Opioid Use and Dependence - how widespread is it?

Heroin

	According to the Office of National Drug Control Policy, in the year 2000, there were more than 977,000 heroin dependent individuals in the United States. Drug Enforcement Administration data indicate that heroin is increasingly available at purer levels throughout the nation. The U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration's 2001 National Household Survey on Drug Abuse reports that during the 1990's, heroin incidence rates rose to a level not reached since the 1970's. The survey shows that an estimated 146,000 persons used heroin for the first time in 2000.
	In 2001, for the first tome since SAMHSA's Drug Abuse Warning Network (DAWN) data have been collected, the number of mentions of narcotic analgesics in emergency departments (approximately 99,000) exceeded the number of heroin mentions (approximately 93,000). These data point to the fact that many prescription opioid drugs are now being abused by large numbers of people and are leading to a large number of emergency department admissions.
	In 2001, there were 638,484 emergency department visits related to drug abuse, or 252 visits per 100,000 population. Heroin accounted for 37 visits per 100,000 or 15 percent of the total emergency visits nationwide. From 1994 to 2001, emergency department mentions regarding heroin increased 47 percent according to 2001 DAWN data.
	Heroin treatment admission rates between 1992 and 2000 increased by more than 100 percent in 18 states. In 1992, no state had a rate higher than 250 per 100,000 population; by 2000 seven states had surpassed that rate, according tot eh 2000 Treatment Episode Data Set (TEDS).

Prescription Opioids

Evidence from around the country suggests that a significant percentage of patients in methadone programs are being treated for prescription opioid dependence. For example, Alaska estimates that there are 15,000 prescription opioid abusers in the state and that most methadone patients are not heroin-addicted individuals. One opioid treatment programs in southwest Virginia reported that 80 percent of the 290 people in outpatient treatment with methadone named OxyContin® as their primary drug of abuse. According to SAMHSA's Center for Substance Abuse Treatment, in 2001, emergency department mentions of narcotic analegics and narcotic analgesic combinations were the most frequently mentioned in drug-related emergency department visits in 2001, constituting 9 percent of all emergency room mentions (99,317). Mentions of these narcotic analgesics and combinations rose 44 percent from 1999 to 2001 and 21 percent from 2000 to 2001. Significant long-term increased in emergency department mentions of narcotic analgesics and combinations were found for hydrocodone and its combinations (up 131 percent since 1994), methadone (up 230 percent), morphine and its combinations (up 210 percent), oxycodone and its combinations (up 352 percent) and narcotic analgesics that were not specified (up 288 percent). One year, from 2000 to 2001, methadone mentions increased by 37 percent and oxycondone and its combinations rose 70 percent. Unspecified narcotic analgesics rose 24 percent. Mentions of analgesics containing hydrocodone were statistically unchanged from 2000 to 2001, but were 41 percent higher than in 1999.

Opiate Use and Addiction - How is it treated?
A variety of treatments are available for heroin abuse and dependence:

	Long- or short-terms residential treatment in a therapeutic community involving counseling in a highly structured residential environment.
	Outpatient programs emphasizing a range of behavioral counseling and psychotherapy.
	Medication assisted treatment that uses agonist or partial agonist medication such as methadone, LAAM or buprenorphine to normalize brain chemistry, block the euphoric effects of opioids and relieve physiological cravings and normalize body functions.
	Use of opioid antagonists, such as natrexone, to block the effects of opioid drugs; often used to prevent relapse to opioid use in highly selected populations.

While not considered formal treatment, self-help fellowships, such as Narcotics Anonymous and Methadone Anonymous, that utilize the "self-help" approach to abstinence can be used.

Methadone Treatment

Methadone treatment provides the patient who is opioid dependent with medication, health, social and rehabilitation services that relieve withdrawal symptoms, reduce physiological cravings and allow normalization of the body's functions. Methadone treatment has been available for over 30 years and has been confirmed effective for opioid dependence in numerous scientific studies.

Moreover, in 1997, the U.S. Department of Health and Human Services' National Institutes of Health (NIH) Consensus Panel found the following concerning methadone treatment: "Of various treatments available, methadone maintenance treatment, combined with attention to medical, psychiatric and socio-economic issues, as well as drug counseling, has the highest probability of being effective."

Methadone treatment programs are staffed by professionals with medical, clinical and administrative expertise. Patients receive medication from a health professional. Patients routinely meet with a primary counselor (social worker, caseworker or certified substance abuse counselor), attend clinic groups and access medical and social services.

