Federal Regulation of Methadone Treatment (1995) / Chapter Skim
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Methadone Diversion Control
Methadone Diversion Control
Pages 92-119
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From page 92... ...
The discussion addresses the following topics:the early concern over diversion and its impact on the development of methadone regulations and legislation, official views on methadone diversion, the available data on diversion, the methods of methadone diversion, the characteristics and motivations of users of street methadone, the public safety and health consequences of diversion, and conclusions and recommendations. EARLY CONCERN OVER DIVERSION The concept of opiate substitution therapy using methadone in the treatment of opiate dependence was a radical break with the established approach to narcotics control in the United States, an approach that had been enforced by the Federal Bureau of Narcotics (FBN)
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From page 93... ...
In addition, in the early 1970s, a number of cities, particularly those on the East Coast, experienced a decline in heroin supplies, owing to a combination of enforcement efforts arid dock strikes; the relative scarcity of heroin stimulated the market demand for illicit methadone as a substitute for heroin. The Bureau of Narcotics and Dangerous Drugs (BNDD, successor to the FEN, FDA, and the Special Action Office for Drug Abuse Prevention developed regulations for the operation of methadone programs primarily in order to control the problem of diversion.
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From page 94... ...
Eighty-seven percent of these addicts reported that they had been offered the opportunity to purchase illicit methadone at least once in the past six months; 55 percent had actually purchased diverted methadone during this period. Thirteen percent had sold i' 1 ·11 '~ .
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From page 95... ...
collected data on drug "mentions" from a variety of sources, including hospital emergency rooms and inpatient facilities, student health centers, county medical examiners and coroners, and community drug crisis centers; later, DAWN reports were limited to hospital emergency rooms and medical examiners. (Briefly, "mentions" refer to medical examiner report that a descendent tested positive for a particular substance.
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From page 96... ...
addressed the two main sources of methadone diversion, namely, practitioners and patients. First, the act required that practitioners who wished to dispense narcotics drugs for maintenance treatment or detoxification needed to obtain a separate registration from the Attorney General; it also specified that such registration could be suspended for failure to comply with the treatment standards established by the Secretary of Health, Education, and Welfare (now Health and Human Services)
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From page 97... ...
Only a minority of respondents reported that they used the drug "to get high." (See chapter 2 for a discussion of the methadone "high.") The studies did find that law enforcement officials, at both federal and local levels, placed a low priority on diverted methadone relative to their enforcement efforts against other illicit drugs.
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From page 98... ...
Perspective of the Drug Enforcement Administration The Drug Enforcement Administration has responsibility, under the Controlled Substances Act of 1970 and the Narcotic Addict Treatment Act of 1974, for preventing the diversion and abuse of methadone by establishing and monitoring security and record-keeping procedures for licensed methadone programs. DEA continues to maintain BNDD's earlier concern over the potential for methadone diversion.
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From page 99... ...
Second, and more pertinent to diversion, methadone patients who continue to use other illicit drugs have an incentive to sell their methadone to purchase other drugs; thus, in DEA's view, methadone programs that fail to address other drug use may, in effect, be subsidizing drug abuse. According to Eugene Haislip, Deputy Assistant Administrator for Diversion Control of DEA, the failure by programs to address other drug use creates "little incentive for an individual to become drug free because their steady supply of methadone provides them with a constant source of illicit income with which to purchase other drugs, primarily cocaine.
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From page 100... ...
This section offers information from a variety of data sources as a preliminary answer to that question. Drug Abuse Warning Network Data One of the main sources relied upon by DEA to document the extent of diversion is the methadone "mentions" in the Drug Abuse Warning Network (DAWN)
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From page 101... ...
The main implication of this discussion is that existing medical examiner data, as reflected in DAWN, most likely overcount the number of drug-related deaths in DAWN reporting cities that can be attributed solely to methadone or to which methadone would be contributing. The difficulty in accurately interpreting DAWN medical examiner data is highlighted by two surveys conducted by Gottschalk and his colleagues (Gottschalk et al., 1979; Gottschalk and Cravey, 1980)
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From page 102... ...
from January 1, 1987, through December 31, 1992. They analyzed data from four sources: Harris County medical examiner data, methadone maintenance treatment data, review by three independent pathologists, and DAWN medical examiner data.
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From page 103... ...
