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methadone more likely to kill you than heroin?
Drs Marcel Buster & Giel van Brussel, MD
(Municipal Health Service Amsterdam)
on literature and analysis of mortality figures Dr Russell Newcombe
concluded that methadone programs as a form of harm-reduction
possibly cause more victims than they prevent. We have doubts
whether the conclusion about methadone is fully justified. Looking
at the mentioned literature gives an one-sided view at the problem.
Moreover, the conclusions drawn are beyond those justified by
the results of the analyses. Several points of debate come to
is not an innocent substance; 'one's methadone maintenance dose
is another's poison' (2). A regular user of opiates develops
a certain tolerance. Therefore, it is possible that a tolerant
person can function normally with dosages which can be fatal
to a non-tolerant person. Also, methadone dosage in the case
of first entry to the program has to be evaluated carefully.
It is wise to begin with a low dosage that has to be increased
slowly in the course of weeks or even months. At entry to the
program it has to be carefully evaluated whether a patient has
a clear and unambiguous heroin dependence. In methadone maintenance
programs, methadone is dispensed to tolerant persons, moreover,
this tolerance remains high because of daily use of methadone.
Therefore, it is not surprising that deaths at the King's College
Hospital caused by methadone were not those of participants
of a methadone maintenance program but were those of 'recreational'
users of illicit methadone. In cases where more than one drug
is used, the drug responsible for death due to overdose is difficult
to establish. Moreover, the same drug prescribed by physicians
can also be bought on the street. In seventy percent of the
deaths due to overdose studied in Glasgow and Edinburgh a combination
of different drugs was found (3). Prescribed drugs such as temazepam
were often encountered in deaths in Glasgow. However, among
only 14 of the 34 persons who died in 1992 and where temazepam
was found, this was prescribed by their physician. Because of
the presence of other drugs it is not clear whether temazepam
really caused the death of these people. Probably the combination
of these different drugs was fatal to them. This was also the
case with the methadone deaths in Edinburgh. However, in Edinburgh,
the authors could not determine whether methadone was prescribed
or not. Both Hammersley and Obafunwa report that heroin/morphine
deaths seldom occur in Edinburgh (4). 'The fall of the deaths
due to overdose in the Lothian and Borders Region of Scotland
(LBRS) after 1984 reflects in part the strict policing that
took place, in particular in the Edinburgh area'. 'The increase
of methadone deaths is probably due to the introduction of a
street trend to use this agent as a substitute to heroin'. The
author suggests that methadone deaths are mainly caused by the
use of illicit methadone.
Wrong quotes: Dr. Newcombe assumes that the drug related deaths
among participants of a methadone program studied by Oppenheimer
et al., were methadone related deaths (5). The correct quote
should have been '18 of the 28 deaths were caused by overdose,
an opiate as a primary overdose drug was mentioned in only 22%
of the cases'. Methadone is not mentioned as the cause of death
of these persons. The suggestion that methadone would be the
cause of death ('invariably methadone') is not based on the
findings of Oppenheimer. Also, the suggestion by Godse et al.
that deaths due to medically prescribed drugs were caused by
methadone ('invariably methadone') is not completely true (6).
The most frequently encountered drugs as main cause of death
were barbiturates (287 of the 745 cases where the used drugs
were known). However, the number of deaths where methadone was
implicated was high; 107 cases. Dr Newcombe is quoting Harvey
with 'up to 1977 methadone accounted for the majority of drugs
deaths attributed to strong analgesics'. However, he did not
quote the next sentence which says 'in 1979 the position has
been reversed with 11 heroin/morphine deaths to 2 methadone,
possibly indicating a greater availability of heroin' (7). Interpretation:
For estimating the death rates, Dr. Newcombe uses cumulative
figures of drug users (only deceased persons are subtracted)
from the Home Office. Drug users have been registered since
1968. He assumes that two thirds of this group still uses heroin.
He multiplies this number by five and calculates an annual death
rate of 6 per 10.000 heroin users, which is a very low mortality
figure that is unlikely to be true. The low figure is probably
caused by a considerable overestimation of the actual number
of active heroin users. The calculated mortality figures on
deaths caused by methadone are higher. Based on the calculation
of the death rates caused by methadone, Dr Newcombe accuses
physicians of prescribing a deadly drug. He concludes that clients
of methadone programs are at high risk of death due to an overdose.
To draw conclusions like this he should restrict his study to
clients of methadone programs. Dr. Marks already made an effort
in this direction but he divided all methadone deaths by the
officially registered methadone clients and found an astonishingly
high mortality rate (8). If he would have limited himself to
those occurring within the population of methadone clients this
mortality figure would have been much lower. There are studies
were drug users in methadone maintenance programs are compared
with drug users on a waiting list for methadone programs or
drug users who left treatment. Grönbladh et al. for example,
report mortality among clients of methadone programs to be 1.4
% per year; among the drug users on a waiting list mortality
was 7.2% per year (9). Significantly, mortality due to heroin
overdose in this group was high (4.8% per year). Also Davoli
et al. report that the risk of overdose is lower during methadone
maintenance. 'A high risk of overdose death occurred among subjects
who left treatment compared with those still in treatment (odds
ratio 3.55, 95% confidence interval 1.82-6.90)' (10).
these figures suggest that participants of methadone programs
are at lower risk of death due to overdose. However, this does
not mean that methadone is an innocent substance. The high and
increasing number of methadone deaths in Britain is alarming
and certainly needs more attention. The first priority should
be to establish whether the methadone causing death has been
prescribed within a methadone program or bought on the street.
