Methadone Maintenance & Buprenorphine Therapy

(effectiveness of opiate dependence treatment) "Over the past two decades, clear and convincing evidence has been collected from multiple studies showing that effective treatment of opiate dependence markedly reduces the rates of criminal activity. Therefore, it is clear that significant amounts of crime perpetrated by opiate dependent persons are a direct consequence of untreated opiate dependence."

(opiate 'treatment gap') "NTPs (Narcotics Treatment Programs) are the most highly regulated form of medicine practiced in the US, as they are subject to Federal, State, and local regulation. Under this regulatory burden, expansion of this system has been static for many years. This has resulted in a 'treatment gap' which is defined as the difference between the number of opiate dependent persons and those in treatment. The gap currently is over 600,000 persons and represents 75-80% of all addicts."

(opiate treatment programs) "In order for a substance abuse treatment facility to use these opioid drugs in treatment, it must be certified as an Opioid Treatment Program (OTP).⁴ In addition, individual physicians may take specialized training as authorized under the Drug Addiction Treatment Act of 2000 to prescribe buprenorphine addiction products in their practices.⁵"

(medications to treat opiate addiction) "Medications to help prevent [opiate] relapse include:

"Methadone, which has been used for more than 30 years to treat heroin addiction. It is a synthetic opiate medication that binds to the same receptors as heroin; but when taken orally, as dispensed, it has a gradual onset of action and sustained effects, reducing the desire for other opioid drugs while preventing withdrawal symptoms. Properly prescribed methadone is not intoxicating or sedating, and its effects do not interfere with ordinary daily activities. At the present time, methadone is only available through specialized opiate treatment programs."

"Buprenorphine is a more recently approved treatment for heroin addiction (and other opiates). Compared with methadone, buprenorphine produces less risk for overdose and withdrawal effects and produces a lower level of physical dependence, so patients who discontinue the medication generally have fewer withdrawal symptoms than those who stop taking methadone. The development of buprenorphine and its authorized use in physicians’ offices give opiate-addicted patients more medical options and extend the reach of addiction medication."

"Naltrexone is approved for treating heroin addiction but has not been widely utilized due to poor patient compliance. This medication blocks opioids from binding to their receptors and thus prevents an addicted individual from feeling the effects of the drug. Naltrexone as a treatment for opioid addiction is usually prescribed in outpatient medical settings, although initiation of the treatment often begins after medical detoxification in a residential setting. To prevent withdrawal symptoms, individuals must be medically detoxified and opioid-free for several days before taking naltrexone. Naloxone is a shorter acting opioid receptor blocker, used to treat cases of overdose."

(methadone and buprenorphine/naloxone - HIV transmission) "The unparalleled international epidemic of injection drug use as a major cause of global HIV transmission, coupled with the research evidence supporting the efficacy of methadone treatment in decreasing drug injection and HIV transmission, and the unique pharmacological properties and potential acceptance of buprenorphine and the buprenorphine/naloxone combination, mean that the world is poised for implementation and evaluation of these treatments as a method to stem the spread of HIV."

(comparison - buprenorphine, levomethadyl acetate, and methadone) "As compared with patients taking low-dose methadone, those taking levomethadyl acetate had a significantly higher rate of continuous abstinence from opioids, and those taking high-dose methadone and buprenorphine had a trend toward a higher rate of continuous abstinence."

(comparison - buprenorphine, levomethadyl acetate, and methadone) "In summary, levomethadyl acetate, buprenorphine, and high-dose methadone were more effective than low-dose methadone in reducing the use of illicit opioids. As compared with low-dose methadone, levomethadyl acetate produced the longest duration of continuous abstinence; buprenorphine administered three times weekly was similar to levomethadyl acetate in terms of study retention and was similar to high-dose methadone in terms of abstinence."

