Archive for Monday, March 19, 2007

As painkiller, methadone proves deadly

Synthetic narcotic developed to treat addiction now prescribed as analgesic; deaths up 389 percent in five years

March 19, 2007


Methadone - no pain, any gain?

Kansas University psychiatry professor William McKnellly describes opiate addiction. Enlarge video

At the clinic, they mix the fix with generic orange drink.

Dr. William McKnelly and his staff at the Kansas City Metro Methadone Program have been doling out sips of methadone for decades as a way to keep addicts from going onto the streets trying to buy heroin or other opiate drugs. Patients pay $9 per day to show up at the clinic, drink their dose and go about their day.

"You're still strung-out, addicted, but you don't have to pay vast sums to your heroin dealer or be at the mercy of what they call 'the man,'" McKnelly said.

Methadone has been linked to an alarming number of deaths nationwide, including the death of the son of Anna Nicole Smith in September. Smith, who died earlier this year, herself had received a prescription for methadone.

Between 1999 and 2004, the number of methadone poisoning deaths grew nearly fivefold, and in Kansas, deaths grew from four to 25 in that time frame.

Methadone clinics seem an obvious place to look for answers to this trend. But what happens daily at McKnelly's clinic - essentially a few dozen people showing up to sip from cups - is just one piece of the picture.

In the bigger picture, a growing emphasis on pain control is causing a dramatic jump in the amount of methadone and other opiate drugs prescribed by doctors to kill pain, not to treat addiction. A 2004 report by the U.S. Department of Health and Human Services found that increased prescription of methadone through pharmacies is the driving force behind the growth in methadone-related deaths.

"The pain doctors are starting to use it big-time," McKnelly said, but some "have no clue" about the drug and its powers.

About methadone

Methadone, created in a lab by Germans to replicate morphine, first gained attention in the mid-20th century as a promising cure for heroin addicts. McKnelly, a professor of psychiatry, says he had the first methadone program west of the Mississippi, founded in 1966 in affiliation with the Kansas University Medical Center.

One of Lawrence's most famous residents, writer William S. Burroughs, was a patient at McKnelly's clinic. A heroin addict early in his adult life, Burroughs returned to the drug in the late 1970s while living in New York.

Burroughs' longtime companion, James Grauerholz, said that if it hadn't been for methadone, Burroughs may never have been able to stop using heroin, leave the drug scene of New York's Lower East Side and move to Kansas, which he did in the early 1980s.

For about 16 years, until his death in 1997, Burroughs went to McKnelly's clinic several times per month to pick up his supply. Eventually, he earned the right to take home two weeks' worth at a time.

"I think he had reached a point in life where it was just a routine thing. Frankly, he would wake up, take his medication and go back to bed," Grauerholz said. "By the time he'd get up an hour and a half later he was feeling a lot better than you should at age 81."

Deaths rising

Methadone isn't just dispensed in liquid form. It can also be prescribed as tablets and diskets.

Methadone-related poisoning deaths grew 389 percent between 1999 and 2004, according to the National Center for Health Statistics, from 786 to 3,849. At the same time, heroin deaths declined slightly.

Recent years have seen a shift from methadone as an addiction-treatment drug to an analgesic, or painkiller, prescribed by doctors.

"We need to better determine why the use of prescription opioids has increased so markedly over the course of the last several years, especially the prescription of methadone as an analgesic," the American Association for the Treatment of Opioid Dependence said in a 2005 statement. "It would appear that physicians are prescribing methadone as an analgesic to an increasing number of patients without providing appropriate therapeutic safeguards."

Methadone is just one of a number of opiates on the rise. Oxycodone prescriptions grew 50 percent between 1999 and 2002, and morphine prescriptions grew 60 percent, according to a study cited in January's Journal of the American Medical Association. The single-most prescribed drug nationwide is the painkiller hydrocodone, with more than 100 million prescriptions in 2005.

Why such an increase? The American Medical Association article attributed it to a growing emphasis on treatment of pain, a trend that's only likely to increase in coming years as the population ages and more people suffer from arthritis, cancer and back pain.

"This increase in legitimate use of these medications has paralleled ... a rise in abuse of these drugs," the article said.

McKnelly and his staff members say they've seen more patients in recent years who come into the clinic hooked, not on heroin, but on prescription pills. McKnelly calls OxyContin - which is often crushed into powder and snorted to bypass its time-release feature - "the worst thing in the world."

Biological dependency

Methadone-maintenance therapy has three goals: to block cravings, to dull any euphoric sensations related to taking other drugs and to keep the person from going into withdrawal.

