NEW YORK-A withdrawal wringer is getting anesthetized opiate addicts clean without an agitation cycle.   The first five days of withdrawal are compressed by precipitation into about six hours-anesthesia letting patients tolerate an otherwise unbearable opioid-antagonist load.   After awakening, patients may still have nausea, aches and pains, diarrhea, and other problems for weeks, but they are clean. So they can begin taking the opioid antagonist naltrexone, which blocks opiate euphoria.   Proponents of the dramatic treatment say it gives addicts a head start on staying clean and, if combined with comprehensive aftercare and naltrexone, could provide a viable and healthier alternative to methadone maintenance.   Critics say the treatment is too risky and is being pushed for profit as a painless magic bullet to a vulnerable population. Intensive aftercare is essential, but some independent practitioners have reportedly provided patients with only the phone number of Narcotics Anonymous.   Some authorities say lack of aftercare leads to expensive repeat therapy. And a New Jersey internist’s ads for “four-hour detox” led the state to propose new rules (see related story).   Fans and critics of the treatment, pioneered by Dr. Norbert Loimer in Vienna a decade ago, agree on one thing: all patients complete the detox process, giving them a chance to start taking naltrexone. Only a minority of those who go through conventional detox reach that stage.   But keeping patients on naltrexone is tough.   Yet, the procedure appears to help blunt desire for the drug, notes Dr. David Gastfriend, director of addiction medicine at Mass General, who is running a six-patient pilot study of detox under anesthesia. All in his study must have a spouse who is abstinent or in recovery and pay for three months of individual, couple, and group therapy after detox. The all-inclusive fee is $5,500.   Four hospital-based clinics began doing precipitate detox last year in conjunction with CITA-Americas, a for-profit company. They have treated more than 500 patients in the ICU, for an upfront fee of $7,000, plus mandatory aftercare. CITA says surveys of patients treated at the New York and Miami clinics during the first six months showed that more than half had stayed clean.   The clinics at Metropolitan Hospital in New York, Cedars-Sinai in Los Angeles, the University of Illinois in Chicago, and Mount Sinai in Miami, which all do the detox in the ICU, require individuals to sign up for aftercare with a drug-free significant other. CITA says it monitors patients closely for at least six months. Some are skeptical of this claim.   The clinics use CITA’s proprietary table of dosages and duration. For this CITA gets $2,000 a procedure, hospitals keeping the rest. It’s a cash procedure attractive to hospitals. But some addiction specialists are highly critical of CITA’s approach, arguing that it markets the process too aggressively, isn’t selective enough about whom it treats, and doesn’t provide enough aftercare.   CITA-Americas’ parent company, CITA-International (for Centro de Investigacisn y Tratamiento de las Addicciones), has been a magnet for controversy. Dr. Juan Legarda, a Spanish psychiatrist and CITA-International’s founder, claims scientific primacy, though he didn’t publish until six years after Dr. Loimer. He also attempted to patent the technique and allegedly overstated pain reduction. CITA-International’s holding company has threatened to sue a London physician if he continues to perform the procedure.   The recipient of the threats, Dr. Colin Brewer, calls CITA-International a “disgusting organization.” He says one CITA patient in London died during detox. CITA denies it.   Addiction specialists say detox under anesthesia is appropriate for some patients, such as those who can’t spare time away from work to go through a more lengthy withdrawal. Also, some say, it can be a good thing for patients who have failed standard detox several times.   Columbia psychiatrist Herbert Kleber is seeking NIDA funding for a $2.5-million, 2½-year study of detox under anesthesia, comparing CITA’s method with two other approaches. CITA declined to fund it.   The real-world arbiter of acceptability is the third-party payer, and Dr. Bennett Oppenheim, COO of CITA-Americas, claims he’s making progress. One major union, he says, and Aetna in California have agreed to cover the procedure on a case-by-case basis. New York Medicaid is reviewing reimbursement.   Physicians working with CITA in the U.S. say the procedure engenders resistance because it poses a threat to methadone maintenance, which represents billions in funding to hospitals. Dr. Clifford Gevirtz, an anesthesiologist at New York Medical College who oversees rapid detox at Metropolitan Hospital, calls methadone maintenance “a whole little cottage industry.”   Others note, however, that anesthesiologists have been particularly hard hit by managed care and detox is welcome employment, considering an estimated national population of 600,000 to 800,000 heroin addicts.   Dr. Michael Miller of Madison, Wis., a member of the American Society of Addiction Medicine’s public-policy panel, says rapid detox is good medicine backed by good science. The key question, he adds, is whether the results will wind up sufficiently better than standard detox to offset the much greater cost and added risk of anesthesia. -Anne S. Harding