(comparison - buprenorphine, levomethadyl acetate, and methadone) The New England Journal of Medicine published a study comparing methadone with LAAM [levomethadyl acetate] and buprenorphine. According to the report, "Most of the development and evaluation research on buprenorphine has been based on daily doses. Our study used thrice-weekly doses and found that outcomes were approximately equivalent to those with either daily methadone or thrice-weekly levomethadyl acetate. Thus, thrice-weekly buprenorphine may also offer greater convenience to patients and clinic staff."

(effectiveness of levomethadyl acetate, buprenorphine, and high-dose methadone treatment) The New England Journal of Medicine published a study comparing methadone with LAAM and buprenorphine. The authors concluded that "Levomethadyl acetate, buprenorphine, and high-dose methadone were all effective in treating opioid dependence and were were superior on multiple measures to low-dose methadone. The percentage of patients retained at 17 weeks compared favorably with rates reported elsewhere for these medications."

Buprenorphine (Subutex^® and Suboxone^®)

(buprenorphine - treatment locations and formulations) "Federal statute, the Drug Addiction Treatment Act of 2000 (DATA 2000), has established a new paradigm for the medication-assisted treatment of opioid addiction in the United States (Drug Addiction Treatment Act of 2000). Prior to the enactment of DATA 2000, the use of opioid medications to treat opioid addiction was permissible only in federally approved Opioid Treatment Programs (OTPs) (i.e., methadone clinics), and only with the Schedule II opioid medications methadone and levo-alpha-acetyl-methadol (LAAM), which could only be dispensed, not prescribed.* Now, under the provisions of DATA 2000, qualifying physicians in the medical office and other appropriate settings outside the OTP system may prescribe and/or dispense Schedule III, IV, and V opioid medications for the treatment of opioid addiction if such medications have been specifically approved by the Food and Drug Administration (FDA) for that indication. (The text of DATA 2000 can be viewed at http://www.buprenorphine.samhsa.gov/fulllaw.html.)

"In October 2002, FDA approved two sublingual formulations of the Schedule III opioid partial agonist medication buprenorphine for the treatment of opioid addiction. These medications, Subutex® (buprenorphine) and Suboxone® (buprenorphine/naloxone), are the first and, as of this writing, the only Schedule III, IV, or V medications to have received such FDA approval and, thus, to be eligible for use under DATA 2000."

(buprenorphine - forumulation) "Buprenorphine is a long-acting partial opioid agonist^91,92 that is classified as a Schedule III narcotic, in contrast to methadone and levomethadyl, which are Schedule II. Its potential advantages include a higher degree of safety than with methadone, coupled with an ameliorated withdrawal syndrome. This is due to its partial agonist property at the μ-receptor along with its being a weak antagonist at the k-receptor.^93-95 It is available in a tablet form for sublingual administration and in parenteral form. ... The brand name for the buprenorphine monotablet is Subutex, and the combination buprenorphine hydrochloride–naloxone hydrochloride tablet is Suboxone. ... Both formulations come in strengths of 2 and 8 mg. The combination product contains 0.5mg of the opioid antagonist naloxone hydrochloride and is designed to decrease the potential for abuse."

(buprenorphine - treatment goals and uses) "Buprenorphine can be used for either longterm maintenance or for medically supervised withdrawal (detoxification) from opioids. The preponderance of research evidence and clinical experience, however, indicates that opioid maintenance treatments have a much higher likelihood of long-term success than do any forms of withdrawal treatment. In any event, the immediate goals in starting buprenorphine should be stabilization of the patient and abstinence from illicit opioids, rather than any arbitrary or predetermined schedule of withdrawal from the prescribed medication."

