treatment (MAT). In the U.S., the Substance Abuse and Mental Health Services Administration (SAMHSA) certifies methadone opioid treatment programs (OTPs) and issues buprenorphine waivers to practitioners. The driving principle behind ORT is the patient's reclamation of a self-directed life. ORT facilitates this process by reducing symptoms of drug withdrawal and drug cravings; a strong euphoric effect is not experienced as a result of the treatment drug. In some countries (not the U.S. or Australia), regulations enforce a limited time for people on ORT programs that conclude when a stable economic and psychosocial situation is achieved. (People with HIV/AIDS or hepatitis C are usually excluded from this requirement.) In practice, 40–65% of patients maintain abstinence from additional opioids while receiving opioid replacement therapy and 70–95% can reduce their use significantly. Medical (improper diluents, non-sterile injecting equipment), psychosocial (mental health, relationships), and legal (arrest and imprisonment) issues that can arise from the use of illegal opioids are concurrently eliminated or reduced. Clonidine or lofexidine can help treat the symptoms of withdrawal. The period when initiating methadone and the time immediately after discontinuing treatment with both drugs are periods of particularly increased mortality risk, which should be dealt with by both public health and clinical strategies. ORT has proven to be the most effective treatment for improving the health and living condition of people experiencing illegal opiate use or dependence, including mortality reductionMichel et al.: Substitution treatment for opioid addicts in Germany, Harm Reduct J. 2007; 4: 5. and overall societal costs, such as the economic loss from drug-related crime and healthcare expenditure. A review of UK hospital policies found that local guidelines delayed access to substitute opioids, for instance by requiring lab tests to demonstrate recent use or input from specialist drug teams before prescribing. Delays to access can increase people's risk of discharging themselves early against medical advice. ORT is endorsed by the World Health Organization, United Nations Office on Drugs and Crime and UNAIDS as effective at reducing injection, lowering risk for HIV/AIDS, and promoting adherence to antiretroviral therapy. Buprenorphine and methadone work by reducing opioid cravings, easing withdrawal symptoms, and blocking the euphoric effects of opioids via cross-tolerance, and in the case of buprenorphine, a high-affinity partial opioid agonist, also due to opioid receptor saturation. It is this property of buprenorphine that can induce acute withdrawal when administered before other opioids have left the body. MethadoneImportant considerations when initiating