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Is methadone more likely to kill you than heroin?
Drs Marcel Buster & Giel van Brussel, MD
Based on literature and analysis of mortality figures Dr Russell Newcombe concluded that methadone programs as a form of harm-reduction possibly cause more victims than they prevent. We have doubts whether the conclusion about methadone is fully justified. Looking at the mentioned literature gives a one-sided view at the problem. Moreover, the conclusions drawn are beyond those justified by the results of the analyses. Several points of debate come to mind:
is not an innocent substance; 'one's methadone maintenance dose is another's poison'
(2). A regular user of opiates develops a certain tolerance. Therefore, it is
possible that a tolerant person can function normally with dosages which can be
fatal to a non-tolerant person. Also, methadone dosage in the case of first entry
to the program has to be evaluated carefully. It is wise to begin with a low dosage
that has to be increased slowly in the course of weeks or even months. At entry
to the program it has to be carefully evaluated whether a patient has a clear
and unambiguous heroin dependence. In methadone maintenance programs, methadone
is dispensed to tolerant persons, moreover, this tolerance remains high because
of daily use of methadone. Therefore, it is not surprising that deaths at the
King's College Hospital caused by methadone were not those of participants of
a methadone maintenance program but were those of 'recreational' users of illicit
methadone. In cases where more than one drug is used, the drug responsible for
death due to overdose is difficult to establish. Moreover, the same drug prescribed
by physicians can also be bought on the street. In seventy percent of the deaths
due to overdose studied in Glasgow and Edinburgh a combination of different drugs
was found (3). Prescribed drugs such as temazepam were often encountered in deaths
in Glasgow. However, among only 14 of the 34 persons who died in 1992 and where
temazepam was found, this was prescribed by their physician. Because of the presence
of other drugs it is not clear whether temazepam really caused the death of these
people. Probably the combination of these different drugs was fatal to them. This
was also the case with the methadone deaths in Edinburgh. However, in Edinburgh,
the authors could not determine whether methadone was prescribed or not. Both
Hammersley and Obafunwa report that heroin/morphine deaths seldom occur in Edinburgh
(4). 'The fall of the deaths due to overdose in the Lothian and Borders Region
of Scotland (LBRS) after 1984 reflects in part the strict policing that took place,
in particular in the Edinburgh area'. 'The increase of methadone deaths is probably
due to the introduction of a street trend to use this agent as a substitute to
heroin'. The author suggests that methadone deaths are mainly caused by the use
of illicit methadone.
Therefore, these figures suggest that participants of methadone programs are at lower risk of death due to overdose. However, this does not mean that methadone is an innocent substance. The high and increasing number of methadone deaths in Britain is alarming and certainly needs more attention. The first priority should be to establish whether the methadone causing death has been prescribed within a methadone program or bought on the street. It also should be evaluated at what point during the course of the methadone program death takes place. Further instruction doctors prescribing methadone could be necessary. The use of non-prescribed methadone without medical supervision can lead to high risks, especially when it is used as a substitute for heroin in order to get a 'high' instead of to prevent withdrawal symptoms. Physicians have to be aware of this danger and they should make sure that the prescribed methadone (as well as other psycho-active drugs) does not end up in the 'grey market'.
In our opinion heroin users can get great benefit from participation in a well-implemented methadone program. Denigration of methadone programs before a profound study of the real causes of the observed methadone deaths has been performed carries the risk that the baby will be thrown out with the bath water.
Q.) Where did Methadone come from?
A.) Methadone was originally developed by the Nazis during World War II. When the supply of opium was cut off, Nazi addicts like Hermann Goering (Commander in Chief of the Luftwaffe and Hitler's designated successor) wanted to avoid the possibility of withdrawal. He instructed the German drug companies to produce a wholly synthetic opiate that didn't need to rely on the poppy. The chemists came up with a drug that not only worked, but also lasted a long time. As a result, Methadone has become the drug of choice for doctors who are trying to help users manage their opiate dependency. Heroin wears off after a couple of hours, thus requiring several hits each day. Methadone, on the other hand, lasts anywhere between 24 and 72 hours, depending on the dose that you take and on your individual metabolism.
Q.) How is Methadone used?
A.) Methadone is a (synthetic opiate) narcotic that when administered once a day, orally, in adequate doses, can usually suppress a heroin addict's craving and withdrawal for 24 hours. Patients are as physically dependent on methadone as they were to heroin or other opiates, such as Oxycotin or Vicodin. Each time an addict uses heroin, there is a cycle of consisting of intoxication, initially, followed by a period of normal mental functioning which then yields to the discomfort of withdrawal and craving (flu-like symptoms with pain, anxiety and depression).
The cycle that repeats every 4 to 8 hours with heroin is eliminated by expert methadone maintenance treatment. This is possible because methadone is released more slowly into the system and lasts much longer than heroin and most other opiates. Short acting opiates, like heroin, hydrocodone and morphine perpetuate and/or create abnormal processes in the brain, which interfere with feeling normal and functioning normally. Taking methadone, instead, stops most aspects of this destructive process while normalizing important neurobiological functions. After stabilization on the proper dose, methadone does not produce the rush or high associated with heroin abuse.
Q.) What are the effects of Methadone?
A.) The most common side effects of Methadone are: drowsiness; lightheadedness, weakness, euphoria, dry mouth, urinary retention, constipation, and slow or troubled breathing. Some occasional side effects are: allergic reactions, skin rash, hives, itching, headache, dizziness, impaired concentration, sensation of drunkenness, confusion, depression, blurred or double vision, facial flushing, sweating, heart palpitation, nausea, and vomiting. The least common side effects of Methadone are: anaphylactic reactions, hypotension causing weakness and fainting, disorientation, hallucinations, unstable gait, tremor, muscle twitching, myasthenia gravis. The risks include kidney failure and seizures. Symptoms of overdose are: marked drowsiness, confusion, tremors, convulsions, stupor leading to coma, cold and clammy skin, hypotension, bradycardia.
Q.) What are the symptoms of a Methadone overdose?
A.) Body as a whole ~muscle spasticity
Q.) What does detoxification from Methadone involve?
A.) For detoxification treatment, methadone is administered under close supervision. During detoxification a patient may receive methadone when there are symptoms of withdrawal. Such symptoms are sneezing, yawning, tearing of eyes, runny nose, excessive perspiration, fever, dilated pupils, abdominal cramps, nausea, body aches, tremors and irritability. After several days of stabilizing a patient with methadone, the amount is gradually decreased. The rate at which it is decreased is dependent on the reaction of the individual . . . keeping withdrawal symptoms at a tolerable level is the goal.
Q.) Is Methadone addictive?
A.) In blind trials, users who were given both drugs orally were unable to distinguish between the effects heroin and methadone. An added problem for those using methadone to recover from heroin addiction is withdrawal. Withdrawal from heroin should be over after seven to ten days. Withdrawal from methadone though, can take up to a month or even longer.
Ironically, methadone used to control narcotic addiction is frequently encountered on the illicit market and has been associated with a number of overdose deaths. Tolerance and addiction to methadone is a dangerous threat, as withdrawal results from the cessation of use. Many former heroin users have claimed that the horrors of heroin withdrawal were far less painful and difficult than withdrawal from methadone.
Many people go from being addicted to heroin to being addicted to methadone, and continue with this "treatment" for years, fearing the withdrawal that will occur when they stop. Methadone does not have to be the way of life for former heroin addicts. Gradual cessation followed by a drug-free program of rehabilitation may be the answer for many sufferers.
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