(history - heroin treatment) "In the early part of the 20th century, physicians faced with persons addicted to narcotic drugs prescribed heroin and morphine. In 1914 the Harrison Act was passed, and as a result addiction was viewed primarily as a criminal problem rather than a medical concern. The Harrison Act resulted in significant trepidation among physicians treating narcotic addicts. Treatment for addiction was essentially unavailable until 1935 when US Public Health Services started a hospital in Lexington, Ky. The treatments were entirely detoxification-based. Interest in narcotic management began to rise again with the 1955 publication of a position paper by the New York Academy of Medicine.²⁸ In 1963, the New York Academy of Sciences recommended that clinics be established to dispense narcotics to opioid-dependent patients.²⁸

"During the 1960s, heroin addiction was the leading cause of death in African American men in New York City.²⁹ In response to this growing epidemic, Vincent Dole, MD, and Marie Nyswander, MD, from the Rockefeller Institute, New York, pioneered the use of the synthetic opioid methadone for treating heroin addicts. They found oral morphine to be unsuccessful because patients alternated between feelings of intoxication and withdrawal. Methadone, because of its long half-life, could avert this problem if given once daily.³⁰The initial efforts of these two physicians guided development of the methadone maintenance treatment paradigm.³¹

"In 1972, the US Food and Drug Administration created stringent regulations governing methadone. This reduced the amount of flexibility for practitioners caring for opioid dependent patients. The 1974 Narcotic Treatment Act established guidelines that limited methadone to opioid addicts. States added their own rules, which further complicated care delivery. Some experts have suggested that the current system emphasizes regulatory process more than medical judgment.³² In part because of these restrictions,many heroin addicts had limited access to methadone maintenance, resulting in a significant treatment gap nationwide.

"The Office of National Drug Control Policy subsequently made changes in the 1995 Federal Regulations of Methadone Treatment to encourage the development of a less restrictive approach³³ and give physicians more latitude in prescribing methadone.³⁴ In 1997 a National Institutes of Health consensus conference published its support for methadone and recommended the medicalization of treatment.³⁵"

(buprenorphine - clinical trials) "A number of clinical trials have established the effectiveness of buprenorphine for the maintenance treatment of opioid addiction. These have included studies that compared buprenorphine to placebo (Johnson et al. 1995; Ling et al. 1998; Fudala et al. 2003), as well as comparisons to methadone (e.g., Johnson et al. 1992; Ling et al. 1996; Pani et al. 2000; Petitjean et al. 2001; Schottenfeld et al. 1997; Strain et al. 1994a, 1994b) and to methadone and levo-alpha-acetyl-methadol (LAAM) (Johnson et al. 2000). Results from these studies suggest that buprenorphine in a dose range of 8–16 mg a day sublingually is as clinically effective as approximately 60 mg a day of oral methadone, although it is unlikely to be as effective as full therapeutic doses of methadone (e.g., 120 mg per day) in patients requiring higher levels of full agonist activity for effective treatment. "A meta-analysis comparing buprenorphine to methadone (Barnett et al. 2001) concluded that buprenorphine was more effective than 20–35 mg of methadone but did not have as robust an effect as 50–80 mg methadone -- much the same effects as the individual studies have concluded."

(buprenorphine in primary care offices) "This study has implications for future treatment of opioid dependence. First, the results support the feasibility of transferring stable patients from NTPs to the offices of trained primary care physicians and extends prior research inthis field.These findings, along with recent trials demonstrating the effectiveness of buprenorphine for untreated opioid-dependent patients in primary care settings, offer encouragement regarding the use of primary care offices to help expand access to treatment for opioid dependence."

(buprenorphine project in Copenhagen) The Danish National Board of Health reported in 2000 that "The Buprenorphine project was initiated in the City of Copenhagen during the autumn of 1998 and was evaluated this year. In conclusion the report points out that this type of substitution therapy is suitable for clients who have not previously been subjected to methadone treatment and which are resourceful. Furthermore, the report concluded that buprenorphine treatment may contribute by a significant percentage to the drug addict becoming drug-free and being able to revert to normal life through work, activation and education rather than any other kind of therapy.²⁰"

(buprenorphine - treatment and counseling) Researchers from Yale University "investigated the use of counseling and different frequencies of medication dispensing in primary care treatment with buprenorphine-naloxone. Neither the primary outcomes (the frequency of illicit opioid use, the percentage of opioid-negative urine specimens, and the maximum number of consecutive weeks of abstinence from illicit opioids) nor the proportion of patients who completed the study differed significantly among the three groups. Specifically, outcomes among patients receiving brief counseling combined with once-weekly medication dispensing did not differ significantly from outcomes among patients receiving either extended counseling or thrice-weekly medication dispensing ....