"Trying to get off any opiates is awful. It's hell," said Kerry McLay, a Lawrence substance-abuse counselor. "You have extreme body aches and nausea. Most people need to go to the hospital and medically detox."

McKnelly said he started his program with the view that he would work his "magical psychotherapeutic skills" on patients to help cure them of their addiction. He saw his first patients three to five times per month and, eventually, he recalls them saying, "These talks are great, but do we have to talk to get the medicine?"

That's when he realized it may be an unrealistic goal to wean people from the drug. For a certain group of people - regardless of their class or moral character - the pull of opiate addiction is just too strong.

"It wouldn't matter who you were, whether you were Mother Teresa, or Rush Limbaugh or a junkie down here by the mission," McKnelly said. "There are a lot of things you can do to assist people around the edges, but you can't talk them out of a biological dependency."

He realizes that clinics such as his "bother some idealistic people" who see it as swapping one drug for another. But he said dispensing the drug in a legal setting reduces crime and the chances of people getting HIV or hepatitis from a needle.

"If we had something like this for cocaine, I could get the Nobel Prize nomination," he said.


Janet Lowther 11 years, 1 month ago

Up until quite recently, physicians have been terrified of giving high enough doses of pain killers to allow patients with chronic pain to live reasonably pain-free.

Anyone who has witnessed someone expire in excruciating pain because their physician would not prescribe adequate pain relief will have no doubt whatsoever that a few hundred overdose deaths is worth the benefit for the hundreds of thousands who do not have to live in agony because physicians are terrified of prescribing the drugs.

It needs to be remembered that when pain killer doses are adjusted to control the pain and no more, the patient does not get the feelings of euphoria or of a rush which leads to addiction.

Indeed if a pain patient feels those feelings, he needs to consult his physician about reducing the dose, or simply reduce the dose himself by increasing the time between doses, breaking tablets in half or some other means to see that the pain is just balanced by the pain killer.

lori 11 years, 1 month ago

I think part of the problem with the recent rise in methadone deaths can be attributed to health care providers' ignorance of the produce; which in turn can be attributed to our fear of using drugs like marijuana, morphine and the like. We worry about the legal issues, and then don't get the research we need.

The problems that I have seen with methadone here in our local hospital have to do with switching someone over from another drug for chronic pain to methadone. The time that it takes to metabolize it is longer, and patients (and docs) who are used to other forms of chronic pain medication sometimes don't take it/prescribe it appropriately. It is not in an attempt to get a high or abuse the drug; I think it is just a lack of education which stems from a reluctance to be associated with the drugs that have such a "dirty" reputation.

I have a lot of admiration for the work of Dr. McKnelly and the docs who appropriately prescribe pain management meds--I mean appropriately in terms of the patient feels their pain is controlled. It is not always a well-respected job, and many of their patients are difficult to work with. Not necessarily in terms of personality, but really in terms of their pain--it is so misunderstood, and a lot of research continues on pain, including where it originates, the causes, and the appropriate treatments for the different types. I hate that, because of our outdated views on certain drugs, we cannot offer a full-spectrum of pharmacological pain management.

mom_of_three 11 years, 1 month ago

Part of the problem not mentioned in this article (and perhaps it is in another one) is the selling of methadone prescriptions. Some doctors aren't paying attention to whom it is being prescribed to or how often the patient returns. Then the pills end up on the street, and a young person who did something stupid is dead. Maybe one (or a hundred) overdoses isn't very important to some, but it is to my family. There needs to be a good way of dispensing this and other pain medicines to those who need it.

OfficeGirl 11 years, 1 month ago

My adult son was given methadone in pill form by someone who supposedly had a legitimate prescription for them. Unfortunately, he didn't know about the absence of the euphoric part and died in his sleep after taking more that night than the night before. (I guess)They also build up in your system and have somewhat of a residual effect that he didn't know about. Rural MO police wouldn't prosecute even after they talked to the person who gave them to him and the guy admitted giving them to him.
I would have to agree with mom_of_three. Maybe the # of overdoses isn't important to some, but it certainly is to my family as well. If doctors are prescribing this stuff and it is known that the drug is being abused by people who don't know what they have, there needs to be a lot more education out there to prevent more needless deaths.

TheGoldenBoy 11 years, 1 month ago

For people with medical conditions that require strong analgesics, methadone and oxycodone are wonder drugs! I see no justification to deprive patients who have legitimate medical conditions that require the medicines. One of the reasons for the increase in the use of Oxcontin is simply because most other analgesics aren't potent enough to provide adequate pain relief and they often contain acetaminophen. Why prescribe something containing acetaminophen when research studies have already revealed conclusive proof that it causes extensive liver damage. You can't survive without a liver folks. Most of the transplant lists are five years long. You DON'T want your liver damaged alright. What I would like to see is hydrocodone marketed as a single entitity. Maybe they could call it Hydrocontin or something! As for the increase in the prescribing of Methadone for pain, well there are probably some good reasons for that. Reasons such as side effects and half-life!

