WHEN I first heard the CNN broadcast and then later read the New York Times story about patients who receive general anesthesia to break opioid addiction, my immediate response was, “Well, sure it will work-until the patient wakes up. An addict cannot take drugs while asleep, but the basic biochemistry of his or her brain will not change.” But on further consideration, I think it is possible that the mechanism that produces the unconscious state during general anesthesia and prevents an addict from “feeling” may indeed permanently alter brain biochemistry. A crazy thought? In this issue of Anesthesiology, Kienbaum et al. [1]describe the rapid detoxification of addicts during general anesthesia with the use of [micro sign]-opioid receptor blockade. The investigators do not speculate about the mechanism behind this therapy. My question is, does the therapy really work? To call the therapy effective, Kienbaum et al. must show that in the long term, brain biochemistry in their subjects was changed. Or failing that, proof is needed that the subjects abstained from drugs long term.
The study, which presents one therapy to reverse the biochemistry of addiction, may teach us something about the biochemistry of anesthesia. We know that opioids and general anesthetics suppress the autonomic nervous system. Many studies have suggested that these drugs work synergistically rather than additively. In the 1970s, I spent a year at NIH trying to confirm the changes in brain receptors caused by opioids. I was searching for changes that would make a receptor more “appealing” to volatile anesthetic effects or vice versa. I was never able to prove my hypothesis during that year.
The article by Kienbaum et al. once again reminds us of the strong interaction between opioid agents and anesthetics. The synergy may exist on a molecular biologic level, one strong clue to the mechanism of general anesthesia, or at least to the cardiovascular effects and control mechanisms that operate during general anesthesia. Thus this article, like many in the anesthesia literature, leads us more toward reexamination of questions than evaluation of answers.
O'Connor and Kosten [2]recently reviewed the scientific literature on rapid detoxification techniques in addicts. They indicated the limitations of the available studies: lack of randomized design, of comparison with other treatment methods, and of control groups; short follow-up periods (days, in some studies); and variation in protocols. Although we cannot endorse the therapy for addiction described by Kienbaum et al. without the results of further research, we can seek to understand what this treatment tells us about opioid addiction and the mechanism of general anesthesia, two-until now-unrelated subjects.
Michael F. Roizen, M.D.
Professor and Chairman; Department of Anesthesia and Critical Care; Professor of Internal Medicine; University of Chicago; Chicago, Illinois 60637