"Nonetheless, although we did not demonstrate the superiority of extended counseling or thrice-weekly medication dispensing over the relatively limited nurseadministered counseling and once-weekly dispensing, our findings support the feasibility of buprenorphine–naloxone maintenance in primary care."

(buprenorphine and naloxone combination) "Buprenorphine and naloxone in combination and buprenorphine alone are safe and reduce the use of opiates and the craving for opiates among opiate-addicted persons who receive these medications in an office-based setting."

Naloxone

(naloxone - profile) A Drug Profile for Naloxone HCl from the Arizona Department of Health Services describes the drug as a “narcotic (opioid) agonist” marketed under the name Narcan^®. Its "Mechanism of Action" includes: "Competitive inhibition at narcotic receptor sites" and "Reverses respiratory depression secondary to narcotics." Its adult dosages come in IV, intra-nasal, and continuous IV infusion forms. As an antidote to opioid overdose, Naloxone “Reverses respiratory depression secondary to narcotics.” Its "Adverse Reactions include "Withdrawal symptoms, especially in neonates (nausea, vomiting, diaphoresis, increased heart rate falling blood pressure, tremors). Be prepared for combative patient after administration."

Special Notes: "Opioid drugs include heroin, Dilaudid, morphine, meperidine, codeine, methadone, Lomotil, Darvon, Darvocet, Talwin and others. Large amounts of the drug may be needed for Darvon, Darvocet, and Methadone."

(overdose prevention with naloxone) "The heart of the challenge is the possibility that things could be different: overdose is a public health problem that can be solved. Unlike many of the other leading causes of death, death from opioid overdose is almost entirely preventable,²¹ and preventable at a low cost.²² Opioids kill by depressing respiration, a slow mode of death that leaves plenty of time for effective medical intervention.²³ Overdose is rapidly reversed by the administration of a safe and inexpensive drug called naloxone. Naloxone strips clean the brain’s opioid receptors and reverses the respiratory depression causing almost immediate withdrawal.²⁴ A growing number of harm reduction organizations in the United States are offering overdose prevention programs that provide injection drug users with resuscitation training and take-home doses of naloxone.²⁵"

(heroin - naloxone & overdose) "This pilot trial is the first in North America to prospectively evaluate a program of naloxone distribution to IDUs to prevent heroin overdose death. After an 8-hour training, our study participants' knowledge of heroin overdose prevention and management increased, and they reported successful resuscitations during 20 heroin overdose events. All victims were reported to have been unresponsive, cyanotic, or not breathing, but all survived. These findings suggest that IDUs can be trained to respond to heroin overdose by using CPR and naloxone, as others have reported. Moreover, we found no evidence of increases in drug use or heroin overdose in study participants. These data corroborate the findings of several feasibility studies recommending the prescription and distribution of naloxone to drug users to prevent fatal heroin overdose."

(prescription limitations on naloxone use) "A more prosaic, but no less important, legal barrier to widespread naloxone access is the Food and Drug Administration’s (FDA) classification of naloxone as a prescription drug. This means that public health and harm reduction agencies cannot distribute naloxone like condoms or sterile syringes. Instead, naloxone must be prescribed by a properly licensed health care provider after an individualized evaluation of the patient. Because health care providers have to be involved, naloxone programs must deal with concerns about liability, which among doctors can be powerful even when they are not wellfounded in fact.³¹ The prescription status raises the cost of naloxone distribution and makes it illegal to give naloxone to lay people willing to administer the drug to others suffering an overdose."

