 7/20/11.
  7. Centers for Medicare and Medicare Services NCD 130.5 for Treatment of Alcoholism and Drug Abuse in a Freestanding Clinic. Accessed - 7/20/11.
  8. Centers for Medicare and Medicare Services NCD 130.6 for Treatment of Drug Abuse (Chemical Dependency). Accessed - 7/20/11.
  9. Centers for Medicare and Medicare Services NCD 130.7 for Withdrawal Treatments for Narcotic Addictions. Accessed - 7/20/11.
  10. Collins ED, Kleber HD, Whittington RA, Heitler NE. Anesthesia-assisted vs. buprenorphine – or clonidine-assisted heroin detoxification and naltrexone induction: a randomized trial. JAMA. 2005 Aug 24; 294(8): 903-13.
  11. ECRI Hotline Response article, “Intensive Narcotic Detoxification (Rapid Detox) for Opiate Addiction”, (08/01/07).
  12. Gowing L, Ali R, White J. Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD002022. DOI: 10.1002/14651858.CD002022.pub2.
  13. Gowing L, Ali R, White JM. Opioid antagonists with minimal sedation for opioid withdrawal. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD002021. DOI: 10.1002/14651858.CD002021.pub2.
  14. National Guideline Clearinghouse. Practice guideline for the treatment of patients with substance use disorders. Updated by ECRI 07/20/09.
  15. National Institute for Health and Clinical Excellence. NICE clinical guideline 52, Drug misuse – Opioid detoxification. 07/07.
  16. U.S. Department of Health and Human Services Public Health Service. Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment. Detoxification From Alcohol and Other Drugs; Treatment Improvement Protocol (TIP) Series 19; DHHS Publication No. (SMA) 95-3046; Printed 1995; accessed 06/07/07.
  17. U.S. Department Of Health and Human Services, Center for Substance Abuse Treatment. Detoxification and Substance Abuse Treatment: A treatment Improvement Protocol TIP 45. 01/18/06.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 08/25/11.

GUIDELINE UPDATE INFORMATION:

08/15/05

New Medical Coverage Guideline.

08/15/06

Scheduled review; no change in coverage statement.

07/15/07

Scheduled review; reformatted guidelines; updated references.

09/15/08

Scheduled review; no change in position statement; references updated.

09/15/09

Scheduled review; no change in position statement; references updated.

09/15/11

Scheduled review; position statement unchanged; references updated.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: August 23, 2017: 06:07 AM