Methadone is not a Substitution of One Drug for Another

Methadone is not a substitute for opioids or any other short-acting opioid, and does not affect individuals in the same way. Methadone does not create a pleasurable or euphoric feeling; rather it relieves physiological opioid craving and is generally chosen by
Opioid-dependent individuals. Methadone normalizes the body's metabolic and hormonal functioning that was impaired by the use of heroin or other opioids. It is a corrective, not curative, treatment. Unlike the disruptive nature of short-acting chemicals on the brain, methadone has long-acting properties that provide metabolic stability. For example, methadone creates the physical stability that allows female menses to return to normal cycle after its disruption from heroin use. Methadone allows embryos and fetuses to develop a safe and stable metabolic environment instead of experiencing withdrawal from heroin every six hours due to mother's use.

Absence of Serious Adverse Effects

When taken as prescribes, long-term administration of methadone causes no adverse effects to the heart, lungs, liver, kidneys, blood, bones, brain or other vital body organs. Some side effects arise, such as constipation, water, retention, drowsiness, skin rash, excessive sweating and reported change in sexual drive. These may occur during the initial changes of treatment. These symptoms generally subside or disappear as methadone dosage is adjusted and stabilized, or when simple medication interventions are initiated. The myth that methadone rots the bones and teeth and is otherwise physically harmful has been shown to be scientifically unfounded. LAAM a long-acting agonist medication, has been associated with cardiac irregularities.

Medication Interactions

Patients on methadone can be treated with most medications without serious interactions or contraindications. For example, patients with conditions such as hypertension, diabetes, pneumonia, cardiac conditions, cancers, psychiatric disorders, etc. may be treated effectively with routine regimens and medications. However, as with any medication, treatment program physicians must be aware of all other medications that their patients are taking. Coordination of methadone with certain other medications is necessary. For example, certain medications used to treat HIV/AIDS, epilepsy, tuberculosis, and hepatitis C may prompt the need for the program physician to change the medication dose level. Medications such as dilantin for epilepsy and rifiampin for tuberculosis increase the body's metabolism of methadone and, thus, prompt the need for an adjustment in the methadone dose or possibly splitting the dose to be taken twice daily instead of once. Therefore, it is very important that all physicians (primary care provider, surgeon, methadone treatment program physician, ect.) be aware of each other's involvement with the patient.

Use of Pain Medication with Methadone Patients

Methadone patients, at all dose levels, experience normal pain and, therefore, need analgesia following surgical procedures or any other painful medical or dental procedures. Pain management, which may also include medication, is required for chronic malignant and nonmalignant pain. Methadone maintenance should be continued without lowering the maintenance dose. Opioids such as morphine, oxycodone, and pain-control analgesia (PCA) and even methadone itself can be used to treat methadone patients. However, because of their tolerance to opioids, methadone patients possibly will require higher doses of opioids and at more frequent intervals.

When prescribing methadone as a pain medication, the regular maintenance dose should be maintained and the methadone used for analgesia should be prescribed separately three to four times per day, since methadone's analgesic properties last only four to six hours. Methadone patients should not be prescribed medications for pain that contain opioid antagonists since the antagonists will precipitate withdrawal. According to the NIH Consensus Panel Report, methadone patients can be safely prescribed as both opioid and non-opioid analgesics without antagonist properties.

Methadone Treatment Truths

Cost Effectiveness

Methadone treatment is an effective contributor to the reduction of the economic and social burdens linked to opioid use. Most methadone maintained patients are able to secure and maintain gainful employment, remain free of illicit or inappropriate use of opioids, improve health and reduce the risk of exposure to HIV/AIDS.

Methadone treatment has positive outcomes for the individual and for the community. It has been found to be highly cost-effective. The Institute of Medicine in its 1995 report concluded the "methadone maintenance pays for itself on the day it is delivered, and post-treatment effects are an economic bonus."

Reduction in Heroin and Other Opioid Use

Methadone treatment dramatically reduces opioid use after admission to methadone treatment and further declines as patients remain in treatment. SAMHSA's Services Research and Outcomes Study (SROS) validated these findings in 1998. The study found that clients in methadone facilities composed the only group showing a significant decrease in heroin use (21 percent decline). Additional outcome follow-up from the California Drug and Alcohol Treatment Assessment (CALDATA), and the National Treatment Improvement Evaluation Study (NTIES) and Drug Abuse Treatment Outcome Study (DATOS), compiled by Gerstein and Johnson of the National Opinion Research Center (NORC) in 1999, found a 39 percent, 51 percent and 69 percent reduction in heroin use respectively.

