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MedLock Team | November 22, 2022
The term "harm reduction" is frequently used within the addiction treatment space. But, what does it actually mean and how can packaging add to a harm reduction program? This article will explore this topic.
What is Harm Reduction?
In sum, harm reduction is a set of strategies and practices aimed at reducing the negative consequences of drug use. This includes anything that can harm one's physical or mental health as well as social harms. Reducing potential harms to other people in the addict's life also falls under harm reduction. From a treatment perspective, harm reduction is an evidence-based approach that is centered around the individual receiving the treatment. Visit https://ontario.cmha.ca/harm-reduction/ for a more in-depth explanation.
One important thing to note is that harm reduction practices do not necessarily require individuals to completely abstain from using substances. Because of this, there are also harm reduction efforts in place that can protect other people in the addict's life.
Harm Reduction in the Context of MAT
MAT stands for "medication assisted treatment". This type of treatment is primarily used to treat those with an opioid addiction (e.g., heroin, fentanyl, morphine, oxycodone, etc.). The three most commonly used drugs in MAT programs are methadone, buprenorphine, and suboxone.
In the United States, clinics and treatment programs must be registered and approved by the Substance Abuse and Mental Health Services Administration (SAMHSA) in order to dispense methadone. While a supply of a maximum of 30 take-home doses has been approved at the federal level, each state has its own set of regulations in place regarding take-home methadone that vary substantially from state-to-state.
In Canada, methadone can be prescribed as a treatment within inpatient and outpatient programs, at dedicated methadone clinics, and at pharmacies. One of the main differences between methadone programs in Canada versus the United States is that Canadians are allowed to pick up their methadone doses from a pharmacy. However, compared to the United States, Canada is a bit more conservative with the amount of take-home doses patients are allowed to have. In Canada, two weeks (or fourteen days) worth of take-home doses.
Challenges With Take-Home Doses
While allowing take-home doses has many important benefits for those undergoing treatment, it also comes with several key challenges. Some of these include:
Ensuring the safety of other people in the household, especially children and teens.
Difficulty establishing chain of custody.
Preventing methadone diversion (i.e., when methadone doses are sold to others).
Dosage compliance.
Is there a solution to all of these problems? It might surprise you to know that packaging could be the answer. Let's discuss how...
Why is Packaging Important for Harm Reduction?
Many take-home methadone programs currently use packaging that does not possess the safety features required to address the aforementioned challenges. While packaging cannot erase these problems, it can certainly help reduce the likelihood of their occurrence. Let's start with the easiest challenge to address: potential harm to others.
Packaging Can Reduce Potential Harms to Others
For those who have been approved for take-home methadone, there are additional risks for the people living in the same household. This can include children, other addicts, and even pets. Since methadone is a liquid, the substance can easily be ingested by a child or pet if not stored safely.
Consider this scenario: a child sees their parent drinking a dose of methadone every morning and thinks it's special juice. The child is curious about this juice and wonders why they can't try it. The child's parent sets a closed bottle down on the counter and turns away to open the refrigerator for water to drink after taking the dose they set out; something that takes only seconds. While the parent's back is turned, the child climbs a stool and takes the bottle off the counter. While the bottle should be stored far out of reach from children, accidents and inattentiveness can unfortunately happen.
Child Resistant Caps
The above scenario is a real story that has happened to real people. Without safe storage, the outcomes can be fatal. For these reasons, take-home methadone bottles should absolutely have child resistant tested and certified caps. Furthermore, the cap must prevent bottles from leaking. Adding a child resistant cap keeps children safe and therefore contributes to a reduction in potential harms that have arisen as a result of an individual's drug use.
Lock Boxes
Individuals taking methadone doses to their homes should also consider adding another layer of protection. This is great for those undergoing MAT who have children or teenagers as well as those who may be living with another addict. One option is to get a methadone lock box that can safely store several bottles. Adding a padlock will ensure that no one can gain access to the contents of the box without a key. Click the button below for more info.
Packaging Can Help Establish Chain of Custody
Another, more complex, issue associated with take-home methadone doses is establishing a clear chain of custody. What does this mean? Since methadone is an opioid, it is imperative to keep track of who is handling a dose and when a dose is passed from one person to another. For individuals taking supervised doses, chain of custody is not as big of a concern. This is because such individuals must physically go to the clinic and ingest the dose in front of someone. After the dose has been ingested, the bottle is handed right back to the treatment provider.
However, for those approved for take-home doses, chain of custody is critical. While it cannot be definitively proven, there is one packaging feature that can contribute to tracking chain of custody: a tamper evident band.
