An estimated 1.7 million individuals abused or were dependent upon opioids in 2002 1. Though Becky fortunately is in recovery, many more people are still in need of treatment. Without the help of medication, abstinence from opioid use is very difficult. In fact, death claimed nearly half the opioid dependents tracked in a 33-year study conducted by researchers at the University of California at Los Angeles. Of those still alive, 20.7 percent tested positive for heroin and showed high rates for disability, hepatitis, mental health disorders, and criminal activity. Only about 10 percent of the sample were involved actively in methadone maintenance treatment2.
Opioid addiction has been treated with methadone for more than 30 years. The medical consensus is that it is among the most effective treatments available3. Now, in addition to methadone, buprenorphine can be used to treat opioid addiction.
The information provided in this brochure will give you some facts about opioid use and misuse in the United States, inform you about medication assisted opioid treatment, and illustrate how methadone maintenance can be used to manage inmates both in and out of jail.
On May 18, 2001, new regulations for the use of narcotic drugs in the maintenance and detoxification treatment of opioid addiction were issued and the old narcotic treatment regulations enforced by the Food and Drug Administration (FDA) were repealed. The new rule shifted administrative responsibility and oversight from the FDA to the Substance Abuse and Mental Health Services Administration (SAMHSA), both of which are agencies of the United States Department of Health and Human Services. This new system is designed to increase medical decision making as well as the overall involvement of the medical community in the treatment of opioid addiction. It is supported by the accreditation model currently in place in most medical institutions. Medication assisted treatment (MAT) is clinically driven with a focus on individualized patient care.
Methadone Treatment
Methadone treatment combines a medical therapy with psychosocial services to improve the health and physical well-being of persons addicted to short-acting opioid drugs such as prescribed pain medications. Methadone helps to stabilize the patient by relieving physical withdrawal symptoms and reducing physiological cravings –without the negative effects and consequences of the short-acting drugs of abuse. Rehabilitation services enable individuals to achieve recovery.
Methadone, when taken as ordered by a physician, is safe and effective and does not create a pleasurable or euphoric feeling, although some patients may experience side-effects such as constipation, water retention, drowsiness, skin rash, excessive sweating, and change in sex drive. The effectiveness of methadone has been shown in many studies over the past 30 years.
Buprenorphine Treatment
Buprenorphine (Suboxone™ and Subutex™) is a recently approved opioid addiction medication that, like methadone, suppresses withdrawal symptoms and blocks the effects of short-acting opioid drugs Buprenorphine has been demonstrated to be effective when combined with psychosocial services, which often are needed to help people with substance use disorders. Buprenorphine treatment is an alternative to and not a replacement for methadone treatment, which is often not available in some communities. Because the two treatments are different, patients and their families need to become familiar with the distinctions in the medications and the psychosocial services provided.
For additional information on buprenorphine, please visit http://www.buprenorphine.samhsa.gov.
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Patients with a history of misusing short-acting opioids frequently enter methadone or buprenorphine treatment with many medical complications, mental health issues, other substance use problems, and infectious diseases, such as HIV/AIDS and hepatitis. Often, the treatment for these other conditions involves medications that may have interactions and, therefore, need to be monitored carefully by the treating physician. For example, patients receiving methadone or buprenorphine who have acute or chronic pain may require special attention because of interactions between methadone and buprenorphine, and commonly prescribed pain medications.
Other Opioid Addiction Medication Assisted Treatments
Opioid-dependent individuals also can be treated with naltrexone (ReVia®) as an additional phase of detoxification or medically monitored withdrawal. Once an opioid-free state is reached, naltrexone is taken to block the effects of opioid drugs, should use occur. It is more prophylactic than therapeutic, and does not address issues of craving. Naltrexone also has been used as an adjunctive treatment for alcoholism. Although it does not block the effects of alcohol, some patients report a reduction in the number of drinking episodes when taking naltrexone.