Reduction in Criminality

Methadone treatment is associated with reduced criminal activity. Decreases in criminal behavior are greater the longer a person is in treatment.

Reduction of Risk of HIV/AIDS and Hepatitis

The relationship between intravenous (IV) drug use, needle sharing, hepatitis and HIV/AIDS exposure is well documented. Higher-dose methadone treatment
(over 80 mgs) is the most effective intervention for reducing the spread of HIV/AIDS and hepatitis, according to the Mount Sinai Journal of Medicine.

Buprenorphine

The Drug Addiction Treatment Act of 2000 (DATA 2000) permits physicians who are specially trained and meet specific qualifications to prescribe certain Food and Drug Administration (FDA) approved scheduled narcotic medications for the treatment of narcotic medications to be approved by the FDA. DATA 2000 requires the physician to complete a special training course or hold a sub-specialty board certification from either the American Board of Medical Specialties or the American Osteopathic Association or certification from the American Society of Addiction Medicine (ASAM). Additionally, DATA 2000 requires physicians to submit a notification for a waiver from the special registration requirements in the Controlled Substances Act for the provision of medication assisted opioid therapy. This waiver allows qualifying physicians to practice medication assisted opioid addiction therapy with specially FDA-approved narcotic medications for up to 30 patients.

Subutex® (buprenorphine hydrochloride) and Suboxone® (buprenorphine hydrochloride with naloxone hydrochloride) were approved by the Food and Drug Administration on October 8, 2002, for the treatment of opioid dependence. These medications currently are being marketed as sublingual (SL) tablets. Buprenorphine medications will be available through specially trained physicians and opioid treatment programs for the treatment of opioid dependence. Research studies show this medication is similar to methadone in its ability to stabilize functioning so patients can participate in comprehensive treatment for their opioid dependence, according to Schottenfeld, R.S., et al.

In addition to drugs like heroin, addiction to prescription pain relievers like oxycodone, hydrocodone and codeine are also treated with new buprenorphine medications. Like methadone, buprenorphine suppresses withdrawal symptoms and blocks the effects of there opioids. A doctor who is qualified can determine if buprenorphine is an appropriate choice of treatment medications for a patient addicted to prescription pain relievers.

People can transfer from methadone to buprenorphine therapy, but because the two medications are different, patients need to be educated by their treatment provider or physician in the effects of, and differences between, agonist (methadone) and partial antagonist (buprenorphine) type drugs. A number of factors affect if buprenorphine is a good choice for someone who is currently in methadone treatment. It is also possible for patients on buprenorphine to be transferred to methadone therapy. Patients interested in learning more about the possibilities of transferring therapies should discuss this with the doctor who is prescribing their medication.

The Food and Drug Adminstration's New Drug Application Labeling states that patients who are methadone maintained and are considering transferring to buprenorphine as a maintenance medication would need to be at a dose of 30 mgs or less to make the transition safely. This is to reduce the interaction of the agonist medication (methadone) with the partial antagonist medication (buprenorphine), The likelihood of developing withdrawal symptoms during the transition increases proportionately with doses above 30 mgs of methadone.

For additional information, please see the chart as the end of this fact sheet, call 1-800-BUP-CSAT or visit the official website at www.buprenorphine.samhsa.gov.

Agonist - Partial Agonist - Antagonist Chart
Click here download the chart.

References
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network. Washington, D.C. 2000 and 2001.

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set, Washington, D.C, 2001.

U.S. Department of Health and Human Services, National Institutes of Health Consensus Panel Report, 1997, Washington, D.C., 1997.

Institute of Medicine, Federal Regulations of Methadone Treatment. Rettig RA, Yarmolinsky A, editors. Washington, D.C.: National Academy Press; 1995.

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Services Research and Outcomes Study (SROS). Analytic Series: A-5, Washington, D.C., 1998.

Joseph Herman et al. Methadone Maintenance Treatment (MMT): A Review of Historical and Clinical Issues. Mount Sinai Journal of Medicine 67 (5) (October - November 2000).

Schottenfeldm R.S., et al, 1997. Buprenorphine Versus Methadone Maintenance for Concurrent Opioid Dependence and Cocaine Abuse. Archives of General Psychiatry 54(8): 713-720.

U.S. Department of Health and Human Services, Food and Drug Administration, New Drug Application Labeling, ND 20, 732, p. 23.