that had been used that someone was addicted to. like, if you were using heroin perhaps you would need another dose of heroin every 4 to 5 hours to avoid going into withdrawal, just simply to keep from getting sick, whereas if you were on methadone it would last more than 24 hours. so it would level it out; you wouldn't get the high or the euphoria that you got with heroin, but it would prevent the withdrawal so that you could begin to normalize your life and get back into employment and improve your family situation; quit having to steal to support your habit. and dr. clark, if an individual was going to be using a medication-assisted therapy to really overcome their addiction, if they decided to really relapse, or if they relapse, what would happen to that individual under these medications? well i think the most important thing is that the individual has engaged either a clinic or practitioner who has some

understanding of the substance use disorder process. a person who has a slip, nothing may happen. a person who is actively using other substances, say a person's on methadone and is actively using heroin, that's something that would have to be addressed in the clinic situation because you risk overdose. and one of the things the clinic would want to do is to try to figure out what is behind the slip, if you will. so the first thing to do is to discuss what's going on in your life with your clinic counselor and/or doctor, or if you're on buprenorphine, with your physician so that you can alter your dose if appropriate, add another medication depending on what's going on -'cause we have to remember co-recurring disorders,

there are other things that go on in people's lives other than the drug of abuse. so what we want is to have this addressed on a case-by-case basis, taking into consideration everything that's going on in a person's life. yes. mark, let's talk a little bit. are medication-assisted therapies regulated in any way? they're highly regulated in the united states as opposed to abroad. and the current regulations governing method of treatment programs are otps are under the ages of hhs, samhsa, csat. and in this regard, these regulations have been in effect since 2001 through an accreditation mechanism. and ultimately every one of the license and approved treatment programs has to go through one of the accreditation surveys in order to continue operations. and in this sense they follow fairly stringent guidelines, not only at the federal level but at the state level also. in this area of medication and medicine you have

federal regulations and you have state regulations in place, and sometimes the state regulations can be even more stringent than in the federal regulations. and dr. clark, let's talk a little bit about those federal regulations. you are the director of the center for substance abuse treatment which has the oversight function for methadone and some of the other medication-assisted therapies. specifically, what does the federal ggovernment do in the oversight process? well we certify opiod treatment programs with regard to methadone used primarily. we also register or provide waivers to the controlled substances act for physicians who want to use buprenorphine. but let's focus on the accreditation process. we rely on a peer review process that's facilitated by accrediting bodies like jcaho or carve, so that they would visit clinics periodically depending upon their accreditation;

either 1 year if you have a temporary accreditation or every 3 years, if you have a long-term accreditation. and they would judge the program based on clinical standards and guidelines which we promulgate and which they use to gauge what's going on at the clinic. that allows us to maintain a certain level of scrutiny on one hand, but also provides feedback to the program as to what is expected of them and how they can best provide quality care to the clients. after they receive their certification, their accreditation, we then certify the programs based on the accrediting body's recommendation. very good. lisa, are there any provisions for patient/clients that use methadone and medication-assisted therapies in these regulations? methadone comes with a whole system, a whole program system that dictates how much take home

and how many times a client has to come into treatment, how often they have to give urinalysis, submit to urinalysis and those sort of things. so methadone in a maintenance regime, especially, would be subject to a lot of regulation. the buprenorphine's available through physician, in- and out-patient setting. so that is not attached to a whole system. and the other medications are usually available as adjuncts and components to full, you would hope, a full continuum of other treatment services. they're not entire treatment magic bullets in and of themselves, and i think that's one of the distortions of information that we have out there. jane, and that's really what i'm getting at is really

if a client or patient goes in. it's really the medication-assisted therapy in and of itself, it's not a self-contained component as lisa was mentioning. but really the patient should be aware that they need also behavioral health interventions and counseling, is that correct? it's just a piece of the treatment. as one counselor said, it relieves the itch or scratches the itch. but you need the counseling, you need the vocational services, the housing services, family counseling. and a lot of these clients also need some good mental health services as well as physical services because they've lived a hard life. so the methadone is really a means to help them attain abstinence and to attain a complete recovery. dr. clark, in the optimum context of addiction treatment, when does a client find him or herself an appropriate candidate

