Source: New York Times
Date: 9 February 2003

Methadone Suddenly Grows as a Killer Drug


PORTLAND, Me. — Methadone, a drug long valued for treating heroin addiction and for soothing chronic pain, is increasingly being abused by recreational drug users and is causing an alarming increase in overdoses and deaths, federal and state officials say.

In Florida, methadone-related deaths jumped from 209 in 2000 to 357 in 2001 to 254 in just the first six months of 2002, the latest period for which data are available.

"Out of noplace came methadone," said James McDonough, director of the Florida Office of Drug Control. "It now is the fastest rising killer drug."

In North Carolina, deaths caused by methadone increased eightfold, to 58 in 2001 from 7 in 1997 - an "absolutely amazing" jump, said Catherine Sanford, a state epidemiologist. In Maine, methadone was the drug found most frequently in people who died of overdoses from 1997 to 2002. It was found in almost a quarter of the deaths. In the first six months of last year, methadone killed 18 people in Maine, up from 4 in all of 1997. Dr. John H. Burton, medical director for Maine Emergency Medical Services, said hospital emergency rooms were seeing "a tidal wave" of methadone-related cases.

The increase in methadone overdoses and deaths has floored many drug experts because methadone, which does not provide a quick or potent high, has long been considered an unlikely candidate for substance abuse. It can be hours before a user feels any effect, and it works more like a sedative than a stimulant.

And because methadone is considered such an important and affordable tool for treating addiction and pain, health and law enforcement officials are facing a quandary: how to stop methadone abuse without curtailing its valuable uses — and especially without driving addicts back to drugs like heroin.

"We've got years of experience with methadone and suddenly we've got this problem," said Dr. H. Westley Clark, director of the federal Center for Substance Abuse Treatment. "We realize that lives are being lost and we're trying to stop that. But we're trying not to do quick fixes that will cause us more problems."

The surge in methadone abuse appears linked to several factors, including the growing abuse of heroin and OxyContin, a powerfully addictive prescription painkiller. Health and law enforcement officials are reporting that some of these addicts are turning to methadone when they cannot get the other drugs.

At the same time, methadone has become more available. Physicians are increasingly prescribing it for pain relief, in part because law enforcement officials have been cracking down on OxyContin, and more methadone clinics have sprung up to treat the growing number of heroin addicts.

"The availability of methadone for treatment and pain has put people who would not normally be in a position to divert drugs in that position," said Sgt. Scott J. Pelletier, who works for the Maine Drug Enforcement Agency handling drug cases in Portland and Cumberland County, where methadone caused at least 30 deaths in 2002, according to the state medical examiner's office.

In most states with increased methadone deaths, the methadone being abused appears to be tablets prescribed for pain. These are sold or sometimes given to addicts by people who have stolen them from patients or, in some cases, by the patients themselves. Addicts either swallow the tablets or grind them into powder that can be inhaled or turned into liquid and injected.

In Maine, however, and to a lesser degree in a few other states, the authorities say much of the methadone has been the liquid form used in drug clinics and spread, in some cases, by clinic patients. Many clinics across the country, following federal guidelines designed to make methadone treatment more accessible, have stopped requiring patients to take all their daily doses at the clinic, and instead are allowing them to take home doses of methadone once a week or more.

In Chicago, "kids are now coming from suburbia and they're buying methadone on the street," said Dr. Ernest C. Rose, a specialist in drug addiction who works for several methadone clinics there.

"In the inner city, you can get 80 milligrams of methadone for $20 to $30, which is a lot cheaper than a heroin habit would be. We do see a lot of methadone getting diverted out here on the street from the clinic, and we have to watch our clients very carefully because it's a secondary source of income for a lot of them."

There are no national figures for methadone deaths or overdoses. But the federal Drug Abuse Warning Network reported that in 2001, 10,725 people turned up in emergency rooms after having abused methadone. That is nearly double the number of such visits in 1999.

Experts say those attracted to methadone fall mostly into two categories: people already addicted to other opiates, and naïve, sporadic drug users who have often never tried methadone before.

"Most people who are addicted for any period of time aren't out chasing the buzz anymore," Dr. Rose said. "Most of them are trying to keep their sick off, and methadone will do that."

Naïve users might be "people who are just at a party and someone will give them some methadone," said Dr. Burton, the emergency medicine specialist in Maine. "They might mix it in with a beer or with some other drug. They take it thinking it's just like any other drug and will give them a buzz, and they end up either dead or deeply unconscious."