(naloxone for heroin overdose) "Heroin is particularly toxic because of high lipid solubility, which allows it to cross the blood–brain barrier within seconds and achieve high brain levels.¹⁰

"Naloxone is also lipid soluble and enters the brain rapidly. Reversal of respiratory depression is evident 3–4 minutes after IV and 5–6 minutes after subcutaneous administration.¹¹"

(naloxone to reduce mortality of heroin) Fear of official involvement may contribute to the problem of overdose deaths. According to research in Australia, "Our findings that an ambulance was called while the subject was still alive in only 10% of cases, and that a substantial minority of heroin users died alone, strongly suggest that education campaigns should also emphasise that it is safer to inject heroin in the company of others, and important to call for an ambulance early in the event of an overdose. Consideration should also be given to trialling the distribution of the opioid antagonist naloxone to users to reduce mortality from heroin use."

Levomethadyl (LAAM)

(levomethadyl - definition and dose) "Development of new opioid substitution pharmacotherapies, designed to build on the strengths and improve on the weakness of methadone, has resulted in 2 alternative opioid agonist agents, levomethadyl and buprenorphine. Levomethadyl, a more potent derivative of methadone, actually has very little opioid effect in its parent form and is functionally a 'prodrug.' ..."

"Because of this, methadone and levomethadyl when taken concurrently may have additive effects. Therefore, patients generally receive one or the other agent, but not a combination, for maintenance therapy.

"Levomethadyl is a synthetic μ-opioid receptor agonist that is commercially available in a liquid suspension. .... the opioid effect of levomethadyl is somewhat slower in onset than that of methadone (90 minutes), but it has a much longer duration of action (48-72 hours) and is therefore able to be dispensed 3 times per week .... Similar to methadone, it suppresses symptoms of withdrawal and produces cross-tolerance."

Methadone and Methadone Maintenance

(methadone - definition and dose) "Methadone is a long-acting μ-opioid receptor agonist, introduced in the 1960s, after being developed in Germany at the end of World War II.⁶⁰ It has an onset of action within 30 minutes^61-63 and an average duration of action of 24 to 36 hours. Its oral bioavailability is excellent and approaches 90%. These unique pharmacologic properties ideally lend themselves to once-daily dosing for maintenance therapy, although, when used to treat chronic pain, methadone is generally dosed 3 times daily. When the dosage is judiciously titrated, methadone treated patients generally do not experience euphoria or sedation, nor do they suffer impairment in the ability to perform mental tasks. One of the most important advantages of methadone is that it relieves narcotic craving, which is the primary reason for relapse. Similarly, methadone blocks many of the narcotic effects of heroin,⁶⁴ which helps reinforce abstinence. Once a therapeutic dose is achieved, patients frequently can be maintained for many years with the same dose.⁶⁵

"Methadone hydrochloride is available in 5- and 10-mg tablets as well as a 40-mg dispersible wafer. However, it is most frequently used for maintenance in a 10-mg/mL liquid concentrate. An intravenous solution is also available but has been linked with bradycardia when administered for sedation."

(methadone - duration and dosing) "Methadone's half-life is approximately 24 hours and leads to a long duration of action and once-a-day dosing. This feature, coupled with its slow onset of action, blunts its euphoric effect, making it unattractive as a principal drug of abuse."

(methadone - results of treatment) "Science-based methadone maintenance treatment [MMT] helps those addicted to opiates sustain their recovery. The result is less crime, fewer emergency room admissions, more citizens working, and less suffering for families and the community. More individuals contribute in taxes instead of costing in health or imprisonment."

(methadone - mortality) "Three primary scenarios characterize current reports of methadone-associated mortality:

"1. In the context of legitimate patient care, methadone accumulates to harmful serum levels during the first few days of treatment for addiction or pain (that is, the induction period before methadone steady state is achieved or tolerance develops).

"2. Illicitly obtained methadone is used by some individuals who have diminished or no tolerance to opioids and who may use excessive and/or repetitive doses in an attempt to achieve euphoric effects.

