Frequently Asked Questions (FAQ's):
Medication-Assisted Treatment
for Opiate Addiction
June 1, 2008
By: Suzanne Gelber, MSW, Ph.D., Managing Partner, The Avisa Group
 Download PDF Version here.
I have heard that overdoses, poisoning and deaths from narcotic medications including methadone that is also used in medication-assisted treatment for opiod dependence, are occurring and increasing Is that true? If so, what does it mean for clients in methadone treatment clinics?
It is true that overdoses, poisoning and deaths that involve (but are not necessarily due to) methadone and other prescribed narcotics such as the painkiller oxycodone have increased nationally and have been described as increases of almost epidemic proportions, when all opiod analgesics are considered (USDHHS/SAMHSA 2007, Shields et. al, 2007, Baker and Jenkins, 2008, Paulozzi and Budnitz, 2006)). However, these deaths must be understood in the context of the surging deaths from all prescribed opiates. Deaths from opiates have increased as sales have escalated, largely due to their increasing use in pain management. Deaths from methadone alone have shadowed its use as a pain prescription, rather than as an opiate treatment medication (Paulozzi and Budnitz, 2006).
Methadone is a powerful synthetic opiate that is effective and safe when used in strict accordance with federally sanctioned, evidence-based guidelines for opiate dependence treatment or for pain control. Unfortunately, according to SAMHSA 2007, “… many health professionals, patients, and members of the public do not understand the dangers of using methadone in ways that do not conform to evidence-based guidelines” (USDHHS/SAMHSA, 2007). Like other narcotics such as oxycodone, methadone can be toxic or lethal to those who have not developed adequate tolerance to it; those who take it at inappropriately high doses, especially including during the early stages of methadone treatment; and those who mix it with prescribed or abused sedatives or other drugs, Such use can more often occur in non-treatment medical practice that is not conducted according to clinical guidelines or when methadone is diverted to improper use by those who unintentionally or intentionally abuse it, often with other drugs (National Institute on Drug Aabuse, Part B_Question1) .
Most of the increasing methadone overdose deaths being reported, however, do not involve patients who are undergoing treatment in approved methadone clinics. People who abuse methadone and other drugs—or those who are beginning or continuing methadone treatment—may have serious or fatal health problems. These include cardiovascular or liver disease or dependence on multiple drugs that interact with opiate dependence and abuse. These conditions may predispose both abusers and those in methadone treatment to illnesses, early mortality and vulnerability to overdose. Researchers report that far more narcotic overdose deaths occur due to prescribed or diverted opiates or involve those who abuse multiple substances than occur among those who take methadone in the course of treatment.
A small number of methadone clients in legitimate treatment programs do overdose and die. Fatal overdoses among methadone clinic treatment patients typically are complicated by or due to health problems or involve multiple drug use (opposed solely to acute methadone intoxication itself) (USDHHS/SAMHSA 2007). In Texas, for example, 22 of the of 89 deaths among methadone treatment program clients in 2006, were due to cardiovascular causes, 14 were drug overdoses, 13 were due to liver disease and 13 deaths were from unknown causes. Of the 14 drug overdoses among methadone clients, seven (50 percent) involved overdoses of multiple drugs—including sedatives, cocaine, antidepressants and alcohol—that methadone users are instructed to avoid because they can be fatal when combined with methadone; five were from acute methadone intoxication, one was from cocaine and one was unknown (Maxwell and Dart, 2007). Of the clients with reported overdose deaths, five of the 14 methadone treatment patients had been in programs for less than three weeks. The Texas Poison Control Center, which has the state’s only reliable information on the type of methadone used prior to overdose or death, reported that most of the poisoning calls involved methadone in pill wafer form, which is not used in methadone treatment clinics. The clinics use liquid only; pills and other forms of methadone, such as wafers, are used by pain clinics.
Deaths and overdoses from all narcotics including methadone and buprenorphine, among other prescribed opiate medications (USDHHS/SAMHSA, 2007), have increased substantially since 1999 (National Drug Intelligence Center, 2007). They will continue to occur and increase because they are more often being prescribed or diverted, and they are powerful and dangerous chemicals when not administered properly. In addition, their use for pain patients is substantially increasing the supply, which can lead to greater risk of diversion and overdose. Among these opiate medications, buprenorphine is most rarely listed as the cause of overdose poisoning.
Depending upon which part of the United States is the focus for state policymakers, poisoning deaths due to opiates—primarily those prescribed for pain, including methadone for pain rather than opiate dependence—may be greater or fewer than those attributable to other abusable substances such as methamphetamine, cocaine, heroin or alcohol poisoning. Most of the overdose or poisoning deaths are more likely to occur with street use when the drugs are diverted or stolen, or occur due to lax prescriber dosing and patient monitoring. As one would expect, such adverse events are much less likely to occur among individuals who are enrolled in methadone clinics or who receive Suboxone ® (buprenorphine mixed with naloxone) from specially qualified private physicians.
