Laura M. Nagel
Deputy Assistant Administrator
Drug Enforcement Administration
American Association for the Treatment of Opioid Dependence
Washington, D.C.
April 14, 2003
Good Morning. Thank you, Mark, for the introduction. I would like to
thank you and the American Association for the Treatment of Opioid
Dependence for the invitation to be a guest speaker at this conference.
I am especially pleased to be afforded the opportunity to provide the
Drug Enforcement Administration’s perspective on the treatment of
opioid dependence. The DEA shares a common goal with the treatment
community: to reduce the incidence of drug abuse in the United States.
During my 24-year tenure as a special agent with the DEA, I have
worked in various field offices as well as at Headquarters. My current
position as Deputy Assistant Administrator of DEA’s Office of
Diversion Control has been both challenging and rewarding. It has
broadened my understanding about many complex issues such as opioid
addiction and its treatment, and has allowed me the opportunity to
collaborate with healthcare professionals such as you.
In 1970, the Controlled Substances Act was enacted and gave the DEA
the responsibility to prevent, detect, and investigate the diversion and
abuse of controlled substances, and eventually, List I chemicals.
The role of treatment providers is similar to that of the DEA in that
each of us has a goal to reduce drug abuse. However, you achieve your
mission through therapeutic interventions that address the needs of the
individual patient experiencing opioid dependence. Your work is often
done in less than optimal circumstances with many barriers and little
recognition. You see the whole person and you do what is humanly
possible to help them succeed. I have enormous appreciation and respect
for the difficulties and accomplishments of the treatment community.
DEA believes that maintaining compliance with existing laws enhances
the benefits of the therapeutic environment. The proper handling of
controlled substances by treatment providers protects the health of
patients, improves the quality of treatment, and safeguards society
against drug abuse and diversion.
DEA supports expanding access to treatment services and increasing
the quality of care received for opioid dependence. DEA has been an
active participant in developing responses to these new directions in
policy, regulation, and law by maintaining its role in establishing a
balance between adequate safeguards against diversion and working within
the spirit of expanding access to addiction treatment. The challenge
facing opioid treatment programs and law enforcement historically is the
process of providing effective treatment while preventing the abuse of
the treatment drug itself. We are again faced with this challenge today
with the introduction of two new buprenorphine treatment drugs.
I would now like to discuss some of the problems that drug abuse
creates, then talk a little about what the DEA is doing to enforce the
controlled substances laws, and finally talk about some of the ways we
can collaborate to ensure that new treatment opportunities and expanded
access to treatment are effectively utilized.
Let me begin with the dimensions of the problems of drug abuse by
offering a few statistics –
- According to the Office of National Drug Control Policy, each
year, roughly 20,000 people die of drug-induced causes. This does
not include the additional tens of thousands of people who die from
drug-related events – such as traffic accidents and homicides.
- About 600,000 hospital emergency room mentions a year were
reported in DAWN by people whose visits resulted from the use of
illicit drugs or the non-medical use of licit drugs.
- Crime and drugs use go hand-in-hand. The Arrestees Drug Abuse
Monitoring program reports that roughly two-thirds of male arrestees
test positive for illicit drugs.
- In 2001 it is estimated that 94 million people had used an illegal
drug at some point in their lives. Today, some 16 million people are
using illicit drugs at least once a month -- about seven percent of
the population.
- The National Household Survey on Drug Abuse reports a significant
increase in "past month, non-medical use" of pain
relievers among those age 18-25 when comparing 2001 data with that
for 2000.
As these statistics illustrate, much work remains to be done toward
resolving the problems of drug abuse. What America really needs is an
honest effort to integrate prevention, treatment, and enforcement.
Toward this goal, the DEA is pleased to join our partners in the medical
and treatment community to help restore the lives of those struggling
with opioid addiction, while ensuring the integrity of our systems.
DEA’s mission is to disrupt and dismantle drug trafficking
organizations. We direct our efforts in three areas – the
international arena, at the national level, as well as working with our
local communities.