The Tamper Evident Band
A tamper evident band that breaks upon first open, is a small but powerful feature for methadone bottles. If the patient is living with another addict, this individual will be able to tell if another member of their household has accessed their methadone. However, it is possible that someone could remove the methadone and replace it with something else. The replacement substance may or may not be harmless. Either way, the tamper evident band would be broken and the patient will know the dose may not be clean and should therefore be avoided. This effectively reduces the risk of personal physical harm.
There is also the challenge of methadone diversion. How can a treatment provider ensure that a patient is not selling - i.e., diverting - their dose to someone else? Unfortunately, methadone diversion is not entirely avoidable. However, for addicts buying methadone off someone with take-home doses, the presence of a tamper evident band can serve as a warning for them as well. If the tamper evident band remains unbroken, the buyer can rest assured that the dose is clean, meaning other substances - like fentanyl - have not been added to it. While it is still possible to overdose on methadone, a clean, measured clinical dose is less likely to be fatal to habitual opioid users who are the most likely buyers. Since most programs require all bottles to be returned to the clinic, these situations do not happen with great frequency.
Random Bottle Recalls
As stated, since most methadone programs require individuals to return all methadone bottles, this prevents individuals from selling the entire physical bottle to another person. While this can be helpful, it is still impossible to tell whether the methadone was ingested by the intended user, another person, or poured into another container to be sold.
One tactic clinics have implemented to help address this issue is random - or surprise - bottle recalls. This means that, at any given time, a patient may be required to bring all their take-home doses back to the dispensing clinic. In this case, the tamper evident band is incredibly useful. A bottle cannot be opened without first breaking the tamper evident band. It can therefore be determined if the patient has been taking more (or less) than their prescribed dose (i.e., if two bottles are being consumed per day instead of one). In this way, the tamper evident band also serves to promote dosage compliance.
In addition, if a patient decides to remove the liquid methadone from a bottle and replace it with something else, the tamper evident band will be broken despite the bottle being full. If a patient's doses are randomly recalled, the dispensing party will ask why the cap was opened but the dose was not taken. In this case, it is difficult to provide a valid explanation as to why this has happened. Even if a reasonable explanation has been given, a full bottle with a broken tamper evident band is an indication that the contents of the bottle should be investigated.
The Best Practice Methadone Bottles for Harm Reduction
To help address some of the harms associated with methadone treatment, LiquiMedLock™ has carefully designed the best practice methadone bottle for enhanced safety. The key feature of the bottle that contributes to harm reduction is the specialized cap. Instead of having a child resistant cap with a separate tamper evident feature (e.g., heat or pressure seal), the caps for these bottles have both elements combined in a single cap.
The child resistant portion of the cap includes an inner and an outer layer. This feature has a "push down and turn to open" format typical of most pharmaceutical packaging.
Attached to the inner layer of the child resistant cap is a tamper evident band. Once the cap is on, it cannot be removed without breaking the tamper evident band.
Including both child resistant and tamper evident features in a single cap makes the fill process more efficient. First, the single cap eliminates the need for a seal or a second piece. This means the cap does not have to be removed to check that the bottle is sealed after the cap has already been secured. Second, the cap is easy to secure to the bottle. When batch filling, this is an important feature that makes the process quicker, easier, and less physically strenuous. Third, the cap is leakproof which, again, eliminates the need for a seal and of course prevents leakage.
Click the button below to view an instructional video with more information on LiquiMedLock™ methadone bottles.
Practical Problems With Other Methadone Bottles
Unlike LiquiMedLock's™ methadone bottles, other products in the market require caps with seals. This could be a pressure seal or a heat seal. Filling bottles and sealing them can be a time-consuming and inefficient process. For instance, after filling a bottle with methadone, someone must remove the cap to check that the seal is in place then put the cap back on before handing it off to the patient. In other words, this is an inconvenient process.
Conclusion & Future Packaging
Methadone packaging plays an important, if not vital, role in harm reduction. Not only can a bottle protect the patient, but it can also protect those around them. Bottles that have child resistant, tamper evident caps can effectively:
Keep children and pets safe.
Reduce potential harms to other addicts.
Help track chain of custody.
Reduce potential harms to the patient.
Aid in preventing methadone diversion.
In the future, smart packaging could truly help prevent some of the most problematic issues with methadone treatment. Adding smart technology to bottle caps could completely over hall the current system. With this technology, treatment programs could track the exact time and day the cap is removed, how often the cap is removed, changes in the weight of the bottle, and other important information. This would be incredible for ensuring dosage compliance thereby adding immense value to harm reduction and MAT.