for medication-assisted therapy? i think the most important thing is that if you have a drug problem, particularly an opius with regard to opioid treatment programs, what you should do is go to a program and talk to an intake counselor where they will review your history. now with regard to other substances like alcohol, the same thing applies. you're talking to your clinicians so that your history is reviewed, your symptoms are reviewed, the cravings that you have, the withdrawals symptoms, if that's applicable, that you have, the length of time that you were on the medication- all of these things need to be evaluated. and then the clinician will decide whether you're a suitable candidate for methadone if it's an opioid treatment program; buprenorphine if it's an outpatient physician,

naltrexone or camprosate if you're concerned about alcohol. very good. when we come back i want to get into the issues of methadone, specifically, because there is some new developments that have been occurring around the use of methadone in this country. and we'll be right back. what is the cost of drug and alcohol addiction? i lost my job. i lost my home. i lost my health. i lost my self-respect. i lost my freedom. if you have a drug or alcohol problem, remember, treatment is effective and recovery is possible. for information on drug and alcohol treatment referral for you or someone you know, call 1-800-662-help, and see what you could save. i got my life back. mornings used to be the toughest. before i got treatment for my addiction, it was the little things that were hardest to bear but

now that i'm free of drugs and alcohol it's the little things that give me the most joy. recovery-it gave me back my life. now i can give back. for drug and alcohol treatment referral for you or someone you know, call 1-800-662-help. [music] i went back to a treatment that i had known that had given me some relief and that was methadone just because i couldn't-i just couldn't be an active addict anymore. [music] at brandywine counseling, we are a full-service outpatient substance abuse agency. we provide opioid treatment for individuals addicted to opiates.

once we are convinced of someone using daily for a year, we will often prescribe methadone. in some cases we may attempt to use buprenorphine. this is a patient who was prescribed for instance percocets, oxycodones, oxycontins in the use of buprenorphine, which has the advantage of removing clinical size withdrawal faster. the disadvantage is it's 10 times as expensive as methadone. it was a miracle, just believe that. it was a miracle, 'cause if i wouldn't got on meth i think i would've been dead by now. as a matter of fact, no, i know i would be dead right now. when you look at cost benefit factors, the drug itself is relatively inexpensive.

annually it's about $4,500, $4,600. it cost about $26,000, $27,000 annually to hold someone in prison in most states. if you can get a person in treatment for methadone, we're talking a third of that. i can sleep normally, i can eat, which is a big thing. when you're on heroin you don't do those things, you know. your life revolves around the drug. this time the methadone, you know, made me normal pretty much where i could function, i could work, i could be a mom. it saved my life; it did. as a person obtains periods of sobriety, starting with 90-day intervals, the first 90 days of what we call negative drug screenings for illicit drugs, they're able to get one take-home bottle. well you have to stay clean; you have to give clean urines. you can't use and get it.

i come like three times a week. i get travels during the weekends; during the week day i get a take-home they call it, you know. all together i get four take-homes. years ago, out of 100 heroin-addicted individuals we saw a success rate of about 10 out of 100. today out of 100 individuals receiving medication-assisted treatment (inaud.) and methadone and rivetter , we're seeing 30 to 40 percent success rate. recovery is possible. medication-assisted treatment is the way to go for individuals addicted to opiates. now we have to use the skill, the knowledge, the science that we have now to treat our clients in the most effective efficient way, and that's what we do here at

brandywine counseling every day. mark, let's go back and start specifically now with methadone. what is methadone, and is it the most widely used medication-assisted therapy? this medication was developed in the 1940s, but first used in the united states during the 1950s as a means of withdrawing federal inmates who happened to be in jail. and they found later on through subsequent studies this was an excellent medication to maintain an individual on. and this was through the rockefeller university studies in the 1960s. it then got very widely promulgated as an effective medicine to treat addiction, narcotic addiction in particular. it does one thing particularly well, and there is an enormous scientific studies and history about the values of this medication. it's a medication. it's combined with other treatment resources

to holistically respond to an individual patient's needs. and the whole mark of treatment when it's effectively administered tends to these broad range of the needs of the individual patient. it is effective and it is safe when it's in the hands of knowledgeable practitioners. i think, an important thing that mark points out is that you need an array of interventions, but you need practitioners who know what they're doing. but such a similar thing can be said for diabetes, for hypertension, cholesterol, for cardiovascular conditions, for almost any medical condition where medication is employed. the medication plays a critical role in the treatment of the disease, but you need other things to help address the condition when you see that, in terms of adherence, compliance, and a healthy lifestyle. well jane, recently we have heard in the news that there is a higher incidence of deaths attributed to methadone.

