Methadone becoming a big killer

From the McMinnville News Register, June 4 2011

Last year, a single prescription drug killed 101 people in Oregon.

Karen Gunson, MD

Karen Gunson, MD

No, it wasn’t the narcotic opiate oxycodone, dispensed primarily under the brand name OxyContin, or its cousin hydrocodone, under the brand name Vicodin. It was methadone, distributed under an array of little-known brand names.

A pure synthetic, methadone is best known for its use in getting addicts off heroin. While equally addictive, it doesn’t provide the euphoric high, so helps facilitate a more manageable two-stage withdrawal.

However, methadone has come into painkilling vogue of late as a cheaper alternative to semi-synthetics like oxycodone and hydrocodone.

According to records kept by the U.S. Drug Enforcement Administration, the amount of methadone distributed in Oregon grew 23-fold between 1997 and 2006, the most recent year for which records were immediately available. It has, in fact. quietly become the most-prescribed narcotic opiate in some parts of the state.

As a result, according to State Medical Examiner Karen Gunson, a robust black market has developed.

Ironically, Gunson said addicts are prone to overdosing on methadone because of the very quality that makes it useful in the treatment of heroin addicts. Users looking for a high tend to load up until they get it, and with methadone, that can easily prove fatal.

She said it is often mixed with other drugs as well, as addicts tend to take virtually any pills they can get. And because it lacks a pronounced high, it’s harder for them to tell how much they have ingested.

Just three years ago, Oregon logged 131 deaths by methadone overdose, so the 101 recorded last year actually represents an improvement, she said.

However, the legally prescribed painkiller still caused more deaths last year than heroin (90) or cocaine (20), and almost as many as methamphetamine (106, up from 87), according to records compiled by the state Medical Examiner’s Office.

Like heroin, falsely billed originally as a less addictive alternative to morphine, oxycodone, hydrocodone and methadone are all narcotic opiates.

While methamphetamine and cocaine are potent central nervous system stimulants, the opiates are powerful central nervous system depressants. That puts users at greater risk for a fatal overdose, particular when cutting and mixing in the street trade makes dosage determinations very difficult.

Methadone originally gained cachet for its use in helping heroin addicts kick the habit. The idea was for addicts to overcome the psychological craving first by switching to methadone, then begin to beat the physical craving gradually by tapering the dosage over time.

Some addicts succeed in achieving step one, but not step two. They continue taking methadone on a permanent basis, as a means of keeping off the more dangerous and expensive heroin and avoiding the criminal lifestyle typically accompanying it.

As a result, methadone clinics have sprung up in big cities across the country, including Portland. They dispense methadone as a pink liquid that must be drunk on the premises, in prescribed dosages and under direct supervision.

However, doctors around the state aren’t prescribing methadone in liquid form for people battling an addiction. They are prescribing it in pill form for people either suffering from chronic pain or successfully mimicking the symptoms.

Because it requires no natural ingredient, methadone is much cheaper than oxycodone. Gunson said that makes it popular with both patients and insurance companies, and thus with prescribing physicians.

According to DEA statistics, painkillers have become a popular prescription all-around. In 1997, Oregon’s pharmacies and hospitals received about 9,000 grams of methadone, 57,800 grams of oxycodone and 134,000 grams of hydrocodone.

Nine years later, in 2006, Oregon received about 218,000 grams of methadone, 616,000 grams of oxycodone and 387,000 grams of hydrocodone.

Although the state used less methadone than either oxycodone or hydrocodone, its distribution grew 23 times, compared to nine times and twice for the other two, respectively.

And in 2006, five years ago, methadone distribution had nearly caught up with hydrocodone. It could very well have passed hydrocodone in those five years, but the DEA doesn’t provide data that current.

Gunson said doctors often prescribe hundreds of methadone pills to a single patient on a single visit, expecting the supply to tide him over for months. But she said a goodly share of those pills get diverted into the street trade.

The trend toward higher rates of methadone overdose isn’t exclusive to Oregon. According to a 2006 study by the Centers for Disease Control and Prevention in Atlanta, methadone overdose have become a national problem.

The agency said the nation logged 3,849 methadone overdoses in 2004, representing a 390 percent increase in just five years.

In 1999, only 4 percent of poisoning deaths were attributed to methadone. By 2004, the figure had climbed to 13 percent.

Between 73 and 79 percent were determined to be accidental and 5 to 7 percent suicidal, the agency said. It said a determination could be made in most of the remaining cases, though a few were classified as homicidal.

According to the agency, Oregon experienced a 14-fold increase in methadone overdoses during the five-year study period. Only two state’s showed a higher rate – West Virginia and Kentucky.

Methadone’s two narcotic opiate cousins also exacted a significant toll last year in Oregon. Oxycodone was responsible for 59 deaths and hydrocodone for 30.

Together, oxycodone and hydrocodone killed almost as many people as heroin and far more than cocaine. Adding the methadone deaths gives the prescription opiates a combined death toll of 190. That almost matches the combined death toll of 200 for methamphetamine, heroin, cocaine and other drugs not available by prescription.

The medical examiner’s office didn’t break the prescription drug deaths down by county, only the street drug deaths. Yamhill County logged five of those last year, losing one resident to heroin, one to cocaine and three to methamphetamine.

Sheriff’s Sgt. Chris Ray, who heads the Yamhill County Interagency Narcotics Team, said the county has a thriving black market for prescription narcotics. However, he said relatively high prices – OxyContin can command as much a $100 a pill on the street – is fueling growing use of heroin as a cheaper alternative.

Gunson said the same market force is leading addicts to methadone. She said it sells legally for less than a $1 a pill, enabling a street selling to add a major markup and still undercut the price of OxyContin.

A change in the OxyContin manufacturing process is also fueling the trend toward heroin and methadone.

Previously, the drug’s time-release control could be short-circuited by crushing the pills, giving the user the instant high he was seeking. But that’s no longer the case.

Gunson serves on the state Board of Medical Examiners, which has long urged doctors to dole narcotics out in smaller quantities, even though doing so forces the patient to make more trips to the pharmacy for re-fills.

But she said the board has seen little improvement, particularly in rural Oregon, where the problem is most prevalent.