Methadone Abuse

Is methadone more likely to kill you than heroin?

-By Drs Marcel Buster & Giel van Brussel, MD
 (Municipal Health Service Amsterdam)

     Based 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 a 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 mind:

Methadone 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.