"3. Methadone - either licitly administered or illicitly obtained - is used in combination with other CNS depressant agents (such as benzodiazepines, alcohol, or other opioids)."

(methadone and Oxycontin - mortality) "The large contribution to mortality from oxycodone and methadone may be because of the long duration of action of methadone and OxyContin. Drug users may accidentally overdose by overlapping doses when the desired euphoric or analgesic effect is slow in coming. Abusers have learned to ingest and inject pulverized OxyContin pills, defeating the controlled-release mechanism and releasing dangerous amounts of the drug within a short time."

(methadone - diversion) "Taken together, the data confirm a correlation between increased methadone distribution through pharmacy channels and the rise in methadone-associated mortality. The data, thus, support the hypothesis that the growing use of oral methadone, prescribed and dispensed for the outpatient management of pain, explains the dramatic increases in methadone consumption and the growing availability of the drug for diversion to illicit use. Although the data remain incomplete, National Assessment meeting participants concurred that methadone tablets and/or diskettes distributed through channels other than OTPs most likely are the central factor in methadone-associated mortality."

(methadone - maintenance) "Of the various treatments available, Methadone Maintenance Treatment, combined with attention to medical, psychiatric and socioeconomic issues, as well as drug counseling, has the highest probability of being effective."

(methadone - maintenance) "Office-based methadone maintenance administered by appropriately trained primary care and specialist physicians has the potential to provide an alternative for selected patients to the current narcotic treatment system that would allow for greater physician involvement and perhaps increased quality of care. Potential benefits from this type of care include increased attention to comorbid medical and psychiatric conditions, decreased stigma associated with the diagnosis and treatment, decreased contact with active heroin users, and increased access to treatment. These benefits may increase patient satisfaction and enhance clinical outcomes."

methadone - maintenance) "Our results demonstrate that methadone maintenance using weekly physician office-based dispensing is feasible, that treatment retention and patient and clinician satisfaction are high, and that illicit drug use does not differ significantly compared with continued treatment in an NTP [narcotic treatment program]. Stable patients demonstrated high functional status and low levels of health and social service use on transfer from an NTP to office-based care. The high level of patient and clinician satisfaction with office-based care and the outcomes observed with office-based treatment run counter to concerns regarding the potential quality of this type of care and the ability to identify a group of physicians interested in providing treatment for opioid-dependent patients."

(methadone - maintenance) "MMT [methadone maintenance treatment] facilitates a process of gradual reduction in heroin use, reduction of syringe sliming and HIV risk, and reduction of criminal activities."

(methadone - maintenance, HIV, hepatitis, and crime) "Prolonged oral treatment with this medicine [methadone] diminishes and often eliminates opiate use, reduces transmission of many infections, including HIV and hepatitis B and C, and reduces criminal activity."

(methadone - maintenance and overdose) "Our results support the hypothesis that harm-reduction-based methadone maintenance treatment decreases the risk of natural-cause and overdose mortality. Furthermore, our data suggest that in harm- reduction-based methadone programs, being in methadone treatment is important in itself, independent of the pharmacologic effect of methadone dosage. To decrease mortality among drug users, prevention measures should be expanded for those who dropout of treatment."

(methadone - maintenance and HIV) "Methadone maintenance treatment (MMT) has been shown to improve life functioning and decrease heroin use; criminal behavior; drug use practices, such as needle sharing, that increase human immunodeficiency virus (HIV) risk; and HIV infection."

(methadone - maintenance) A study reported in the March 8, 2000 edition of the Journal of the American Medical Association showed that traditional methadone maintenance therapy (MMT) is superior to both short-term and long-term detoxification treatment as a method to treat heroin dependence, concluding, "Our results confirm the usefulness of MMT in reducing heroin use and HIV risk behaviors. Illicit opioid use continued in both groups, but frequency was reduced. Results do not provide support for diverting resources from MMT into longterm detoxification."

