Methadone Abuse

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).