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Methadone and Buprenorphine 101: A Guide for Law Enforcement

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Lately, with all the talk about rising rates of opioid use and addiction, we are hearing more about opioid treatment programs (OTPs). OTPs provide opioid-dependent patients with behavioral therapy and medication, such as methadone or Suboxone (buprenorphine), sometimes called medication assisted therapy, (MAT), to control cravings for illicit opioids and help them resume normal lives. Although opioid treatment programs have been around for decades with verified results, information about these programs can be confusing for members of law enforcement and communities. Do these medications cause driving impairment? How do OTPs affect the criminal justice system? What safeguards are in place to prevent abuse?

To get some answers, I spoke with Tad Clodfelter, PsyD, President and CEO of SouthLight Healthcare in Raleigh, North Carolina. SouthLight provides behavioral health care and treatment for addiction and mental illness, including methadone and buprenorphine (Suboxone) treatment for opioid dependence. Here are some of his answers to law enforcement FAQs on opioid treatment programs.

What are OTPs?

Opioid treatment programs (OTPs) combine behavioral care services with the delivery of medications that help control cravings for opioids. OTPs are the only FDA recommended treatment for opioid dependence. They are historically equated with methadone treatment, but over the past 5-10 years these programs have evolved to include other methods of medication assisted treatment (MAT), such as Suboxone (buprenorphine).

What is the difference between methadone and Suboxone?

Suboxone and Methadone are both synthetic opioids and used to treat patients with opioid dependency or addiction; however, they are not necessarily used interchangeably, and there are differences in their effects. Methadone is a full opioid agonist, which means it binds to opioid receptors in the brain to take away the physiological cravings for opioid drugs and abuse, allowing the person to function well in their day-to-day lives without being intoxicated, hold down a job and reclaim their families. Methadone is typically given to persons with heavy opiate habits. Suboxone is a partial agonist that affords similar results, also allowing people to resume normal lives. Different people respond better to one versus the other of these effective medications.

Can OTP medications be abused?

Methadone and Suboxone can be abused and diverted, but are far less likely to be than street opioids or prescription pain medications. OTPs have tight restrictions to limit the likelihood of diversion. SouthLight has a good track record of preventing abuse, as do many reputable clinics.

What are the safeguards in place to prevent diversion and abuse?

At Suboxone clinics the staff do pill counts. Sometimes they have patients come back to the clinic and bring in their pills, which are counted to make sure the patient hasn't taken more than their prescribed dose. With methadone, the patients come to the treatment facility daily to receive their dose under staff supervision. Once they have demonstrated commitment to the program and established a good track record, they earn the privilege of taking home medication in a locked box. The person is mandated to return the medication any time there is any suspicion or concern that they might be abusing it. OTPs check for suspicious behavior using urine drug testing, observing any changes in behavior, and checking the Controlled Substance Reporting System to see if the person might be getting other prescriptions from doctors that might be a concern. A person can qualify for take-home doses after 3 months, but that privilege can be taken away for noncompliance.

Do OTP medications cause driving impairment?

Not when taken as prescribed. Someone leaving a methadone or Suboxone clinic who has just taken their normal dose should not have trouble driving. In a clinic setting, patients are observed closely. A patient is not allowed to leave the clinic if a concern, i.e., intoxication, ever exists.

Do OTPs just substitute one addiction for another?

No. Methadone or Suboxone is essential in opioid treatment. These medications, in combination with evidence-based behavioral therapies, are the FDA-recommended standards of care for opioid dependence. In essence, medication assisted therapy substitutes a controlled synthetic opiate for opiate drugs of abuse. The scientific, medical literature is clear in recommending these treatments for opioid dependence. Why? Sustained or long-term opiate use chemically alters the brain and negatively impacts the sensitivity of the body's opioid receptors. In order to begin the recovery process from opioid addiction, medication assisted or replacement therapy is critical to healing the brain and body. Further, the number of opioid dependent persons who can successfully quit drug use "cold turkey" is extremely low due to intense cravings and withdrawal symptoms, which are part of the opioid dependence syndrome. MAT is used to sustain a person and prevent relapse as well.

At SouthLight Healthcare, we serve 400 people at any given time and have a good track record of solid results during and after treatment. The standard of care works very well if treatment regimens are adhered to by patients. Of course, treatment doesn't work flawlessly in every case, but neither does treatment for any chronic, relapsing disease, which substance dependence is. As such, opioid dependence, like other chronic, relapsing medical disorders, requires a combination of treatments, including medication and behavioral modification or change, in order to achieve impactful and sustained treatment results.

What are some of the benefits of OTPs for patients and the community?

OTPs benefit the communities they serve in tremendous and deep reaching ways, many of which are below the radar. They are real and tangible. The vast majority of our clients are in the workforce with documented jobs, paying taxes and giving back to the community. When people are in treatment and stable and reclaiming or simply living their lives, jobs and families, they are less likely to encounter the criminal justice system. That is a major cost savings to society. Our jails are filled with people who are addicted or mentally ill or both; many have committed nonviolent crimes. Such citizens are better served by treatment, which helps them to mend relationships and realize professional goals - the things that makes life worth living.

The Centers for Disease Control (CDC) lists the following benefits of methadone treatment (MMT):

• reduced or stopped use of injection drugs;
• reduced risk of overdose and of acquiring or transmitting diseases such as HIV, hepatitis B or C, bacterial infections, endocarditis, soft tissue infections, thrombophlebitis, tuberculosis, and STDs;
• reduced mortality - the median death rate of opiate-dependent individuals in MMT is 30 percent of the rate of those not in MMT;
• possible reduction in sexual risk behaviors, although evidence on this point is conflicting;
• reduced criminal activity;
• improved family stability and employment potential; and
• improved pregnancy outcomes.

Cost savings
• the annual costs of methadone maintenance treatment are much lower than the annual costs of either untreated heroin use, incarceration or drug-free treatment programs
• criminal activities related to heroin use resulted in social costs that were four times higher than the cost of methadone maintenance treatment;
• for every dollar spent on methadone maintenance treatment there is a savings to the community of between US$4-$13.