Most of the illicit drugs consumed in the U.S., such as cocaine and
heroin, are grown and processed entirely outside of our borders. The
worldwide drug trade is estimated to be about $400 billion a year. The
drug trade in America is estimated at $65 billion a year. The fight
against drug trafficking, diversion, and abuse transcends world
politics. The DEA supports international investigations by sharing
intelligence, training foreign law enforcement personnel, and developing
common strategies. DEA works with our law enforcement partners to
target, disrupt and dismantle those trafficking organizations
responsible for the importation of these illicit drugs.
In the national arena, DEA targets dealers that are often tied into
regional, national and even international distribution organizations of
illicit drugs. A single DEA operation, aimed at one drug gang, might
also target activities in 10 or 20 cities around the country. At the
same time, there is a large illicit market for legitimately manufactured
drugs, such as OxyContin® and methadone. These investigations present a
unique problem for law enforcement as well as the medical community.
In the local communities there are occasions when drug trafficking
gangs have simply overwhelmed small communities. The violence that
plagues some of our small towns and rural areas are most frequently
related to drug trafficking and drug abuse.
Our communities deserve the benefits of our close cooperation. We
realize there are certain areas in your work in which a collaboration
with law enforcement and regulatory agencies may not be desirable. And
we respect that. But I believe that there are areas in which we can
comfortably combine our different talents and experience, where we can
work together.
The face of opioid addiction treatment has been changing at a rapid
pace with the employment of various new strategies. These innovations
are needed to allow the people who are opioid dependent have access to
the treatment they need.
The Drug Addiction Treatment Act was passed by Congress in October
2000, waived the requirement for a separate DEA registration as a opioid
treatment program for practitioners who dispense or prescribe
FDA-approved Schedules III-V narcotic controlled substances for use in
maintenance or detoxification treatment. DEA and the Center for
Substance Abuse Treatment worked jointly to develop a system for
processing these waivers, which allow physicians to provide addiction
treatment in an office-based setting, thus expanding access to
treatment. To date, DEA and Center for Substance Abuse Treatment has
issued 1,355 waivers.
In October 2002, the FDA approved two new buprenorphine drug products
for use by physicians in office-based settings as permitted under the
Drug Addiction Treatment Act. I’m also told that they will eventually
be available to opioid treatment programs.
The DEA supports many of the innovations that are being adopted –
some whole-heartedly, some with reservations. We support the concept of
addiction treatment, including opioid treatment programs as well as
office-based treatment. However, treatment must go beyond just providing
a drug, it must also include the development of job skills, counseling,
and other ancillary services.
The potential for diversion and abuse of methadone has always caused
concern for DEA. Methadone is the most widely used treatment modality
for opioid addiction. Methadone is a tool of proven effectiveness in
treating heroin addicts. It has been studied more than any other
treatment drug with uniformly positive results enabling many Americans
to once again lead stable lives.
At the same time, methadone has been available as a pain medication
since World War II, but with the recent consensus that chronic pain
should be treated many physicians have begun to recognize its
attractiveness as an effective way to treat pain. The increased
availability of methadone, because of its attractiveness for the
effective treatment of both pain and opioid dependence, has recently had
an unintended effect – it has been associated by the public with death
and injury.
In the last several years, methadone-related overdose deaths have
skyrocketed.
- According to a North Carolina Dept. of Health and Human Services
investigation, such overdoses jumped sevenfold between 1997 and
2001.
- In Maryland, methadone overdose deaths have increased tenfold in
the last five years.
- In Maine, methadone was found more frequently in people who
overdosed than any other drug. The Maine study found that most
people who died from methadone toxicity were not involved in
methadone maintenance programs. The Boston Globe reported
last year that of the 26 methadone overdose deaths reported so far
that year in the Portland area, only one person was a client at the
local methadone clinics.
In many of these cases methadone tablets were involved. These tablets
are generally used in the treatment of pain not the treatment of opioid
dependence.
