Besides its other effects, MMT (methadone maintenance treatment) reduces the high mortality of intravenous heroin addicts to about 30 % of controls. On the other hand, deaths of patients and non-patients have been attributed to methadone. Here, we will report on the major reasons for deaths attributed to methadone and discuss suggestions for their prevention. 69 % of deaths attributed to methadone occurred in subjects not on MMT at the time of their death. 51 % of deaths attributed to methadone in subjects in MMT occurred during the dose-finding period of MMT. Further apparent risk situations are methadone intake in addition to that received for MMT, discharge from prison and intravenous injection of methadone. Intake of methadone in non-patients is almost entirely due to abuse of diverted take-home methadone. Not giving methadone as take-home should reduce methadone deaths most effectively. Replacing take-home methadone by substances acting longer than one day, such as LAAM (levacetylmethadol) or buprenorphine, should also be effective. Restriction of take-home prescriptions to substances with a slow onset of action, such as LAAM, or to partial agonists with an extended safety margin such as buprenorphine should be partly effective. Meticulous evaluation of substance history, slow dose increases and strict supervision of the patient by experienced personal should prevent methadone overdose during the dose-finding period. Discharge from prison closely corresponds to this situation; informing addicts shortly before discharge and psychosocial help during the first months out of prison may reduce this risk. Naloxone as an adjunct to oral agonist preparations should effectively prevent high-risk intravenous injection, for example of methadone syrup. This has been the case with tilidine plus naloxone in Germany. Reducing deaths attributable to methadone increases the net benefit of MMT. Also, reducing deaths attributable to methadone avoids decreases in the public acceptance of MMT.
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Dr. med. Stefan Viktor Vormfelde
Department of Clinical Pharmacology
University Hospital
Robert-Koch-Straße 40
37075 Göttingen
Telefon: + 49-551-39-9651
Fax: + 49-551-39-12767
eMail: stefan.vormfelde@med.uni-goettingen.de