Methadone's delayed narcotic effect and its lack of a potent high are important reasons the drug can be so dangerous, experts say.

"By the time they've actually overdosed, no one is with them to see what's happening," said Kimberly Johnson, director of the Maine Office of Substance Abuse.

Joseph Haddock, an analyst for the Justice Department's National Drug Intelligence Center, said some people, unaware of the drug's delayed effects, "take methadone, don't get the effect that they want, take more methadone, still don't get that reaction, and they take more methadone, so they end up overdosing."

How large a dose can cause an overdose can vary widely. Methadone is often taken in combination with alcohol or other drugs, which may make it more harmful. Typically, experts say, pills prescribed for pain are about 5 or 10 milligrams each, meaning several pills might be needed for an overdose. Liquid for addiction treatment usually ranges from 50 to 500 milligrams.

While methadone has been available as a pain medication since World War II, many physicians have only recently begun to prescribe it, said Dr. Edward C. Covington, director of the chronic pain rehabilitation program at the Cleveland Clinic in Ohio and a past president of American Academy of Pain Medicine.

The change, he said, is partly the result of a new consensus that chronic pain should be treated and a wider awareness that methadone is a legal and effective way to do so.

Doctors wary of prescribing OxyContin because of warnings from the police about the potential for abuse have also turned increasingly to methadone, Dr. Clark and others say. Dr. Covington and other experts say some doctors also prefer methadone because it is far cheaper than OxyContin, it does not generate as much of a high as other drugs, and its effects are slower, seemingly making it less likely to be abused.

But methadone is also complicated to prescribe. Doses are often difficult to calibrate, Dr. Covington said, because of the way the drug accumulates in fatty tissues and is slowly released in the body.

"Methadone is probably one of the very few drugs that I've seen doctors almost kill patients with," he said. "It's that hard to use when you first start to use it. If it's on the street, we're going to be seeing some deaths."

Officials in several states are pressing for electronic monitoring of prescriptions filled by pharmacies, which can indicate whether patients are getting identical prescriptions filled in different places.

Dr. Andrea G. Barthwell, the White House drug czar's deputy director for demand reduction, said her office wants to educate physicians better about methadone and root out unscrupulous doctors who help patients who are abusing or selling the drug. Prosecutors in Virginia, Florida and elsewhere are bringing charges against such doctors.

Grappling with methadone used in addiction treatment may be even more difficult. For three decades, many health experts have praised methadone for pulling addicts away from heroin. While those addicts usually remain on methadone for long periods and may never be able to function without it, many lead productive lives, experts say.

To make methadone more accessible, the Substance Abuse and Mental Health Services Administration in 2001 relaxed its policy on distributing it. In the past, patients who reliably took their methadone each day could earn the privilege of taking as many as six days' worth of doses home. The new rules lengthened that to 31 days, a boon for people who had to travel long distances to clinics.

But while experts like Dr. Barthwell, a past president of American Society for Addiction Medicine, consider patients who earn 31-day take-home privileges to be highly unlikely to sell their methadone, they worry more about another policy that allows clinics to close on Sundays and to send even new patients home with a "Sunday bottle" of methadone.

"Some of these people exchange their Sunday bottle for other drugs or money," Dr. Barthwell said. "It may be their only source of currency until they are on a stabilizing dose" of methadone and are functioning well enough to get a legitimate job.

In Maine, state officials and law enforcement authorities said that take-home methadone - which typically comes in stronger doses than methadone tablets prescribed for pain - had caused most of the deaths. In some cases, Sergeant Pelletier said, clinic patients would "stockpile" a small amount of each take-home dose and sell the methadone, trade it for other drugs or give it to a friend addicted to other drugs.

What is more, the vast majority of the people who died in Maine were not clinic patients themselves.

Maine's methadone clinics are cooperating with state officials and have agreed to tighten procedures. Dr. Marc Shinderman, the operator of CAP Quality Care in Westbrook, said his clinic was now open every day. Longtime patients are permitted to take home at most only two weeks' worth of methadone.

More programs are available to educate patients about the consequences of letting others sample their methadone. Dr. Shinderman's clinic requires that people return empty bottles of take-home methadone, and is switching as many patients as possible to tablets, which the clinic says it hopes will be less likely to lead to overdose.

Dr. Shinderman said he was "mystified" about why so many of the deaths in Maine were attributed to methadone from clinics.

"Methadone has been around a long time and diversion has been around a long time," said Dr. Shinderman, who also operates clinics in Chicago. "It's a kind of a puzzle. People should be somewhat sophisticated about methadone."

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