is that the full picture? no. what is actually happening is that in the past few years there has been a shift for pain patients with intractable pain from other drugs to methadone. and they're being prescribed for the most part to 5- and 10-milligram pills which are not used in narcotic treatment programs. and we've seen a large increase in the amount of these pills that are going to market that are being prescribed and being used. but if the patient doesn't understand the dangers of using the pills, using it inappropriately, if the doctor's not prescribing it correctly then there can be serious adverse events. now what i can see from the texas data, i've seen yes, an increase in methadone deaths. but the number of deaths of patients in methadone treatment programs has actually gone down. it clearly is the pain pills.

it's not the liquid that's used in the methadone treatment programs. so there's a real need to separate out the liquid and what happens in narcotic treatment programs versus the pills that are being used for people with cancer. yeah, and i think it's an important thing that dr. maxwell makes, important thing that we need to take into consideration. pain docs turn to methadone because it's inexpensive. some of the other drugs are a little more controversial. the problem is the pain effects last for 6 to 8 hours, but the half-life of the drug which makes it effective for detoxing treatment is 24 to 36 hours. so what happens is the pain effects wear off, people start adding and taking more methadone. that builds up in the body, and then as a result complications occur. so clinicians as well as consumers need to be aware that this is a unique drug with unique properties and needs

to be administered by a knowledgeable practitioner so the adverse events don't occur. i suspect that some of the deaths that occur particularly in the earlier period of methadone was indeed trying to get that patient regulated appropriately, is that correct? well the most important part of treating a patient is during the induction phase. i mean probably the most significant decisions that are made when a patient appears to a treatment program to be considered for treatment is do you admit the patient or do you not admit the patient. both decisions have consequences on the individual's life. but once you admit the patient, during that first three weeks to four weeks of treatment, the patient goes through a very important induction period as the dosage is being individually titrated to the patient's specific needs. too little medication is inadequate and will not respond to the patient's problems, and therefore they will continue to use other drugs. too much medication too soon will sedate the individual.

so you need a highly vigilant clinical response when you're engaging that patient, especially in that first month of treatment. as i've said in the past, not just giving the medication, but also surrounding the patient with the services they need, whether it's individual or group counseling, trying to understand and know the patient. very good. is there a similar process when an individual is being treated with methadone or buprenorphine or any other drug for pain medication, dr. clark? well if you mean in terms of monitoring the buprenorphine, buprenorphine's a different drug. it doesn't have the same metabolic profile as methadone. nevertheless, because it too has some unique properties, physicians need to be aware of those unique properties and make sure that their patients are aware of those properties, so if anything develops that they contact their physicians right away. methadone, as mark points out, is a drug

that's been around for decades. it is a relatively safe drug. but as with any drug that has powerful effects, if it is used incorrectly negative consequences can ensure. lisa, you have been a patient of methadone. tell us about your story and how you became a patient of methadone. well i certainly had a history of chronic opioid addiction. and i was pretty fortunate that was my main problem. i was a heroin addict and had tried many different treatment, modalities and had many different episodes. and found that i was relapsing again and again, even as an adult, and was very frustrated. and had actually been on methadone. but the difference for me allowed me to enter and sustain

recovery was actually learning about the disease of addiction, of opiate addiction, and how i have brain structure and function changes. and then learning about the pharmacology of methadone in a way that i could appreciate what the medicine could do and couldn't do for me. i mean i had much misinformation that the medicine was compromising my memory and getting into my bones, and all of the safety issues that had been resolved years ago through research that i didn't know about, but that had been passed on to me on the street. and just misinformation, horrible information where i wouldn't allow myself to be on an appropriate dose, mistaking the cravings, the wonderful magic bullet for methadone for addicts, i believe, for me at least was that it diminished or silenced this horrible craving that used to just take over your life. and no matter how motivated you are,

how much support you have or structure, i was not able to overcome the consequences of that craving which always lead, ultimately, to active addiction. i had, you know, all the right setup, but i would inevitably trip over. one time i found drugs and just really totally destroyed my will to live, thinking that i was going to be living with an active addiction chasing me my whole life. well what has methadone allowed you to do now? i mean obviously highly functional back into a whole. well actually learning, you know, correcting that misinformation, learning about this disease and then the pharmacology, and that methadone. i used to think, you know, when i would get on methadone and get stabilized that i was over the addiction. but now i've come to understand exactly what the methadone does for my body, how it quiets the cravings. and that's why i'm not thinking about drugs;