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With a significant increase in the number of drug-related arrests in the New York metropolitan area in 1987, the Correctional Facility on Rikers Island experienced overcrowding and unrest. In response, the Key Extended Entry Program (KEEP) was initiated.
Inmates participating in the program receive a daily dose of methadone according to the Direct Observation Therapy (DOT) method in which a nurse and correction officer directly observe the inmate swallow the methadone. Before leaving the area, each inmate also must respond verbally to the correction officer to ensure ingestion of the medication.
Before the initiation of programs such as KEEP, many opiate-dependent inmates with minor offenses were released to the community before detoxification was complete. Releasing these inmates almost always guaranteed a return to dependency, criminality, and high-risk behavior. Offering inmates a choice of heroin detoxification or methadone treatment allows them to make a transition from their incarceration to community-based methadone treatment centers on their release.
In addition to in-facility programs such as KEEP, there are other ways to address the need for MATs in local jails and “behind the walls” of other correctional facilities. Maryland, Rhode Island, California, and other states have developed alternative treatment mechanisms.
For instance, some centrally located county jails, such as a facility in Anne Arundel County, Maryland, developed Opioid Treatment Programs (OTPs) mainly for the medically monitored withdrawal of newly arriving inmates and the maintenance of those found to be pregnant. Jails in the surrounding counties can refer incoming inmates for withdrawal or maintenance due to pregnancy.
Through a cooperative agreement, Baltimore City Jail and Man Alive Research, Inc., an OTP in Maryland, established a “medication unit” within the jail. A medication unit is the medication administering/dispensing section of an OTP, staffed by program administrators and usually housed in the diagnostic or medical areas within the jail.
Other states such as California and Rhode Island encourage treatment programs to continue treating their patients while they are inmates in the state’s correctional facilities.
Although medically monitored withdrawal is provided to many inmates, maintenance also is provided to pregnant inmates for up to a year. Having services such as KEEP, on site OTPs, medication units, and programs to deliver methadone maintenance therapy (MMT) helps ensure the treatment needs of inmates are met.
Managing a released opioid-addicted inmate in recovery through MAT is much simpler for providers than managing a parolee who went through forced opiate withdrawal. Opioid treatment programs initially interact with the patients daily on both a clinical and medical basis. In turn, probation and parole officers can be confident that their charges are recieving a high level of supervision.
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In 2003, SAMHSA awarded 13 grants totaling almost $15 million over 3 years to fund drug courts that provide treatment for substance-misusing parents, juveniles charged as delinquents in juvenile court, and adults charged in criminal courts who might otherwise be sentenced to jail. This funding expands the Family Drug Treatment Courts (FDTCs) and helps break the cycle of child abuse and criminal behavior linked to drug addiction.
Administered by SAMHSA’s Center for Substance Abuse Treatment, the grants provide funds for two civil courts that serve parents that abuse or neglect their children; eight adult treatment drug courts that work with criminal offenders that misuse drugs and alcohol; and three juvenile treatment drug courts for adolescents with substance use disorder problems.
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For more information about MAT for opioid addiction, call SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI) at (800) 729-6686 or visit SAMHSA's Division of Pharmacologic Therapies at www.dpt.samhsa.gov.
SAMHSA also publishes Treatment Improvement Protocols (TIPS) and Technical Assistance Publications (TAPS) to provide guidance and information to professionals in the field involved with MAT delivery. For more information, please visit www.samhsa.gov or contact NCADI.
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- Substance Abuse and Mental Health Services Administration, (2003) Results from the 2002 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NHSDA Series H-22, DHHS Publication No SMA 03-3836). Rockville, MD.
- National Drug Court Institute. Drug Court Practitioner Fact Sheet. “Methadone Maintenance and Other Pharmacotherapeutic Interventions in the Treatment of Opioid Addiction.” April 2002, Vol. III, No. 1.
- National Institutes of Health. Consensus Statement. “Effective Medical Treatment of Opiate Addiction.” November 17–19, 1997. Vol. 15, No. 6. MD, 2003.