It also should be evaluated at what point during the course
of the methadone program death takes place. Further instruction
doctors prescribing methadone could be necessary. The use of
non-prescribed methadone without medical supervision can lead
to high risks, especially when it is used as a substitute for
heroin in order to get a 'high' instead of to prevent withdrawal
symptoms. Physicians have to be aware of this danger and they
should make sure that the prescribed methadone (as well as other
psycho-active drugs) does not end up in the 'grey market'.
our opinion heroin users can get great benefit from participation
in a well-implemented methadone program. Denigration of methadone
programs before a profound study of the real causes of the observed
methadone deaths has been performed carries the risk that the
baby will be thrown out with the bath water.
Where did Methadone come from?
Methadone was originally developed by the Nazis during World
War II. When the supply of opium was cut off, Nazi addicts like
Hermann Goering (Commander in Chief of the Luftwaffe and Hitler's
designated successor) wanted to avoid the possibility of withdrawal.
He instructed the German drug companies to produce a wholly
synthetic opiate that didn't need to rely on the poppy. The
chemists came up with a drug that not only worked, but also
lasted a long time. As a result, Methadone has become the drug
of choice for doctors who are trying to help users manage their
opiate dependency. Heroin wears off after a couple of hours,
thus requiring several hits each day. Methadone, on the other
hand, lasts anywhere between 24 and 72 hours, depending on the
dose that you take and on your individual metabolism.
How is Methadone used?
A.) Methadone is a (synthetic opiate) narcotic that when administered
once a day, orally, in adequate doses, can usually suppress
a heroin addict's craving and withdrawal for 24 hours. Patients
are as physically dependent on methadone as they were to heroin
or other opiates, such as Oxycotin or Vicodin. Each time an
addict uses heroin, there is a cycle of consisting of intoxication,
initially, followed by a period of normal mental functioning
which then yields to the discomfort of withdrawal and craving
(flu-like symptoms with pain, anxiety and depression).
The cycle that repeats every 4 to 8 hours with heroin is eliminated
by expert methadone maintenance treatment. This is possible
because methadone is released more slowly into the system and
lasts much longer than heroin and most other opiates. Short
acting opiates, like heroin, hydrocodone and morphine perpetuate
and/or create abnormal processes in the brain, which interfere
with feeling normal and functioning normally. Taking methadone,
instead, stops most aspects of this destructive process while
normalizing important neurobiological functions. After stabilization
on the proper dose, methadone does not produce the rush or high
associated with heroin abuse.
What are the effects of Methadone?
The most common side effects of Methadone are: drowsiness; lightheadedness,
weakness, euphoria, dry mouth, urinary retention, constipation,
and slow or troubled breathing. Some occasional side effects
are: allergic reactions, skin rash, hives, itching, headache,
dizziness, impaired concentration, sensation of drunkenness,
confusion, depression, blurred or double vision, facial flushing,
sweating, heart palpitation, nausea, and vomiting. The least
common side effects of Methadone are: anaphylactic reactions,
hypotension causing weakness and fainting, disorientation, hallucinations,
unstable gait, tremor, muscle twitching, myasthenia gravis.
The risks include kidney failure and seizures. Symptoms of overdose
are: marked drowsiness, confusion, tremors, convulsions, stupor
leading to coma, cold and clammy skin, hypotension, bradycardia.
What are the symptoms of a Methadone overdose?
A.) Body as a whole ~muscle spasticity
Respiratory ~difficulty breathing ~slow, shallow and labored
~stopped breathing (sometimes fatal within 2-4 hours)
Eyes, ears, nose, and throat ~pinpoint pupils ~bluish skin ~bluish
fingernails and lips
Gastrointestinal ~spasms of the stomach and/or intestinal tract
Heart and blood vessels ~weak pulse ~low blood pressure
Nervous system ~drowsiness ~disorientation ~coma
What does detoxification from Methadone involve?
A.) For detoxification treatment, methadone is administered
under close supervision. During detoxification a patient may
receive methadone when there are symptoms of withdrawal. Such
symptoms are sneezing, yawning, tearing of eyes, runny nose,
excessive perspiration, fever, dilated pupils, abdominal cramps,
nausea, body aches, tremors and irritability. After several
days of stabilizing a patient with methadone, the amount is
gradually decreased. The rate at which it is decreased is dependent
on the reaction of the individual . . . keeping withdrawal symptoms
at a tolerable level is the goal.
Is Methadone addictive?
A.) In blind trials, users who were given both drugs orally
were unable to distinguish between the effects heroin and methadone.
An added problem for those using methadone to recover from heroin
addiction is withdrawal. Withdrawal from heroin should be over
after seven to ten days. Withdrawal from methadone though, can
take up to a month or even longer.
Ironically, methadone used to control narcotic addiction is
frequently encountered on the illicit market and has been associated
with a number of overdose deaths. Tolerance and addiction to
methadone is a dangerous threat, as withdrawal results from
the cessation of use. Many former heroin users have claimed
that the horrors of heroin withdrawal were far less painful
and difficult than withdrawal from methadone.
Many people go from being addicted to heroin to being addicted
to methadone, and continue with this "treatment" for
years, fearing the withdrawal that will occur when they stop.
Methadone does not have to be the way of life for former heroin
addicts. Gradual cessation followed by a drug-free program of
rehabilitation may be the answer for many sufferers.
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