The diversion of opioid treatment program client take-home doses of
liquid methadone continues to account for some of the methadone found in
the illicit market. However, the concern we all have; what is the source
of the methadone involved in these deaths and injuries? The Center for
Substance Abuse Treatment is conducting a study to address this question
in conjunction with several federal and state agencies (including the
DEA) as well as private organizations, such as American Association for
the Treatment of Opioid Dependence. We are looking forward to the
results of this study to provide an answer to this question.
Whether the source of the methadone is from a clinic or prescribed
for pain management, the outcome of this abuse is detrimental not only
to the individual, but to society as whole –
- DAWN Medical Examiner data for 2001 shows that Louisville, KY, and
Birmingham, AL, have the largest percentage of methadone-related
deaths amongst all reported drug deaths for those cities, indicating
that the problem is not limited to only large metropolitan areas.
However, it should be noted that 2001 data does not include New York
or Los Angeles.
- DEA ARCOS information between 1997 and the first quarter of 2002,
shows a continued, gradual increase in the retail distribution of
methadone.
- DAWN National Emergency Room episodes for January-June 2002, shows
that methadone ranks 13th among of all the controlled substances
reported. It ranks 3rd among the opioid analgesics on the list –
behind hydrocodone and oxycodone. It should also be noted that the
dominant form of methadone reported nationally in DAWN is now
tablet.
The recent reports of death and injury from regions such as North
Carolina and Maine are very disturbing to all of us. A disastrous
proposition emerges if the American public loses respect for this drug
and it’s proven track record in addiction treatment.
DEA’s concern regarding the security of these treatment drugs can
be addressed through the treatment communities’ diligence and
accountability in the dispensing of opioids. Treatment clinics and
office based doctors must comply with established federal and state
regulations as well as recommended practice guidelines such as those
established by the Federation of State Medical Boards in collaboration
with other organizations, including the DEA and the Center for Substance
Abuse Treatment. Additionally, practitioners must strive to institute
practices and procedures which will protect against inappropriate or
illegal prescribing of opioids. Treatment providers must guard against a
lack of diligence in enforcing treatment standards, and ensure patient
compliance with program guidelines in order to maintain the respect for
methadone and its benefits and avoid problems with the new buprenorphine
drug products.
Although there has been a recent shift in the oversight of opioid
addiction treatment within the United States from the FDA to the Center
For Substance Abuse Treatment, the oversight role of DEA in monitoring
compliance with security and recordkeeping regulations under the
Controlled Substance Act remains. DEA will continue to provide this
oversight and require accountability.
You could say that these are the best of times and the worst of
times. It is a period of great promise – and of many pitfalls. It’s
important to get this right, and we are working hard with our partners
in the medical, treatment, and regulatory communities, including
Substance Abuse and Mental Health Services Administration, Center For
Substance Abuse Treatment, and National Institute for Drug Abuse to do
just that. We want to expand access and improve treatment for those
addicted to heroin and other opioids.
New buprenorphine drug products offer a great hope for conquering
addictions and restoring lives. But we want to ensure that those
practitioners who receive a waiver to administer, dispense, or prescribe
these products are knowledgeable about them and are committed to
effective, ethical treatment.
I want to assure you that DEA supports expanding access to addiction
treatment, and that we want to work with you to assure that it is done
right. The diversion and abuse of these treatment drugs have the
potential to undermine public support for addiction treatment. The
regulatory work we do is intended to help protect you from that outcome.
The point of regulation is to solve problems, not to create them.
DEA's mission is to prevent diversion and abuse. We will work with you
to make sure our regulations help to achieve this goal while avoiding
the unintended consequence of inhibiting, or interfering with the
delivery of treatment.
Success comes in many forms. It could be the teenager who chooses a
drug-free life, the person who overcomes an addiction problem, or it
could be the arrest of a major trafficker.
Maya Angelou said, "we cannot change the past, but we can change
our attitude toward it. Uproot guilt and plant forgiveness. Tear out
arrogance and seed humility. Exchange love for hate, thereby, making the
present comfortable and the future promising." That is the goal we
are all ultimately working toward – a promising future.
I am very pleased that you have allowed me to address you today. I
look forward to working with your association's leadership and with the
treatment community as we enter a very promising period in the history
of substance abuse treatment.