- Tractenberg, A. Methadone-Associated Mortality. Epidemiologic Trends in Drug Abuse Volume II: Proceedings of the Community Epidemiology Work Group, Bethesda, MD: National Institute on Drug Abuse, in press.
- Substance Abuse and Mental Health Services Administration, Office of Applied Studies Drug and Alcohol Services Information System (DASIS) Report: Treatment Admissions Involving Narcotic Painkillers: 2002 Update.
- Substance Abuse and Mental Health Services Administration, Office of Applied Studies, Emergency Department Trends From the Drug Abuse Warning Network, Final Estimates 1995–2002, DAWN Series D–24; DHHS Publication No. (SMA) 03–3780, Rockville, MD, 2003.
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You Should Know...
Law enforcement and corrections officials should recognize the need for—and ensure the appropriate provision of—MAT with methadone or buprenorphine, either in a correctional setting or in the probation and parole populations.
Individuals in custody—as well as those on probation and parole—who continue to be treated with methadone demonstrate a high degree of stabilization and success. For those in custody, abrupt termination or forced withdrawal from MAT often results in severe physical and emotional distress, and, in some cases, death. For those on probation or parole, forced withdrawal is associated with a high relapse rate to illicit opioid drug use. Relapse carries added risks, such as overdose and exposure to human immunodeficiency virus (HIV) and hepatitis C virus (HCV), often culminating with a return to criminal activities and reincarceration.
MAT patients can be withdrawn successfully while in custody with tolerable levels of discomfort and limited risks. Thirty days should be adequate for low doses such as 20 mgs. But more typical doses in the range of 80–100 mgs. often require a minimum of 90 days. Individuals facing long-term incarceration should be considered for the withdrawal procedure if maintenance is not available. In cases of short-term incarceration (up to 90 days), continuous MAT should be considered.
Slow withdrawal is suggested since unknown or undiagnosed medical conditions can be exacerbated by a fast detoxification, and may result in life-threatening situations.
Facts About Opiate Use, Dependency, and Treatment
- Commonly used to treat heroin addiction, methadone also is used to treat addiction to other opiates, such as codeine, hydrocodone, oxycodone, and morphine. Methadone also is an effective painkiller, and is increasingly being used for this purpose. According to the Automation of Reports and Consolidated Orders System (ARCOS-2) administered by the Drug Enforcement Administration, the amount of methadone dispensed by retail pharmacies from 1997 to 2000 increased from 397 to 1,600 kilograms per year 4.
- Treatment admission rates for misuse of narcotic pain relievers more than doubled between 1992 and 2002, according to SAMHSA. These admissions increased for all ages, but especially among people aged 20 to 30. Between 1997 and 2002, the proportion of new users – those entering treatment within three years of beginning use – increased from 26 percent in 1997 to 39 percent in 2002 5.
- An estimated 6.2 million people, 2.6 percent of the population aged 12 or older, were current users of prescription drugs taken non-medically. Of these, an estimated 4.4 million used narcotic pain relievers, 1.8 million used anti-anxiety medications (also known as tranquilizers), 1.2 million used stimulants, and 0.4 million used sedatives. Approximately 1.9 million persons aged 12 or older used OxyContin non-medically at least once in their lifetimes 1.
- Use of pain relievers non-medically among those aged 12–17 increased from 9.6 percent in 2001 to 11.2 percent in 2002, continuing an increasing trend from 1989 when only 1.2 percent had ever used pain relievers non-medically in their lifetimes. Among young adults aged 18–25, the rate of ever having used pain relievers non-medically increased from 19.4 percent in 2001 to 22.1 percent in 2002. This rate was 6.8 percent in 2002 1.
- Emergency department mentions of narcotic pain medications rose from 99,317 in 2001 to 119,185 in 2002. The increase from 2000 to 2002 was 45 percent 6.
- Narcotic pain medications accounted for 10 percent of total drug mentions in hospital emergency department visits related to drug abuse in 2002. Over the 8-year period from 1995 to 2002 mentions of narcotic pain medications rose 163 percent 6.
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