Methadone death

Mikolaenko I, Robinson CA Jr, Davis GG. A review of methadone deaths in Jefferson County, Alabama. Am J Forensic Med Pathol 2002 23(3) 299-304. 

Even though methadone treatment reduces the high mortality of intravenous addicts to about 30% of controls, a number of patients and non-patients still overdose on methadone itself (Vormefelde and Poser, 2000), although the availability of methadone itself does not appear to be linked to increases in drug-related deaths (Oliver, 2002). 

Vormefelde SV and Poser W (2000). How to count methadone-related deaths. Drug and Alcohol Review, 19(4), 469-470. 

Deaths, cardiac and resp have been reported during initiation and conversion of pain pts to methadone Tx from Tx w/ other opioids Uses Severe pain detox w/ maint of narcotic addiction Action Narcotic analgesic Dose Adults. 2.5-10 mg IM q3-8h or 5-15 mg PO q8h titrate as needed Feds. 0.7 mg/kg/24 h PO or IM -s- q8h T slowly to avoid resp depression X in renal impair Caution [B/D (prolonged use/high doses at term), + (w/ doses =/> 20 mg/24 h)], severe liver Dz Disp Tabs, inj SE Resp depression, sedation, constipation, urinary retention, T QT interval, arrhythmias Interactions T Effects W/ cimetidine, CNS depressants, protease inhibitors EtOH T effects OF anticoagulants, antihistamines, barbiturates, glutethimide, methocarbamol ... 

Propoxyphene (dextropropoxyphene Darvon) is structurally related to methadone but is much less potent as an analgesic. Compared with codeine, propoxyphene is approximately half as potent and is indicated for the treatment of mild pain. It is not antipyretic or antiinflammatory like aspirin and is less useful than aspirin in most cases of mild pain. Toxicity from propoxyphene, especially in combination with other sedatives, such as alcohol, has led to a decrease in its use. Death following ingestion of alcohol in combination with propoxyphene can occur rapidly (within 20 minutes to 1 hour). The drug is not indicated for those with histories of suicide or depressive illnesses. 

Further situations in which methadone can seem an unsatisfactory substitution agent are towards the other end of the treatment spectrum. In uncomplicated maintenance treatment or for detoxification, the criticisms which are levelled at methadone relate not so much to the subjective effects, but to the aspects of addictiveness, abuse potential and toxicity. The issue of whether methadone is too addictive to be really suitable for detoxification is considered in detail in Chapter 3, and the controversial subject of methadone risks and deaths in Chapter 1. It is in the relatively milder cases of heroin dependence that buprenorphine treatment as an alternative to methadone has risen to great prominence in several countries, although, importantly, the condition definitely does not have to be mild for this medication to be used. Undoubtedly the introduction of buprenorphine is one of... 

It is known, however, that drugs are readily available in many prisons, and the rate of adverse incidents and the time and effort spent in detecting smuggling of drugs in has been enough to persuade some authorities that at least the basics of treatment should be available. The most routine option has become to provide a detoxification for opiate misusers, with for instance lofexidine or dihydrocodeine, and also benzodiazepines will often be issued if there is a history of abuse of these and it is intended to avoid the possibility of fits with a short withdrawal course. The adverse incidents in custody and prisons have included some deaths in users of crack cocaine, with physical explanations postulated but no very satisfactory treatment for cocaine withdrawal indicated. Prison services have typically been wary of methadone, and in favouring lofexidine use it was encouraging that a randomized double-blind trial carried out by prison specialists found lofexidine to be as effective as methadone in relief of withdrawal symptoms (Howells et al. 2002). 

Bigwood CS Coehelho AJ (1990). Methadone and caries. British Dental Journal, 168, 231 Bird SM Hutchinson SJ (2003). Male drugs-related deaths in the fortnight after release from prison Scotland, 1996-99. Addiction, 98, 185-190... 

Shanahan W, Seivewright N Ford C (2003). Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. British Journal of Psychiatry, 183, 304-13 Webster LR (2005). Methadone-related deaths. 

The concurrent administration of methadone to heroin addicts known to be recidivists has been questioned because of the increased risk of overdose death secondary to respiratory arrest. Buprenorphine, a partial M-receptor agonist with long-acting properties, has been found to be effective in opioid detoxification and maintenance programs and is presumably associated with a lower risk of such overdose fatalities. 

Propoxyphene is chemically related to methadone but has low analgesic activity. Various studies have reported its potency at levels ranging from no better than placebo to half as potent as codeine that is, 120 mg propoxyphene = 60 mg codeine. Its true potency probably lies somewhere between these extremes, and its analgesic effect is additive to that of an optimal dose of aspirin or acetaminophen. However, its low efficacy makes it unsuitable, even in combination with aspirin, for severe pain. The increasing incidence of deaths associated with its use and misuse has caused it to be scheduled as a controlled substance. Moreover, banning its use in the United States is under consideration. 

Opioids (heroin) are frequently used in combination with cocaine (speedball) by persons generally involved in crime. Early death may occur as a result of their use. Heroin addicts acquire bacterial infections producing skin abscesses, pulmonary infections, endocarditis, viral hepatitis, and acquired immunodeficiency syndrome (AIDS). There is a range of treatment options for heroin addiction, including medication and behavioral therapies. Methadone, a synthetic opiate medication, blocks the effects of heroin its results are encouraging. 

Eli Lilly s methadone, used in drug addiction clinics as a substitute for other narcotics, has also drawn a great deal of persistent worldwide criticism. It has been diverted for illegal use as a highly addictive narcotic. It has caused many deaths, including a public health crisis that involved an unusual spike in methadone overdose deaths in the Portland area, according to the Drug Enforcement Administration (2007). 

A review of 139 methadone-related deaths between 1998 and 2002 in Palm Beach County supported those of previous investigations and suggested that it is not possible to establish a definitive lethal methadone blood concentration range. Methadone-related death is usually associated with the use of other drugs and toxicological analysis in such cases should be contextualized by the clinical circumstances surrounding the event and even a few months before the incident occurred (50). 

The role of methadone and opiates in accidental overdose deaths in New York City has been investigated using data from the Office of Chief Medical Examiner of all accidental drug overdose deaths between 1990 and 1998 (51). There were 7451 overdose deaths in all during this period, of which 1024 were methadone-induced, 4627 were heroin-induced, and 408 were attributable to both. Thus, 70% of the deaths from accidental overdose were due to opiates. Co-variates significantly associated with methadone-induced deaths were female sex, older age, and absence of cocaine, heroin, cannabis, and alcohol in toxic screens. Co-variates associated with heroin overdose were male sex, Caucasian or Hispanic ethnicity, younger age, and the absence of cocaine and methadone and the presence of cannabis and alcohol in toxic screens. 

Wolf BC, Lavezzi WA, Sullivan LM, Flannagan LM. Methadone-related deaths in Palm Beach County. J Forensic Sci 2004 49 375-8. 

Bryant WK, Galea S, Tracy M, Markham Piper T, Tardiff KJ, Vlahov D. Overdose deaths attributed to methadone and heroin in New York City, 1990-1998. Addiction 2004 99(7) 846-54. 

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