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BMJ No 7108 Volume 315 Letters Saturday 6 September 1997 Treatment of opiate dependent drug misusersGlasgow model should be replicated in other general practicesEditor,The novel Glasgow model of methadone maintenance described by L Opiate dependency is a chronic relapsing behaviour which needs a lot of intervention at certain times and little or no intervention at others. Unlike in hypertension or diabetes, we still do not have clear guidance as to when to refer patients back for specialist treatment. Patients who continue to use illicit drugs should probably be seen regularly and it may be that all patients taking methadone would benefit from an annual review by a specialist. With increasing reports of deaths from opiates, including methadone,(2-3) it is vital to ensure that doses are optimised and that the taking of the methadone is supervised in new or unstable patients. Methadone maintenance treatment should be available to all who need it since it makes death from overdose far less likely.(4-5) Andrew Byrne
75 Redfern Street, References 1 Gruer L, Wilson P, Scott R, Elliott L, Macleod J, Harden K, et al. General practitioner centred scheme for treatment of opiate dependent drug injectors in Glasgow. BMJ 1997;314:1730-5. (14 June.) 2 Williamson P A, Foreman K J, White J M, Anderson G. Methadone related overdose deaths in South Australia 1984-1994. Med J Aust 1997;166:302-5. 3 Cairns A, Robert I S D, Benbow E W. Characteristics of fatal methadone overdose in Manchester, 1985-94. BMJ 1996;313:264-5. 4 Caplehorn J R M, Dalton M S Y N, Haldar F, Petrenas A-M, Nisbet J G. Methadone maintenance and addict's risk of fatal heroin overdose. Subst Use Misuse 1996;31:177-96. 5 GrÍ-nbladh L, Ohlund LS, Gunne LM. Mortality in heroin addiction: impact of methadone treatment. Acta Psychiatr Scand 1990;82:223-7. Doctors in prison must be careful when prescribing methadoneEditor,I was alarmed by the naivety of Laurence Gruer and Jayne Macleod's views about the prescription of methadone in prison.(1) When someone who is prescribed methadone outside prison is taken into custody the prison doctor can check how much methadone that person is prescribed, but the doctor cannot check how much the prisoner actually takes. Some people who take methadone lie about their consumption and sell a proportion of their prescription on the black market. In prison, however, the prescribed dose must be taken in full. As l Patients frequently exaggerate the effects of withdrawal from opiates.(2) No one dies of withdrawal, whereas 90 people died of methadone poisoning in Manchester between 1985 and 1994.(3) Since it is a doctor's first duty to do no harm, it would be more prudent for prison doctors not to prescribe methadone and wait until objective signs of withdrawal develop; in my experience these are infrequent, mild, and treatable with very small doses of methadone. So long as doctors prescribe methadone in custody on the basis of reports alone, and in conditions in which proper medical observation and resuscitation are impossible, further deaths from methadone poisoning in custody may confidently be expected. A M Daniels
National Poisons Information Service (Birmingham Centre), References 1 Gruer L, Macleod J. Interruption of methadone treatment by imprisonment. BMJ 1997;314:1691. (7 June.) 2 Davies J B. The myth of addiction. Reading: Harwood Academic, 1992. 3 Cairns A, Roberts I S D, Benbow E W. Characteristics of fatal methadone overdose in Manchester, 1985-94. BMJ 1996;313:264-5. More people die from methadone misuse than from heroin misuseEditor,As a forensic pathologist I have had the opportunity to study deaths resulting from methadone prescribed both in the community and to prisoners, so I read Laurence Gruer and Jayne Macleod's letter on the interruption of methadone treatment with interest.(1) I am concerned about the misuse of methadone in the treatment of patients with opiate dependence. Methadone is used to control the symptoms of opiate withdrawal in patients with known opiate dependence, and the dose required is often more than 40 mg daily. The patients themselves are involved in the fairly subjective assessment of their required dose, a fact that may lead to overprescription. Methadone hydrochloride is formulated as 1mg/ml and is for oral administration. Since 1993 I have noted in my records a large number of deaths in which methadone has been the principal drug related to the cause of death. I have been required to attend scenes of suspicious death in 13 such cases; during the same period I have been in attendance at only seven deaths that have been found to be due to heroin toxicity. Deaths resulting from methadone misuse have occurred not only in heroin misusers but also in young people unaccustomed to using either methadone or heroin. There is a public health issue surrounding the prescription of methadone to heroin misusers: some use their prescription methadone to supply other people. This is extremely dangerous to those who do not have any tolerance for opiates and who may die as a result of taking much lower doses of methadone. Much greater vigilance is required by medical practitioners who treat drug misusers and who prescribe methadone. My experience in forensic pathology is that more young people are dying as a result of misusing prescription methadone than are dying as a result of misusing illegal heroin. John Haydon McCarthy
The Beeches, References 1 Gruer L, Macleod J. Interruption of methadone treatment by imprisonment. BMJ 1997;314:1691 (7 June).
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