Letters and comment
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We were shocked to see the title of a key article on the cover of last month’s DDN, Kill or cure: the dangers of diverted methadone. DDN’s approach was more in keeping with a tawdry tabloid splash rather than its usually more balanced magazine. Dave Marteau’s article asks: is it time ‘to reappraise our relationship with the life-saving drug methadone?’ He says he will discuss the evidence and this is what we want to challenge.
He starts with how methadone reduces deaths by 50 per cent, reduces HIV infection and how it has been positively evaluated by NICE. Then it seems as if Marteau does not know that methadone and buprenorphine are very different drugs. It is no revelation that methadone is potentially more dangerous than buprenorphine. Thus they are in different legal classes and schedules – unusually a sensible use of the classification system. But simply saying methadone is more dangerous than buprenorphine is like saying insulin is more dangerous than oral hyperglycaemic drugs and therefore we shouldn’t prescribe insulin.
He references the Auriacombe review of drug-related deaths in France between 1994 and 1998, which found buprenorphine was safer. This was when buprenorphine was first licensed and was first used in primary care and prescribed to people with less complex issues. This is a very important point. Many of us writing here are clinicians and have between us many, many years of experience. We will have cared for thousands of patients with drug problems and as a broad generalisation, the more complex, vulnerable, more likely to overdose and sick patients were settled much better on methadone and few of this group did well on buprenorphine. Keeping these patients in treatment is the most important thing – especially at the start. So using the medicine that does this most successfully is the obvious and right thing to do.
In his own study on which this article is based, The relative risk of fatal poisoning by methadone or buprenorphine within the wider population of England and Wales Marteau D, Macdonald R, Patel K. BMJ Open 2015; 5:e007629, they used fairly simple drug-related mortality data from two sources but posed some complex questions. We feel there is not nearly enough data to make any recommendation on ‘safe or unsafe’ prescriptions from this paper. Marteau needs to recognise that the nature of methadone – or buprenorphine – related deaths is a very broad church and association does not necessarily imply causation in all cases.
It is also an area where reporting bias may feature. In the Bell study there were 60 sudden deaths positive for methadone (32 in treatment) and seven buprenorphine-positive decedents (none in treatment). Most out-of-treatment deaths occurred in people with known histories of drug misuse, so is this a failure by drug services to engage with people? Might the diverted methadone actually be keeping many people alive who aren’t able to access treatment or couldn’t manage daily supervision? Also, isn’t it possible that those who were in treatment were inadequately dosed and self-treating with street methadone? It’s notable that the average dose of methadone across the six years of the Marteau paper was 46.6mg per day, way below the accepted therapeutic dose – what part did this play?
Using a single study, which like any academic paper has weaknesses as well as strengths, to suggest blanket recommendations on policy is indefensible. It’s a sensationalist, self-aggrandising approach that does an enormous disservice to public health. Methadone has many complex issues but it is a medication that has saved many lives in this country and around the world and continues to do so. Of course the issue of diversion is important and should be dealt with, but this article is at the very least unhelpful, and at the worst dangerous, particularly in this climate of rising poverty, social exclusion and drug-related deaths.
We implore Marteau to think seriously about the limitations of his paper before recommending potentially dangerous and unjustified policy changes.
Dr Chris Ford, clinical director, IDHDP; Dr Euan Lawson, deputy editor, British Journal of General Practice; Dr Clare Gerada, GP and ex-chair RCGP; Dr Judith Yates, GP and chair IDHDP; Dr Roy Robertson, professor of addiction medicine, Edinburgh; Dr Garratt McGovern, specialist GP, Dublin; Niamh Eastwood, executive director, Release; Dr Icro Maremmani, president, World Federation for the Treatment of Opioid Dependence; Dr Alex Wodak, emeritus consultant, Alcohol and Drug Service, St Vincent’s Hospital, Australia; Dr Robert Newman, director, Baron Edmond de Rothschild Chemical Dependency Institute, US; Joycelyn Woods, executive director, National Alliance for Medication Assisted Recovery, US; Dr Jasna Čuk Rupnik, MD, Center for Prevention and Treatment of Addiction of Illicit Drugs, Slovenia; Professor Barbara Broers, vice-president of the Swiss Society of Addiction Medicine; Dr Herman Joseph, NAMA, US
Dave Marteau responds:
I am reassured that experts now all seem to agree that methadone is more dangerous than buprenorphine. The published evidence to date indicates that it is around five times more lethal. Again, all seem to agree that methadone diverted from the treatment system is the main source of these tragedies. A total of 2,366 of our fellow citizens dying with methadone in their systems in just six years is hundreds, if not thousands, too many.
I have already given my views on this very important subject, so I (and I imagine DDN) would welcome the thoughts of other readers.
DDN is a non-partisan forum for debate and all views are welcome.
I work in an emergency accommodation facility, and I recently completed a two-day trainer course on naloxone. Now we have been told we cannot store naloxone on the premises – neither will they fund a kit for myself! Red tape gone mad… again!
Jim Kirkwood, Glasgow