Psychosis After Ultrarapid Opiate Detoxification

Ms. A was a 45-year-old woman who was taking 100 mg/day of methadone and 4 mg/day of alprazolam concurrently. She desired detoxification because of a 40-lb weight gain that she attributed to methadone therapy, but she did not wish to undergo conventional detoxification. Ms. A was advised to stop taking alprazolam before ultrarapid opiate detoxification, but she refused and mentioned that she had attempted suicide after a past detoxification.

Twelve days before the ultrarapid opiate detoxification, a toxicology screen was positive for methadone and benzodiazepines but negative for all other drugs of abuse. Ms. A discontinued methadone treatment, and hydrocodone therapy was initiated. One day before the ultrarapid opiate detoxification, a toxicology screen was positive for methadone. Ultrarapid opiate detoxification was conducted according to protocol (2) and included benzodiazepine substitution. During extubation and over the next few hours, Ms. A was intermittently agitated despite being fully oriented. Several hours after ultrarapid opiate detoxification, Ms. A was observed ingesting pills not supplied by staff. When staff confronted her, she admitted ingesting alprazolam for anxiety.

Subsequently, Ms. A reported feeling as if the previous few hours had been a bad dream or “bad trip.” She reported believing staff were trying to kill her and that during extubation the anesthesiologist was attempting to choke her. She also reported auditory but neither visual nor tactile hallucinations. These symptoms completely disappeared in 24 hours. At her 3-month follow-up, Ms. A was still in treatment for addiction, but toxicology screens were negative for methadone and other opiates.