In 2005, poisoning from any substance was the second leading cause of injury death in the United States, and most poisoning deaths were unintentional drug overdoses. Both legally prescribed and illegally obtained narcotics played a major role in these statistics. (Fingerhut, 2008)
It also is important to note that, compared to overdose and death rates from heroin among individuals who are not receiving either methadone or buprenorphine treatment, overdoses and deaths from methadone are far fewer than those from unregulated, illegal use of heroin (Zanis and Woody, 1998). Buprenorphine has somewhat less potential for abuse and overdose than methadone due to its pharmaceutical properties. Studies for the U.S. Food and Drug Administration (FDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) by the manufacturer of buprenorphine (Reckitt Benckiser) indicate that most of the relatively few buprenorphine deaths to date have been, like methadone treatment deaths, among individuals who were taking other drugs that were dangerous in combination with buprenorphine.
What approaches and tools do policymakers have to stem the increase in opiod-related deaths and overdoses?
Policymakers first need to obtain timely and accurate federal and state/local data on all narcotic medication overdoses and deaths within a two- or three-year period.
They also need to know the extent to which prescribed narcotics used to treat opiod dependence, opposed to other medications, are considered the official cause of death and are not merely present among other drugs taken by that person.
Opioid-related overdoses and deaths can result if patients or street users take advantage of irregular or uninformed physician prescribing practices. This behavior can be changed by funding increased supervision, certification, training, dosage guidelines (such as those used in Washington and by SAMHSA), tightened state audit and licensure investigation requirements, and/or state prescription opiate monitoring programs (PMPs).
Deaths or overdoses also can occur if these medications are diverted from the patient to someone else, such as a friend or family member. A strong but simple public communication effort can deter such diversion. that uses all culturally relevant media; by enhanced patient education and supervision about risks and deterrents; by state prescriber and dosage monitoring to eliminate excess medication or doses; or by some other means, such as local efforts to identify and address possible narcotic supply or storage theft.
To obtain information, policymakers can monitor the 2008 National Drug Threat Assessment (www.usdoz.gov/dea/concern/18862/appenda.htm). This site examines the United States by region and reports which drugs of abuse and illegal suppliers are emerging in specific areas and the extent to which these areas differ from the norm nationwide. For example, the current report indicates that, in the Western Region (Denver, Salt Lake City and environs), retail thefts of opioid pharmaceuticals drugs (some used to treat opioid dependence) have increased substantially since 2004 in metropolitan areas. The Drug Enforcement Agency reports that thefts in these areas were 50 percent higher in each of the last two years. In this case, enforcement and better distributor and retail supply chain management and security clearly have a role, since drugs often are reported to be stolen from pharmacies; drug warehouses; distribution, warehouse or delivery trucks; or hospitals, physicians’ offices or pain clinics and then diverted to the illegal market.
Unnecessary opiate deaths and overdoses also can result from street users’ lack of information or emerging preferences for certain drugs, from dramatic increases in drug purity, and from the pharmaceutical effects of opiate and medication mixes—such as sedatives and sleeping pills, marijuana and/or alcohol. Policymakers need to understand that it may not be possible to determine which of several discovered causes is the most important determining factor in an observed rise in methadone deaths or overdoses in their location. They may have to use a range of tools to address the situation and change the approach to fit trends they carefully monitor.
How are methadone and buprenorphine being diverted from treatment to abuse that can lead to dependence, overdose and even death? What can policymakers do?
Accurate data on these phenomena are difficult to obtain because such diversion is underground and illegal. By interviewing users, however, it is possible to study how prescription opioids and methadone are being diverted. For example, Inciardi (Inciardi, 2007) and a team in Florida found that, according to street opiate users, sources of abused prescription opioids and methadone were varied. For example, sources of abused opiates currently reported in Miami included friends and acquaintances, street sellers, corrupt physicians and pharmacists, pharmacy and hospital theft, sales in nightclubs, opiate supplies left over from legitimate prescriptions, residential burglaries, pharmacy robberies, underground flyers with dealers’ phone numbers, and theft from medicine cabinets. Surreptitious purchase on the Internet was low on the list of sources reported in Miami.
Carrieri and colleagues (Carrieri et al, 2006) show that in France, which has the longest and most extensive history of buprenorphine treatment, buprenorphine diversion appears to be associated with inadequate dosages, the social networks and vulnerabilities of patients, and patients' ability to obtain multiple prescriptions from various prescribing physicians. In the United States, new data are emerging. Earlier U.S. data indicated that the then-rare phenomenon of buprenorphine diversion involved patients who reported giving or selling buprenorphine to friends who wanted to try treatment without supervision or who wanted to stave off withdrawal symptoms without going to a physician or treatment program. (Center for Substance Abuse Treatment, 2006.) Recent newspaper and other media reports indicate state-level diversion and abuse of buprenorphine in Maine; Maryland/Baltimore; the New York metropolitan area, including New Jersey; Florida; and other states. Clearly, diversion of buprenorphine, as with methadone, can lead to overdose or even death, especially if other medications that are contraindicated—such as benzodiazepines—are used at the same time.
