Important Considerations

The addictions treatment field can now offer a choice of medications and treatment approaches to patients seeking help for an opioid problem. These developments have made medication-assisted treatment accessible to more individuals, but also raise a number of important issues that treatment providers must consider. The Learn More sections below introduce some of them and provide links to more in-depth information.

Learn more

Workforce Development

Medication-assisted treatment is now considered the standard of care for opioid dependency. SAMHSA supports dissemination of best practice information through a training collaborative led by the American Academy of Addiction Psychiatry, along with several partners. The Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT) offers a variety of professional development resources, including web-based trainings, professional mentoring opportunities, and a library of practice guidelines. The collaborative also coordinates a Providers’ Clinical Support System-Opioids. Recent webinar topics have included medication-assisted treatment with veterans and active duty military, community overdose prevention with naloxone, and clinically significant medication interactions in opioid agonist treatment. Archived presentations and a calendar of upcoming events are available.

Diversion

Methadone and buprenorphine are the only medications approved in the United States for opioid replacement therapy. They are both controlled substances, and therefore have the potential for diversion and abuse. Methadone has the higher abuse potential, but has been used safely for many years to treat opioid use disorder. Methadone treatment programs are closely monitored, and maintain strict controls to prevent diversion. However, over the last several years, fatalities involving methadone have increased dramatically. Many of the deaths have been among patients taking methadone for pain management. According to the National Drug Intelligence Center, far more fatalities involve methadone diverted from hospitals, pharmacies, and pain management physicians, than from opioid treatment programs.

Emergency room visits due to buprenorphine abuse have increased four-fold in recent years. Most fatalities have involved poly-substance abuse of buprenorphine with other central nervous system depressants. Buprenorphine diversion is a significant problem in correctional facilities, especially the sublingual film form which is easily concealed. The Drug Enforcement Administration reports that seizures of diverted buprenorphine have included both products approved for addiction treatment and those used in pain management.

Harm Reduction

Harm reduction can include HIV risk reduction measures, overdose prevention programs, and syringe replacement. Harm reduction principles stress accepting individuals and their decisions about drug use and increasing safety by reducing high risk behaviors. Research shows some harm reduction measures have demonstrated public health benefits. New policies promote effective harm reduction programs, such as naloxone access, to reduce overdose and lifting the ban on Federal funding for syringe replacement programs.

The Office of National Drug Control Policy (ONDCP) has adopted the Principles of Modern Drug Policy. These principles were developed by the United Nations, and guide global efforts to reduce drug use and its consequences. To learn more about harm reduction, visit the Harm Reduction Coalition Online Training Institute, which offers training materials, professional development courses, and archived webinars.

For links to more information on U.S. drug control policy, see Provider Resources.

Overdose Prevention

The Centers for Disease Control and Prevention (CDC) reports that overdose is the leading cause of accidental death in the U.S., exceeding motor vehicle fatalities. The rates of death due to opioid analgesics have nearly doubled over the last decade. Prolonged opioid use leads to physiological tolerance requiring larger and more frequent doses to achieve an effect. After a period of abstinence, tolerance decreases and dosages that once were tolerated may become dangerous. Some populations are at particularly high risk for overdose. For example, studies in Washington State indicate an offender’s risk of death from drug overdose in the first two weeks post-release is between 40 and 129 times higher than the rate of the general population.

The Substance Abuse and Mental Health Services Administration developed the Opioid Overdose Prevention Toolkit that offers information on policies and practices that can reduce opioid-related fatalities. The toolkit encourages providers, persons at high risk, family members, and others to learn how to prevent and manage opioid overdose. The Centers for Disease Control also offers consumer information, safety tips, fact sheets, and instructions for safe storage of prescribed medications. The National Prescription Drug Take Back Days encourage safe disposal of leftover prescribed medications and have resulted in the collection and destruction of many tons of medications from more than 5,000 collection sites nationwide. The U.S. Department of Justice has more information on National Prescription Drug Take Back Days.

For more information on overdose prevention, see the Online Resources.

Naloxone Programs

In 2014, the U.S. Food and Drug Administration approved a hand-held Naloxone auto-injector that can be used by family members or others for emergency treatment of a person known or suspected to have had an opioid overdose.

Naloxone is an opioid blocker that can reverse the onset of respiratory failure in overdose victims, and halt other fatal effects. In addition to training first responders to administer naloxone, many programs teach potential overdose witnesses to recognize signs and administer naloxone. Programs have trained parents of drug users, people leaving prison, and people in methadone maintenance programs. Yale University researchers found that people who use drugs can learn to identify and respond to opioid overdoses as effectively as medical professionals.

Several states have enacted “Good Samaritan” laws that protect people from drug possession charges when they seek help for an overdose, or for someone in danger of overdosing. Some states have laws that also protect prescribers and people who administer naloxone to prevent an overdose. The Office of National Drug Control Policy (ONDCP) has developed a national map that indicates which states have laws pertaining to the use of naloxone for overdose prevention.

For more information on overdose prevention, see the Online Resources.

Prescription Drug Monitoring Programs

Prescription drug monitoring programs (PDMPs) have been authorized by 48 states to help combat increasing rates of opioid analgesic prescription drug misuse and diversion of controlled substances. Each state develops and maintains an electronic database that tracks and monitors prescribing information when a controlled substance is dispensed.

The information collected varies by state, but typically includes the date, patient’s name, address, gender, and date of birth. Data also identifies the prescriber, pharmacist, medication, and quantity. Authorized enforcement professionals can identify and investigate suspicious prescriber habits. Providers may check PMDPs when patients begin medication-assisted treatment to reduce the risk of medication interactions.

Patients should be informed about Prescription Drug Monitoring Programs, the information that is collected, and which authorities can access the information. Providers and prescribers can become familiar with their obligations regarding PDMPs at Prescription Drug Monitoring Programs: What You Need to Know in 2014.

For links to more information on PDMPs, see the Provider Resources.

Confidentiality

Clinicians are bound by multiple confidentiality mandates and are responsible for ensuring patient privacy. Some community treatment providers have started to check state prescription drug monitoring programs (PDMPs) for a list of controlled drugs the patient may have been receiving prior to beginning medication-assisted treatment. If medication misuse and drug interactions appear to be a risk, the provider can educate and work with the patient on establishing a safe treatment plan before medication induction begins. Patients receiving prescriptions for controlled substances that are monitored by the state PDMPs should be informed that this information is monitored, collected, and accessible to approved authorities.

Medication Interactions

Interactions between drugs used to treat addictions and other prescribed medications are common, may be clinically significant, and can increase the risk of overdose fatality, especially in patients receiving methadone. In some cases dosage adjustments of one or both medications or consideration of an alternative medication may be necessary.

Medication interactions occur with drugs that are used to treat conditions that commonly co-occur with opioid dependency, such as HIV/AIDS and mental health disorders, but have also been reported with antibiotics, blood pressure medications, other commonly prescribed medications, some over-the-counter preparations, and alternative remedies. In about half of reported methadone fatalities benzodiazepines are present, making both medical and non-medical use high risk.

For links to more information and medication interaction checkers, see the Online Resources.