that's why i'm able to focus my life on other aspects. and i was very fortunate to have very committed and very educated counseling that helped direct me to other areas of my life that challenged my knowledge-base most specifically, and then helped me arrive at an appropriate dose, and then learn that this is a chronic disease; there is no cure for this. i could be clean, you know, 10 minutes or 10 years and have a relapse. there are certain triggers that come from anywhere, you can't possibly guard against those in abstinence. but this medication can help give me a sense of confidence that i don't have to be looking over my shoulder my whole life, and it's enabled me to reach new heights that i never imagined. when we come back we're going to continue to talk a little bit more about methadone. we'll be right back. for more information on national alcohol and drug addiction recovery month, events in your town,

and how you can get involved, visit the recovery month web site at recoverymonth.gov. drug and alcohol addiction- you lose your way. but there is a way out. you can find direction, find support, treatment, find yourself and your life, your direction home. for drug and alcohol treatment referral for you or someone you know, call 1-800-662-help. [heavy breathing] feeling overwhelmed by current events? don't turn to drugs and alcohol.

hey! how was your run? great! substance abuse is not the way to manage life. if you or someone you know needs information or treatment referral, call 1-800-662-help. [music] you know, alcohol dependence is a significant problem in the united states. there are issues related to wife abuse, to child abuse, issues related to falls, accidents, car accidents, suicides, drownings, a number of problems as a result of severe alcohol dependence. pharmacology, medication can be a tremendous assistance

to helping people recover from this very serious disease of alcohol dependence. we have medications available to us that help people stay away from their substances. this has been most developed when it comes to alcohol where we've had disulfiram, also known as antabuse, for many years. in recent years we've also had naltrexone and most recently we have acamprosate. naltrexone is a medication that's taken orally. it's taken as a pill once a day for alcohol or opiate dependence. if they go to a party and take a drink they find that it just doesn't do anything for them. so there is a blocking of the effect of alcohol. there's a decrease in the craving for alcohol. so with this medication we have one more medication we can use in treatment of alcohol dependence which does not require people to stop drinking before they get their first dose. this would not be possible to give antabuse to these people because you have to be off alcohol, and if you used any alcohol you'd get very sick. with campral, acamprosate, it's recommended that people

be abstinent before they've started on acamprosate. so if people are motivated for treatment- that's the most important thing-and they're taking naltrexone, they can do very well in terms of reducing their drinking and stopping it altogether. [music] dr. clark, some groups have come forward and have shared concerns with the public about the use of methadone and other medication-assisted therapies. are their concerns warranted? i think whenever you have complications associated with a medical treatment, the concerns of advocacy groups and of citizens should be taken seriously. one of the things that we're trying to do is to make sure

that practitioners are in the field because we believe that the majority of these adverse events are occurring amongst pain docs prescribing for pain, and we want to educate those docs about that. we also believe that a clinic system which has over 1,100 clinics, you may have practitioners who are not as knowledgeable about what it is that they should know. and consumer groups can help bring that to their attention so that we can redouble our efforts to make sure that all of our credited and certified programs are practicing the best medicine possible or providing the best treatment possible. this is healthcare; it is an art form; it does rely on science- and evidence-based practices. nevertheless, some misadventures do occur and it's important for our patient advocates to remind us that it's a dynamic process

and a lot of people are affected by it; both patients and providers and families. one of these things that has come out of this movement has been more attention is being focused on continuing education for doctors who are prescribing methadone for pain patients for medical students on how to prescribe that you cannot prescribe methadone like you prescribe oxycontin or other drugs. and then also more attention through mark's organization on more training, more education, more best practices for narcotic treatment programs. so in a way i think they've made a significant contribution in helping us raise the standards and look at some places maybe we needed to address. and lisa, in terms of the patients who are using methadone, what are their areas of responsibility

on how to safeguard their own safety as well as the safety of others in the use of methadone. well, if you're taking a medication you need to know about that medication. but certainly you would have demonstrated a responsibility in maintaining that medication in a safe and secure environment so that it would not be child accessible, for example. but also, i think we all have an obligation to be informed about what some of the issues are and to get involved so that our image is not distorted by others so that we're representing ourselves. just for an example, the press typically perpetuates the image of methadone patients as selling medication or using, you know, nodding out on the street. and we want to be able to say that there are many,