Der Forcierte Opioidentzug in Narkose (FOEN) - eine neue Heraus­forderung für Anästhesisten und Intensivmediziner

Zusammenfassung.

Kompetitive Rezeptorantagonisten wie Naloxon und Naltrexon werden seit den frühen siebziger Jahren zur Behandlung der Opioidabhängigkeit eingesetzt. Durch die Anwendung dieser Substanzen wird der körperliche Entzug zwar beschleunigt, es kommt andererseits jedoch zu einer erheblichen Verstärkung der Entzugssymptomatik. Ursache dafür ist die sympatho-adrenerge Hyperaktivität, die mit einer gesteigerten Noradrenalinfreisetzung einhergeht. Das Risiko des Antagonisten-induzierten Opioidentzuges ist gegenüber konventionellen Entzugsverfahren erhöht. Mit Hilfe der Allgemeinanästhesie gelingt es, Ungleichgewichte des vegetativen Nervensystems einzudämmen und Organfunktionsstörungen zu verhindern. In diesem Artikel wird die klinische Relevanz forcierter Opioidentzugsverfahren in Narkose auf der Basis der verfügbaren Literatur sowie unter Berücksichtigung eigener Erfahrungen diskutiert. Wir schlußfolgern, daß diese Methode besonders bei abstinenzmotivierten und sozial integrierten Patienten, die jedoch wegen der starken körperlichen Entzugssymptomatik wiederholt Therapien abgebrochen haben, geeignet ist.

Treatment of opioid addicts by means of competitive opioid receptor antagonists was developed at the University of Vienna in 1987 by Loimer and co-workers. They compared two withdrawal regimens: The short Opiate withdrawal using a staggered naloxone regimen and the rapid opiate detoxification during general anesthesia by means of high doses of naloxone. Based on the latter concept, various modifications have been developed world-wide using either naloxone or as an alternative, naltrexone, an antagonist available for oral administration only. However, there are considerable objections to opioid detoxification during general anesthesia. The main criticism is based an the supposedly unacceptable high risk : benefit-ratio, the higher costs, the lack of psycho-social support, and the lack of prospective studies. However, first results suggest that rapid detoxification procedures are more successful in decreasing relapse than methods which are based on psychiatric treatment alone. As sympathetic hyperfunction is common in rapid detoxification procedures using high doses of opioid receptor antagonists, it is essential to avoid severe autonomic imbalance with possible subsequent impairment of organ functions. To prevent those disturbances, general anesthesia plays an important role. So far, there is almost no information about such methods in the anesthesiological literature. In this article the clinical relevance of such methods is discussed summarizing both the available literature and our own experience and we conclude that rapid opioid detoxification under general anesthesia is a safe and efficient method to suppress withdrawal symptoms. This treatment may be of benefit in patients who particularly suffer from severe withdrawal symptoms and who have failed repeatedly to complete conventional withdrawal.

Schlüsselwörter:

Opioide - Narkose - Entzug - Naltrexon

Key words:

Opioids - Anesthesia - Withdrawal - Naltrexone

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