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Rapid Responses: Rapid Responses published:
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Safer methadone prescribing: an oxymoron
- Clive L Morrison (28 June 2009)
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Re: Safer methadone prescribing: an oxymoron
- David J Young (29 June 2009)
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Cannot show causation.
- Richard Watson (10 July 2009)
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Clive L Morrison, General Practitioner Pendyffryn Medical Group, Ffordd Pendyffryn, Prestatyn, Denbighshire, LL19 9DH
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McCowan et al [1], propose several strategies for making methadone prescribing safer. What is conspicuous by its absence is the suggestion to withdraw the licensing indication for methadone in the treatment of drug dependence. The withdrawal of methadone would have the greatest impact on public health of any intervention in recent times, by instantly saving at least 295 methadone related deaths a year (up 11.7% on the previous year) [2]. This would replicate the success of co-proxamol withdrawal [3]. Methadone is a dangerous drug with a narrow therapeutic window. No amount of tinkering with the logistics of prescribing is going to make the drug safer and supervised consumption of methadone does not eliminate the risk [4]. More drug users die of methadone than HIV. The large numbers of deaths does not justify the aims of methadone prescribing such as the non- health related targets of a reduction in acquisitive crime and reoffending rates. The small number of users who become drug free on a methadone programme does not ethically validate the tragic losses of families who have a relation that dies. Perhaps there is some form of perverse incentive in the system, as death is without doubt a permanently drug free state. References 1 C McCowan, B Kidd, and T Fahey Factors associated with mortality in Scottish patients receiving methadone in primary care: retrospective cohort study BMJ 2009; 338: b2225 2 Drug-Related Deaths in the UK-Annual Report 2008. :National Programme on Substance Abuse Deaths, International Centre for Drug Policy, (last accessed 28 June 2009 http://www.addictiontoday.org/files/drug-deaths-st- georges-report-2008.pdf ) 3 Hawton K, Bergen h, Simkin S, Brock A, Griffiths C, Romeri E, Smith KL, Kapur N, Gunnell D Effect of withdrawal of co-proxamol on prescribing and deaths from drug poisoning in England and Wales: time series analysis BMJ 2009;338:b2270, doi: 10.1136/bmj.b2270 (Published 18 June 2009) 4 Zador D, Mayet S, Strang J Commentary: Decline in methadone-related deaths probably relates to increased supervision of methadone in UK International Journal of Epidemiology 2006;35:1586–1587 doi:10.1093/ije/dyl248 Competing interests: None declared |
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David J Young, GP Principal, GPwSI S Misuse Derby DE217RJ
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I am interested in Dr Morrison's response suggesting that methadone should be withdrawn from the treatment strategy for opiate dependance . Having reviewed some of the evidence with peers as part of the RCGP SM course I felt that the arguments weighed in favour of opiate substitution, detoxification and maintenance. Where long term addition and co - morbidity render opiate abstinence unlikely and doses of street heroin have been high, methadone appears to acheive superior rates of retention in treatment and lower mortality and morbidity. Would Dr Morrison advocate eliminating opioid therapy entirely? Or would he compromise and use a safer alternative? Buprenorphine,for example,in elephantine dosage might work to an extent in heavier i.v. heroin users but this group seems only to find stability in daily methadone doses typically ranging from 80 to 120 mgs. Buprenorphine at a 32mg daily maximum seems to equivocate to only about 50mgs methadone. Many heroin users would simply walk away and continue their street habit. I think that our clinic helps to reduce violent and acquisative crime as well as overdose and AIDS but realistic opioid therapy is needed to do this alongside counsel, support, general education and needle exchange. Competing interests: None declared |
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Richard Watson, General Practitioner 11 Craigallian Avenue, Glasgow, G72 8DQ
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The authors acknowledge that a retrospective cohort study such as this cannot show causation. But they then go ahead and make recommendations as though it can. Patients prescribed benzodiazepines had a higher drug related death rate. Perhaps they were being prescribed them because they had previously been taking illicit doses of dozens of tablets per day? Perhaps they reverted to this and died partly as a consequence of this? The total number of patients prescribed benzodiazepines is not given, but I presume that the number who died was a small proportion, albeit a greater proportion than in those who were not prescribed them. It may be that the prescribing was in fact protective for the majority. Similar arguments apply to those prescribed higher doses of methadone - they may have had more severe problems. I would stress that I don't feel I have any particular axe to grind here. I do not prescribe benzodiazepines to most of my patients on methadone. Nor am an expert on study design and if anyone, especially the authors, can show me that my argument is wrong I will be delighted. Thanks for all the hard work that clearly went into the study. Competing interests: None declared |
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