Drug Abuse Warning Network (DAWN) Medical Examiner Data The CDC researchers drew on DAWN data to investigate trends in methadone and heroin/morphine mentions in reports of drug-abuse deaths from 7 Some of these 60 decedents might have been enrolled in one of three clinics that were closed in March and April 1992, whose records were not available to CDC investigators.
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From page 104... ...
Other Data on Diversion DEA cites DAWN data in support of its view that a significant amount of the available methadone produced each year is diverted and that street methadone is a major drug of abuse. In a table prepared by DEA using 1991 DAWN data, methadone ranked twentieth out of the top 20 controlled substances in terms of drug mentions at hospital emergency rooms.
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From page 105... ...
Interviews with ER staff at one of the major DAWN reporting hospitals indicated that overdoses from methadone alone were rare; methadone mentions most often occurred in patients enrolled in methadone maintenance treatment who were being seen in the emergency room for diseases or other effects associated with drug abuse (National Institute on Drug Abuse, 1989~. 9 The calculation is as follows: (1,800 kg)
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From page 106... ...
. For instance, in 1992, street methadone use was reported by 5 percent or fewer of female booked arresters in all but 6 of the 21 cities that interviewed females (the exceptions being New York (Manhattan)
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From page 108... ...
In all DUF cities and among both men and women, current dependence on street methadone was reported to be less than 1 percent. Arrestees may underreport their use of illicit drugs; these low rates of selfreported concurrent use of illicit methadone, however, were supported by results of voluntary urine tests.
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From page 109... ...
Initial interviews were conducted with 43,443 injection drug users and with 9,791 sex partners. (The NADR public use data tape and documentation were provided by Richard Needle, Ph.D., M.P.H., Community Research Branch, National Institute on Drug Abuse.
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From page 110... ...
Such estimates would be useful in assessing the degree of harm that diverted methadone might be causing.
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From page 111... ...
The rarity of thefts of substantial amounts of methadone has led federal drug enforcement officials to conclude that the traditional sources of illicit drugs smuggling from other countries, domestic illicit manufacture, and distribution by organized crime—play little or no role in the marketing of street methadone. Sale by Patients: Who Sells and Why?
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From page 112... ...
Over half of the sample of heroin users not currently in treatment reported that they used illicit methadone in the week before the interview, 60 percent of these to eliminate withdrawal symptoms, and the remainder to get "high." The researchers identified a number of reasons for using street methadone: · To substitute for heroin when heroin supplies are low, when prices are high, or when it is inconvenient or difficult to contact a dealer; · To avoid formal treatment when wishing to withdraw from heroin or to create an unsupervised program; |3 As an example of the effect of program policy, in one city illicit supplies of methadone increased when a program dismissed many of its maintenance patients for nonpayment of fees. Presumably, this group increased demand for illegal methadone.
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From page 113... ...
There is no information on the degree to which methadone is implicated in drug-related crime or how much police effort is devoted to the prevention of its diversion. The lack of such information suggests that diverted methadone plays a small part in the overall drug-crime problem and receives a low priority in law enforcement efforts.
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From page 114... ...
While methadone has a high addiction liability, instances of primary methadone addiction are few. Thus, while some street methadone is abused, it constitutes a relatively small part of the drug abuse problem generally.
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From page 115... ...
Rather, it has mainly served as a way to avoid or end withdrawal symptoms, as a form of self-treatment for heroin addiction, or as a substitute for heroin or other opiates when they are in short supply. How much medical harm does diverted methadone do?
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From page 116... ...
This belief rests on limited data and thus the committee recommends careful monitoring of effects of the suggested changes with a plan to act quickly to reinstate restrictions if diversion becomes a major health problem. Further, the committee concludes that the risks to the public safety and the public health of diverted methadone do not outweigh the benefits of making methadone treatment more readily available.
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From page 117... ...
In 1991, a reported rise in the number of methadone-related deaths in Harris County led to increased scrutiny by authorities over local methadone treatment programs. Most methadone treatment programs in Houston and the surrounding areas are private, and forprofit, having been developed to fill the void left when local government abandoned the service delivery of methadone treatment.
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From page 118... ...
1976. More Effective Action Needed to Control Abuse and Diversion in Methadone Treatment Programs: Food and Drug Administration, Department of Health, Education and Welfare, Drug Enforcement Administration, Department of Justice.
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From page 119... ...
Eff cacy of Drug Abuse Treatment Programs. Hearings, July 25, August 2, 1989.
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