An estimated 1.7 million individuals abused or were dependent on opioids in 20021. Though Renee is fortunately in recovery, there are many more people who are still in need of treatment. Opioid addiction has been treated with methadone for more than 30 years. The medical consensus is that it is among the most effective treatments available2. Now, in addition to methadone, buprenorphine has been approved to treat opioid addiction. Unlike methadone, buprenorphine treatment is office-based, though it also can be administered in a clinical setting. This means—with required training and waiver—you and other physicians can treat opioid-dependent patients in your own office, just as you would patients with any other medical condition.The information 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 describe the stigma individuals in medication assisted treatment (MAT) often face.
Back to top
On May 18, 2001, new regulations for the use of narcotic drugs in the maintenance and detoxification treatment of opioid addiction were issued. Older narcotic treatment regulations enforced by the Food and Drug Administration (FDA) were repealed.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. MAT is clinically driven with a focus on individualized patient care.The Drug Addiction Treatment Act of 2000 (DATA 2000) expands the clinical context of MAT by permitting qualified physicians to dispense or prescribe specifically approved Schedule III, IV, and V narcotic medications for the treatment of opioid addiction in offic-based settings. On October 8, 2002, the FDA approved the use of buprenorphine (SuboxoneTM and SubutexTM). Physicians who choose to practice MAT for opioid addiction need to apply for and receive waivers of the special registration requirements defined in the Controlled Substances Act.
Methadone Treatment
Methadone treatment combines 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 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.
Patients on methadone can be treated for pain with most pain medications without serious interactions, though coordination of methadone with certain pain medications may be necessary. Patients treated with methadone experience normal pain and need analgesia following surgical procedures or for chronic pain. Methadone patients should not be prescribed medications for pain that contain opioid antagonists, since the antagonists will precipitate withdrawal.
Buprenorphine Treatment
Buprenorphine is a partial agonist and, like methadone, suppresses withdrawal symptoms and blocks the effects of other opioids. It is important that patients understand the differences between agonist and partial agonist-type drugs. Knowing these differences can help patients make treatment decisions, such as transferring from methadone to buprenorphine therapy. Buprenorphine, as a partial agonist, requires the patient to reduce his or her dose of methadone before transferring.
The treatment of pain in patients receiving buprenorphine is somewhat different than patients receiving methadone. Buprenorphine has powerful analgesic properties comparable to that of morphine; however, the onset of action has been found to be inadequate for urgent care (Nikoda et al. 1998). Its partial antagonist activity tends to block the activity of short-acting pure agonists. Therefore, in patients being maintained on buprenorphine whose acute pain is not relieved by non-opioid medications, the buprenorphine treatment should be discontinued and usual, more aggressive pain management techniques should be instituted, including the use of short-acting, full agonist medications.
For additional information on buprenorphine, please visit http://www.buprenorphine.samhsa.gov.
Other Opioid Addiction Medication Assisted Treatments
Opioid-dependent individuals 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.
Back to top
Patients who misuse narcotics frequently have a high prevalence of medical complications, mental health issues, and co-morbid illnesses such as HIV and hepatitis when they enter methadone treatment. Assessing patients for their medical and mental health needs is critical. Developing a system of referrals, cross-training medical and clinical staff, and working in cooperation with other health programs are highly beneficial.
Back to top
The challenges faced by MAT programs and clinics are not limited to accreditation and opening their doors for business. Stigma and discrimination against people in treatment and recovery, as well as the treatment centers themselves are other complicating factors.
This stigma can affect access to care for other serious health problems. For instance, opiate-dependent patients receiving opiate replacement therapy (e.g., MAT) are underrepresented in liver transplantation programs. Often this is because of requirements that state that methadone patients must stop MAT to be considered for a liver transplant. Yet, no evidence base supports the practice of discontinuing maintenance treatment for liver transplantation. Such a policy may induce relapse in formerly stable patients, and actually may disqualify these patients for surgery.
This illustrates the need for studies that identify factors affecting transplantation outcomes and that examine the effect of addiction treatment requirements3.
In order to educate the medical community about addiction treatment and what it means to be in recovery, SAMHSA began the Opioid Education Initiative. This initiative ensures that anyone with an interest in methadone and MAT recognizes that addiction can be a relapsing medical condition for which both proper treatment and a continuum of care are required. Through the initiative, methadone patient advocates and their organizations provide accurate information to other methadone patients, those who need to be educated about this issue, and those who affect the perceptions of the public—such as policymakers and the media. Such education can help change attitudes and break down barriers to understanding opioid addiction and dependency.
Back to top
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 publishes Treatment Improvement Protocols (TIPS) that discuss buprenorphine (TIP 40), methadone (TIP in draft), and their pain related treatment issues (TIP 20) in more detail. There are also Technical Assistance Publications (TAPS) available to provide guidance and information to professionals in the field involved with MAT delivery. You can obtain these and other TIPS and TAPS through NCADI or you can visit www.samhsa.gov.
For information about available buprenorphine physician training opportunities, call (866) BUP-CSAT (866-287-2728).
- 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 Institutes of Health. Consensus Statement. “Effective Medical Treatment of Opiate Addiction.” November 17–19, 1997. Vol. 15, No. 6. MD, 2003.
- Koch, H. and Bonys, P. (2001). Liver Transplantation and Opioid Dependence. JAMA 285(8): 1056–58.
- 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.
|
What You Should Know...
Medical professionals can provide care to individuals who receive MAT with methadone or buprenorphine, just as they would any other patient.
These medications, when taken appropriately, effectively treat opiate dependency—a condition now recognized as a neurochemical disorder. Thus, when treating MAT patients, it is important to be familiar with a patient’s maintenance dose of medication and to be in contact as necessary with physicians associated with the treatment program through which the patient receives his or her maintenance medication.
In providing care, non-narcotic analgesics should be used when pain is not severe. In the event of severe pain, the use of opioid agonist medications is appropriate. The dose of these medications, such as morphine, usually is increased to compensate for the opioid cross-tolerance established by methadone. Also, the duration of analgesia may be shorter than usual. Doses must be individually titrated to ensure adequate analgesia. Best results are obtained with a scheduled dosing opposed to pro re nata (PRN). Morphine may be required every 2 to 3 hours at whatever dose provides relief.
Partial-agonist and full-antagonist medications should never be used for MAT patients since severe withdrawal symptoms can be precipitated. Both propoxyphene and mepridine are known to produce central nervous system (CNS) excitatory metabolites and also should be avoided.
The administration of opioid-agonist drugs should be supervised closely in terms of quantities and duration. Prescribing for self-administration also should be carefully monitored.
To assure the best possible treatment for their patients, treatment program physicians often will draft a letter for their patients to share with other medical providers attesting to the foregoing information.
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 year4.
- 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 20025.
- 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 lifetimes1.
- 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 20021.
- 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 percent6.
- 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 percent6.
|
