The diversion of methadone from legitimate purposes has increased rapidly over the past decade. Methadone, when properly prescribed and used in accordance with doctors’ orders, is both an accepted treatment protocol for opioid addiction and an accepted treatment for pain management. Methadone that is diverted or abused contributes to dire, and many times fatal, consequences.
To address the mounting problem of methadone-related overdoses and deaths, Senate Resolution 135 of 2007 (P.N. 1163) directed the Joint State Government Commission to assemble an Advisory Committee to make recommendations to the General Assembly on how the diversion, misuse, and abuse of methadone can be reduced in the Commonwealth. Individuals with expertise in the medical and pharmaceutical, drug treatment, and criminal justice communities were included in the Advisory Committee. The Advisory Committee was divided into two subcommittees: Opioid Treatment Programs (OTP) and Physicians and Pain Management (PPM). This report is the product of the Advisory Committee’s input and expertise in the use of methadone for opioid addiction and pain management.
Though the topic of methadone is not without controversy, and certain issues that the Advisory Committee addressed remain unresolved in this report, common ground was found on some recommendations that were discussed. The Advisory Committee reached agreement on a number of recommendations which comprehensively cover the fields of methadone maintenance treatment (MMT) and pain management. They include topics relevant to both MMT and pain management settings, such as the induction period, adverse heart effects, the Commonwealth’s prescription monitoring program, diversion and theft, and death reviews. Recommendations are also targeted to address each subcommittee’s focus. For example, OTP recommendations relate to polysubstance abuse, counseling, clinic security, and parking lot security. Recommendations more specific to PPM relate to patient education, physician education, and protocols for prescribing methadone for pain management.
A recommendation to require that physicians provide Narcan, a drug commonly prescribed to forestall overdose, to all methadone patients is not recommended by the Advisory Committee as a body. Similarly, the Advisory Committee did not find agreement on whether or not regulations should be revised to increase counseling hours for certain patients.
The Advisory Committee sought to discuss as many issues as possible, in accordance with the Joint State Government Commission’s long-standing protocol to develop meaningful, useful consensus. Where the Advisory Committee did not reach consensus on recommendations perhaps opportunities exist to revisit those topics in future reports. Where the Advisory Committee did reach consensus on recommendations, legislators and policy makers will find the final report is a useful base of information on the diversion, misuse, and abuse of methadone.
The Advisory Committee makes the following recommendations:
Induction Period. The Advisory Committee recommends increased testing of new patients during the induction period.
Adverse Heart Effects. The Advisory Committee supports the continuing work of the Substance Abuse and Mental Health Services Administration (SAMHSA) with regard to methadone maintenance treatment and heart safety. This work is widely supported by the American Association for the Treatment of Opioid Dependence (AATOD), the Pennsylvania Association for the Treatment of Opioid Dependence, (PATOD), Save A Life, and the Drug and Alcohol Service Providers of Pennsylvania (DASPOP).
Polysubstance Abuse. The Advisory Committee recommends the development of special treatment protocols for patients with polysubstance abuse problems.
Prescription Monitoring Program. The Advisory Committee recommends that the General Assembly continue its dialogue regarding the prescription monitoring program to determine if it is achieving its goals.
Diversion and Theft. The Advisory Committee recommends that clinics maintain and continue to improve their theft and diversion policies and procedures.
Clinic Security. The Advisory Committee recommends clinics implement best practices to handle threats to clinic and patient safety.
Parking Lot Security. The Advisory Committee recommends that clinics employ security guards and install security cameras for parking lots and outside property.
Take-Home Doses. The Advisory Committee recommends that clinics implement best practices for patients’ take-home doses.
Diversion. The Advisory Committee recommends that in the OTP setting patients be observed taking the liquid dose and required to speak with the dosing nurse before and after receiving the dose. In the pain management setting, diversion is far harder to control and the physician community needs to establish best practices for noncompliant patients, and for prescribing and following up appropriately.
Methadone Incident and Death Reviews. The Advisory Committee recommends that the standardization of methadone incident and death reviews be made a priority across all delivery settings: OTPs, pain management clinics, and physician offices.
Physician Education. The Advisory Committee recommends that physician education be revised to include training in addiction and treatment.
Patient Education. The Advisory Committee recommends that patients prescribed methadone be educated about how to properly use the drug and what the major concerns are that accompany it.