How Safe is Methadone?

 Yes, I'm still in Nashville and CSICon is an awesome experience that I'll be writing about eventually.   In the meantime, here is another post to tide you over.

While methadone clinics are a familiar sight in most cities these days,the synthetic opioid's reputation as a safe treatment for heroin and morphine addiction has been shaken by the rising number of overdose deaths linked to its use.  

Since it was first developed in Germany during the 1930s, the analgesic that eventually became known as methadone has been praised as a safe and effective pain medication with fewer dependency issues than more powerful opiates such as heroin.   While going under a range of different names (including Dolophine, Symoron and Amydone), the drug was rechristened as "methadone" in 1947 when it became generic.  Although methadone treatment was eventually phased out during the 1950s as better analgesics came along, everything changed in 1964 when Doctors Marie Nyswander and Vincent Dole began using methadone to treat heroin addicts.   Since methadone has cross-tolerance with other opioids with a long effect duration and very similar effects,  addicts were successful in weaning themselves off more dangerous opioids such as morphine and heroin and methadone maintenance programs became widely used in many countries.  Higher doses of methadone can even block the euphoric "highs" that addicts experience with heroin and other addictive opiates. 

Physicians typically require specialized licensing and training to prescribe methadone safely and precautions are usually needed to prevent potential abuse.   Given the potential for methadone to be diverted for use as a street drug, methadone clinics often require added security and safety procedures for proper dispensing.   Some clinics provide methadone in concentrated form to reduce the number of daily doses needed although safeguards need to be in place to avoid the possibility of overdose.   With careful management, methadone maintenance treatment (MMT) can be maintained for months or years depending on the policies of the clinic administering the medication.   MMT use is still controversial though and many countries ban its use  (Russia for example).   In the United States and Canada, conservative politicians have advocated against MMT and argue in favour of total abstinence programs instead.  

In recent years, methadone has also become more popular as an analgesic as well as a way of weaning chronic pain patients off other pain medications to which they have become addicted.   That includes Oxycontin and codeine which have become major street drugs in their own right.   Along with methadone's (largely exaggerated) reputation for being non-addictive, or at least less addictive than other alternatives, methadone is also low-cost due to being generic.  It is also more effective against neuropathic pain since methadone acts directly on the NMDA receptor.   Unfortunately, methadone has a longer half-life than other analgesics (remains in the system longer) which causes it to build up in the system over time.   This leads to an increased risk of breathing and cardiac problems.    Due to cautions over methadone use and the continuing need for special licensing to prescribe it, methadone is still not as common as other analgesics.  In 2009 alone, only two percent of all pain prescriptions were for methadone in the United States. 

While not as popular as other pain medications, recent statistics issued by the Center for Disease Control's Vital Signs report show that methadone has been implicated in nearly a third of all overdose deaths linked to prescription pain relievers.   National data covering the years from 1999 to 2010 shows that four out of every overdose deaths from a single pain medication implicated methadone in some way.   With the rise in methadone use as an analgesic unfortunately, there has also been a corresponding rise in its popularity as a street drug.    According to CDC director, Dr. Thomas R. Frieden:

Deaths from opioid overdose have increased four-fold in the past decade, and methadone now accounts for nearly a third of opioid-associated deaths ... Methadone used for heroin substitution treatment does not appear to be a major part of this problem. However, the amount of methadone prescribed to people in pain has increased dramatically. There are many safer alternatives to methadone for chronic non-cancer pain.

To curb the rising trend of methadone-related deaths, the CDC recommends the following:

• screening potential methadone patients for substance abuse and other mental health problems
• prescribing only the amount needed based on the expected duration of pain
• using patient-provider agreements in conjunction with regular urine testing to monitor people taking methadone for  long-term treatment
• using prescription drug monitoring programs to flag patients abusing methadone or other pain relievers
• educating patients on the proper dosage, safe use and storage of prescription pain

While methadone is available in tablet or ampoule form, the U.S. Department of Health has strongly warned against prescribing them to patients due to the added risk of illicit sales and/or vein damage if they are injected directly in veins.  The U.S. Drug Enforcement Agency has been particularly militant in shutting down "pill mills" in Florida and other states producing methadone pills for illegal use.   

Along with a Federal bill signed into law by President Barack Obama in 2010 making it easier for local authorities to dispose of unneeded or expired pharmaceuticals, most U.S. states have also passed laws against "doctor shopping".   Since many prescription drug abusers often see multiple doctors with the pain symptoms, they are able to accumulate large hoards of prescription drugs through repeated prescriptions.  Patient registries allow physicians to check drug histories of prospiective pain patients to identify the abusers.

Although these measures are promising, the grim toll of methadone-related deaths is unlikely to change in the forseeable future.   While the current safeguards in methadone drug treatment programs appear to be working (few methadone deaths have been linked to formal clinic practices), patients receiving methadone for pain should only take it as prescribed by their doctors.   Those patients wishing to go off methadone should follow medical instructions carefully since "cold turkey" withdrawal can have devastating consequences as well.

Patients should also store methadone safely to ensure that no one else in their household can take it, either accidentally or on purpose.   Consult your pharmacist for advice on safe disposal (not in the nearest trashcan!).

For more information.

 

 

 

 

 

 

Comments

[Tonya Roberts]

Unfortunately, the deaths from addiction treatment are more common than are reported to the CDC. Many of these patients are also taking other presctibed drugs that may not have an effect on methadone but are reported as a poy drug death with no mention of methadone. SAMHSA does not require these deaths be reported although many states do. In the states that do require reporting, this is not being done and the few that are reported are NOT being investigated.
One of the problem with these clinics are that MANY provide substandard care. Many patients are started on methadone based only on a positive drug screen for opiates. There are federal and state guidelines in place to try and prevent these clinics from just being a supplier of drugs, but in many cases these are not being enforced. Many of the doctors working in these clinics do not understand the unique properties of methadone and this puts patients at an increased risk for death. Most deaths occur within the first two weeks of starting methadone. The risk of death during this time is up to 6.7 times higher than that of a heroin addict. Many of these clinics do not properly monitor and assess (vital signs, pupil checks, ect.) patients during this dangerous time . There are clinics that will continue to dose patients knowing that the patients are abusing other drugs that have lethal interactions with methadone.In fact SAMHSA (the federal agency that oversees these clinics) recommends this practice. Patients are not being assessed and monitored for signs of intoxication and sedation during the continued treatment with methadone. The federal guidelines do not require that a continued assessment (with vital signs, pupil checks ect.) be done after the first two weeks of induction. Many clinics are routinely starting all patients on a 30 mg dose even though SAMHSA has stated that this is NOT a safe dose for every patient. This has caused MANY deaths.Best Practices for methadone treatment needs to be updated to address these deaths.Should patients receive substandard care because they are being treated for a drug addiction? How many people have to die before we address these issues? www.stopmethadonedeaths.com

[Joan Price]

My sister was given methadone to treat a chronic pain condition. She became addicted, and couldn't stop taking it. She suffered major methadone withdrawal once she tried. I think there needs to be more regulation for these drugs. If the "cure" is worse than or equally as bad as the "disease," it's time we look for a new treatment.