(methadone - maintenance) An editorial in the March 8, 2000, edition of The Journal of the American Medical Association states that following the Scottish example and allowing primary care physicians to dispense methadone "can provide a 3- to 5-fold increase in access. It can also reduce the cost per patient, although added access will clearly increase short-term substance abuse treatment costs while reducing long-term costs associated with overdose emergencies, HIV infection, and crime."

(methadone - maintenance) "The unnecessary regulations of methadone maintenance therapy and other long-acting opiate agonist treatment programs should be reduced, and coverage for these programs should be a required benefit in public and private insurance programs."

(methadone - maintenance) "The safety and efficacy of narcotic agonist (methadone) maintenance treatment has been unequivocally established."

(methadone - maintenance) According to the National Institutes of Health (NIH), "Methadone maintenance treatment is effective in reducing illicit opiate drug use, in reducing crime, in enhancing social productivity, and in reducing the spread of viral diseases such as AIDS and hepatitis."

(methadone - treatment goals) "Although a drug-free state represents an optimal treatment goal, research has demonstrated that this goal cannot be achieved or sustained by the majority of opiate-dependent people. However, other laudable treatment goals, including decreased drug use, reduced criminal activity, and gainful employment can be achieved by most MMT [methadone maintenance treatment] patients."

(methadone treatment - HIV and risk behaviors) "In summary, data from studies conducted in Australia, Europe, Asia and the United States have, with few exceptions, found strong associations between participation in methadone treatment and reductions in the frequency of opioid use, fewer injections and injection-related HIV risk behaviors, and lower rates of HIV prevalence and incidence. Few randomized controlled trials have been conducted due to ethical concerns regarding the random assignment of individuals to no treatment or other potentially less effective treatment modalities. Despite this fact, the consistency of findings from the observational and case–controlled studies cited here provide a preponderance of evidence suggesting that sustained treatment of opioid-dependent injection drug users with methadone is associated strongly with protection from HIV infection."

Methadone Maintenance & Buprenorphine Therapy - Data

(2008 - methadone or buprenorphine client types) "On the survey date of March 31, 2008, the following numbers of clients received either methadone or buprenorphine dispensed by facilities that offered OTPs [Opioid Treatment Programs]:
● 268,071 clients received methadone
● 4,280 clients received buprenorphine

"Of these, 255,850 clients were in an outpatient methadone/buprenorphine maintenance program.

"On March 31, 2008, OTPs were serving the following clients:
● 266,236 outpatient methadone clients
● 1,001 residential methadone clients
● 834 hospital inpatient methadone clients
● 3,955 outpatient buprenorphine clients
● 131 residential buprenorphine clients
● 194 hospital inpatient buprenorphine clients"

(2008 - treatment, fees, and insurance) "Substance abuse treatment facilities can accept various types of client payment or insurance for substance abuse treatment. Of the facilities with OTPs [Opiod Treatment Programs]:

● 6 (1 percent) offered free treatment to all clients—no payments accepted
● 1,086 (97 percent) accepted cash or self-payment
● 549 (50 percent) accepted private health insurance
● 711 (64 percent) accepted Medicaid
● 333 (30 percent) accepted Medicare
● 362 (34 percent) accepted State-financed health insurance
● 201 (19 percent) accepted Federal military insurance
● 578 (51 percent) offered a sliding fee scale
● 378 (34 percent) offered free treatment for those clients who could not afford to pay
● 487 (45 percent) had agreements or contracts with managed care organizations for providing substance abuse treatment services

"In addition to types of client payment, 526 (47 percent) facilities with OTPs received funding or grants from the Federal, State, or county or local governments to support their substance abuse programs. This funding did not include Medicare, Medicaid, or Federal military insurance."

