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The death of methadone?

FOR years I have been both a lover and hater of methadone, but hopefully that should be coming to an end.

I love the special pharmacology of the drug, and the way that it seems to help in a variety of post-traumatic stress type elements of addiction. It is certainly true that a high percentage of people with addiction problems have a significant history of personal trauma in their background, and I have often been shocked hearing the stories behind people’s addiction and wonder if they will ever live through it – of course many don’t. However, I remain disappointed by the naivety and pomposity of the blinkered few who misunderstand the true horror behind addiction.

I hate methadone because it is a killer: we regularly lose children to inadvertent overdose. However, this isn’t just caused by children getting hold of what they think is a nice-looking green liquid and take a swig, it’s also due to criminally irresponsible adults who have give it to children in their care as a soother to help them sleep! Unbelievable, but true. I’ll never forget the day I actually shouted at someone who called these types of incidents “unavoidable collateral damage”.

We also lose adults, as they take other drugs in addition to the prescribed methadone, particularly those that leave prison, as let’s face it, we usually have little idea about the volume (and strength) of drugs that they actually have been taking. It leaves families bereft and children without parents. Oddly, we seem content to regularly disregard NICE when it clearly advises us to take into consideration family situations when choosing treatment, and instead, go ahead and prescribe methadone anyway.

We seem to feel comfortable trying to prevent these deaths by offering naloxone injections, or encouraging them to store their methadone securely in a safe purchased specifically for that purpose, rather than using safer alternatives. We also know that methadone liquid is traded on the open market – even liquid that has been regurgitated.

Continued use
Given all this, why do we still use it? I’ll tell you.

We protect this system of supply and treatment because, so far, it is less expensive than alternatives and the supervised consumption has been fairly easy — remember supervised consumption was introduced because methadone was so deadly. Institutions protect it, they simply install a machine and crack through 60 patients an hour.

We tolerate and are complicit in slow titration and general under-dosing. It is great to hear the phrase ‘start low and go slow’, but does that really work in this case?  In my experience it doesn’t, as in reality it means that you introduce methadone at a low dose and the client maintains their link to the dealer and continues to use illicit drugs. You titrate up in small amounts asking the client to avoid the dealers ‘deal of the day’ and slowly reduce the quantity of illicit drugs used until you reach a point where you think you can stop increasing the methadone and the client can say goodbye to the dealer.

The fact is that often the methadone dose is not high enough, so the client tops up. You might have titrated within 30 days, but it is not unusual for this to take longer. By not breaking the relationship with the dealers immediately – withdrawal is very difficult.

We don’t worry about the slight fog that methadone creates, and in fact it is often thought as an advantage by the prison guards. But it does seem to hamper thinking and affects the ability to hold down a job or start a job, which is one of the most important elements of a withdrawal program.

Slow progress
Times have changed a little as generic buprenorphine may be less expensive than methadone and is way safer in overdose. Titration can also be quicker — within three days. Dosing may be less frequent, with less supervision and the mind may be slightly clearer, which enables choice. On the one hand, topping up is less effective, but on the other hand the little tablets can be ground down and injected — it is a balance of risks, benefits and collateral damage. Some addiction centres have changed — I should really call out their names in celebration. I didn’t want to mention Europe, but some European countries just don’t use it.

OK – I have to say that the black market for buprenorphine is rampant and I am told that it is now the common currency in prisons – it is certainly easier to throw over the wall.

The future
Depot buprenorphine is on the way and I am excited by it. Once I get over the size of the dose, I think the rapidity and duration of effect might be very useful. Just think about administering one dose a month and immediately destroying the prescription element of the black market. Avoiding methadone in people’s homes would save 10 children’s lives a year and prevent harm to the other 30 that get admitted to hospital through inadvertent overdose.

There will always be methadone – some people will need it, but the balance may change. Perhaps even supervised consumption will become a thing of the past. Just as the new pharmacists chuckle when I tell them about making creams and ointments, they will ask – did you really give out little bottles of methadone liquid and make the client drink it in the pharmacy?

This article was written by a pharmacist who wished to remain anonymous

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