Law enforcement agencies and the criminal justice system clearly have a role to play to interrupt street purchases and identify and address addiction to opiates in those who are arrested and incarcerated (not merely to force arrestees to withdraw without access to treatment with opiate dependence medications). However, using law enforcement as the sole approach is not likely to be effective or a good use of taxpayer funds. Multiple interventions are needed.
State policymakers have a responsibility and an opportunity to adequately fund accountable, quality-oriented, medication-assisted narcotic treatment programs and outpatient physician practices. Patients who are dependent on narcotics rarely can kick their habits over the long-term without formal treatment and may be at risk of death if they attempt to do so outside of evidence-based clinical practice. Opiate-dependent clients may enroll in treatment when they wish to reduce the size and expense of their habit or to free themselves from their illegal habit. Policymakers can publicize appropriate state and federal treatment websites and initiatives to address addiction.
The roles of opiate treatment programs and prescribing physicians are at least equal to that of the criminal justice system. They can provide addicts with access to long-proven approaches to help them redirect their undesirable behavior over the long-term.
Can opiate/methadone overdoses and poisoning deaths—whether due to street drugs or drugs obtained from clinics, family or friends, pharmacies or elsewhere—be prevented?
In addition to the tools mentioned above, lawmakers can mandate that physicians and treatment programs that prescribe to opiate dependent people circulate and use updated opiate prescribing guidelines and monitor patients' use of the drugs.
Physicians and policymakers can work closely with state prescription drug monitoring programs to reduce or eliminate excess off-label prescribing of opiates.
Lawmakers can work with the media to inform the public about drug-related issues:
• Friends do not supply friends with opiates even when they ask for them for pain;
• Methadone and other opiate overdoses and deaths are increasing needlessly;
• Overdoses and deaths burden the private and public health care systems; and
• Obtaining treatment is more effective than using emergency rooms, jails or cemeteries to address out-of-control dependence on methadone or other opiates.
NOTES
Baker, D.D., and A.J. and Jenkins. “A comparison of methadone, oxycodone, and hydrocone-related deaths in Northeast Ohio." J Anal Toxicol 32, no. 2 (March 2008): 165-71.
Carrieri et al “Buprenorphine use: the international experience,” Clinical Infectious Disease 43 (Dec. 15, 2006) Suppl 4: S197-215
Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration. The Determinations Report: A Report on the Physician Waiver Program Established by the Drug Addiction Treatment Act of 2000 (“DATA”) March 2006 http://buprenorphine.samhsa.gov/SAMHSA_Determinations_Report.pdf
Fingerhut, Lois. Increases in Poisoning and Methadone Related Deaths: United States, 1999-2005. Washington, D.C.: National Center for Health Statistics, Office of Analysis and Epidemiology, Centers for Disease Control, 2008, http://www.cdc.gov/nchs/products/pubs/pubd/hestats/poisoning/poisoning.htm#figure1
Inciardi, P. “Mechanisms of prescription drug diversion among drug-involved club- and street-based populations” Pain Med. 8, no 2 (March 2007): 171-83
Maxwell, Jane C., and Richard C. Dart. Increases in Methadone-Related Adverse Events: Is it pills or liquid? PLACE: PUBLISHER, DATE.
National Drug Intelligence Center. Methadone Diversion, Abuse, and Misuse (Document ID: 2007-Q0317-001 Government Publications Office, Washington, D.C.
National Drug Intelligence Center “Methadone Diversion, Abuse and Misuse” November 2007 http://www.usdoj.gov/ndic/pubs25/25930/index.htm
National Institute on Drug Abuse. Methadone Research Web Guide, Part B: 20, Questions and Answers Regarding Methadone Maintenance Treatment Research, http://international.drugabuse.gov/collaboration/guide_methadone.
National Institute on Drug Abuse http://international.drugabuse.gov/collaboration/guide_methadone/partb_question1.html
Paulozzi, L.J., and S. Budnitz. ”Increasing Deaths from Opiod analgesics in the United States." Pharmacoepidemiol Drug Saf, 15, no. 9 (2006): 628-31. 632-34.
Shields, L.B. et al. “Methadone toxicity fatalities: a review of medical examiner cases in a large metropolitan area." J Forensic Sci 52, no. 6 (November 2007): 1389-95.
USDHHS/SAMHSA. Summary Report of the Meeting: Methadone Mortality—A Reassessment. Washington, D.C.: PUBLISHER, July 20, 2007.
Zanis, DA and Woody, GE “One-year mortality rates following methadone discharge. Drug and Alcohol Dependence 1998; 52:257-60
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