(2008 methadone maintenance facilities) "Methadone or buprenorphine may be used for maintenance or detoxification in the treatment of opioid addiction. OTP [Opioid Treatment Program] Only facilities were more likely than OTP Mixed facilities to offer methadone maintenance (and not offer buprenorphine maintenance) (72.3 vs. 53.1 percent) and less likely to offer both methadone maintenance and buprenorphine maintenance (27.7 vs. 44.7 percent). Just 2.2 percent (11 facilities) in the OTP Mixed group offered buprenorphine maintenance without also offering methadone maintenance."

"OTP Only facilities were more likely than their counterparts to be operated by a private organization (92.9 vs. 83.3 percent). However, OTP Only facilities were more likely to be operated by private for-profit organizations (60.0 percent) than private non-profit organizations (32.9 percent), while OTP Mixed facilities were equally likely to be operated by private for-profit (41.7 percent) or private non-profit organizations (41.6 percent). Relatively few OTPs were operated by public entities (7.1 vs. 16.7 percent for OTP Only and OTP Mixed facilities, respectively)."

(1999 - treatment for opioid dependence) "The current narcotic treatment system is able to provide the most effective medical treatment for opioid dependence, opioid agonist maintenance, to only 170,000 of the estimated 810,000 opioid-dependent individuals in the United States."

(1997 - financial cost of opiate dependence) "The financial costs of untreated opiate dependence to the individual, the family, and society are estimated to be approximately $20 billion per year."

Methadone Maintenance & Buprenorphine Therapy - Law and Policy

(opioid treatment restrictions) "The marginalization of medical care for opioid dependence and the stigma attached to this diagnosis and methadone maintenance treatment play an important role in untreated opioid dependence. Current federal regulations restrict the care of opioid-dependent patients to federally licensed narcotic treatment programs (NTPs) with little to no involvement by community-based physicians. Recent calls from federal and scientific bodies, including the Institute of Medicine, a National Institutes of Health consensus panel, and the Office of National Drug Control Policy, have recommended restructuring the regulatory processes involved in the treatment of opioid-dependent patients, including increased involvement of primary care physicians."

(politics of opioid treatment) "The wide international variation in the availability of opioid agonist treatment for opioid-dependent injection drug users, despite documented scientific evidence in support of its efficacy, highlights the impact of political and philosophical forces that determine the availability of this treatment. Few proven therapies for medical conditions are restricted in this fashion. Therefore, efforts to address the political and philosophical opposition to opioid agonist treatment are needed to meet the global needs to prevent HIV transmission."

(policy - methadone maintenance) In November 1997, the National Institutes of Health (NIH) convened a Consensus Panel on Effective Medical Treatment of Heroin Addiction. The panel of national experts concluded:

"• Vigorous and effective leadership is needed within the Office of National Drug Control Policy (ONDCP) (and related Federal and State agencies) to inform the public that dependence is a medical disorder that can be effectively treated with significant benefits for the patient and society.

"• Society must make a commitment to offering effective treatment for opiate dependence to all who need it.

"• The panel calls attention to the need for opiate-dependent persons under legal supervision to have access to MMT [methadone maintenance treatment]. The ONDCP and the U.S. Department of Justice should implement this recommendation.

"• The panel recommends improved training of physicians and other health care professionals in diagnosis and treatment of opiate dependence. For example, we encourage the National Institute on Drug Abuse and other agencies to provide funds to improve training for diagnosis and treatment of opiate dependence in medical schools.

"• The panel recommends that unnecessary regulation of MMT and all long-acting agonist treatment programs be reduced.

"• Funding for MMT should be increased.

"• We advocate MMT as a benefit in public and private insurance programs, with parity of coverage for all medical and mental disorders.

"• We recommend targeting opiate-dependent pregnant women for MMT.

"• MMT must be culturally sensitive to enhance a favorable outcome for participating African American and Hispanic persons.

"• Patients, underrepresented minorities, and consumers should be included in bodies charged with policy development guiding opiate dependence treatment.

"• We recommend expanding the availability of opiate agonist treatment in those States and programs where this treatment option is currently unavailable."