Jersey_Girl 11 years, 1 month ago

Deaths like Anna Nicole's son are prime examples of why one should have all their prescriptions filled at the same pharmacy. As I recall, his death was a reaction between the methadone and an antidepressant. For those of you who have lost a friend or family member to a drug overdose, I'm sorry for your loss. But cracking down on the doctors who prescribe the pain meds is not going to stop overdoses, especially of those for whom they are not prescribed. It just makes it harder for those of us with chronic pain to get sufficient pain relief.

mom_of_three 11 years, 1 month ago

If there is a bad doctor in the system who is overprescribing the drugs, and not doing his job correctly, then getting them out of the medical world would do a great service to all.
If someone is caught selling methadone, prosecute them. And if the prescription isn't theirs, prosecute them to the full extent of the law. And if a doctor providing the drugs without doing his job correctly, then prosecute them, too.
It gives everyone else a bad name.

Melis11577 11 years ago

I am writing on behalf of HARMD (Helping America Reduce Methadone Deaths). We are the families of victims and those yet to be victims of methadone. I have come together with many other families throughout the United States who have lost loved ones to methadone.

We are asking government agencies to enact stricter guidelines in prescribing methadone for any reason. It must be mandatory that all doctors be certified and trained in the pharmacology of methadone; inpatient stays must be required during induction to methadone; all staff be extensively trained in monitoring methadone patients for symptoms of toxicity. Clinic patients should be tested for legal and illegal drugs that are taken with methadone to get "high" or experience "euphoria" such as benzodiazepines, alcohol, cocaine, heroin, marijuana etc: and face severe consequences / mandatory detoxification from methadone program. When presenting inebriated at clinic, clinic should also document such activity as well as prevent client from driving. Take home doses for all patients receiving methadone should be eliminated thus preventing the risk of diversion or precautions such as pill safe should be implemented.

Current statistics show that nearly 4000 people a year die from methadone. These deaths are mostly happening to pain management and detoxification patients within the first 10 days of taking initial dose. Most of these deaths are related to methadone prescribed with other medications that react as additives with the methadone. Diversion of methadone is a serious problem because it lands this most deadly drug on streets. Statistics also state that methadone is contributing to more deaths nationwide then heroine and only second to cocaine deaths.

At what point do we value human life over the convenience of others? Methadone patients, whether they are pain or clinic pose a risk to themselves and society as a whole if they are not monitored, dosed, and assessed correctly. Clinic patients getting into cars after being dosed who are using benzodiazepines, alcohol, marijuana or other opiates are killing innocent people on the road. This type of harm reduction is not saving lives it's taking them. The government cannot continue to be a legal drug dealer in order for its citizens to "behave".

There is A LOT of money to be made from methadone but what expense is that money being made at? When do the risks outweigh the benefits of this drug? How many more people must die before changes are made that actually save lives? The potential of abuse, diversion, and overdose to new patients being prescribed methadone is overwhelming. The unique properties of methadone, it's long half life, short analgesic properties, cardiac risks and it's negative interaction with numerous drugs make it an optimal choice as a last result treatment for chronic pain.

Thank you for taking the time to read this letter.


Melissa Zuppardi

releanoyed 11 years ago

I am a chronic pain sufferer. I have a degenerative condition that can never be cured and will only get worse until I die. If not for pain control prescriptions I would be unable to get out of bed 90% of the time. When I first developed the conditon I wasted over six months on a doctor who never seemed to be able to figure it out. I discovered years later when I became fully disabled that the docter had put in his notes that he felt I was just looking for pain meds and thus did not bother to follow up with extensive tests. As things are today, the simple fact that I use pain meds stigmatizes me. Although my doctor understands my condition (and how to treat it) his office's staff clearly treats me with suspicion and I often get negative glances when I turn in scripts at a pharmacy. If I need to go to a hospital for an emergency I am invariably looked at as a junkie until proven otherwise. Regardless of meaning well, articles like this and groups like HARMD are better at making the life of people like me more miserable then helping anybody. HARMD plans equal treating a patient as a junkie and criminal for simply being damaged. Their ideas are degrading and dehumanizing to the patients. It is true that abuse of any narcotic is dangerous both to the user and others. However, anybody can make themselves just as dangerous through the abuse of alcohol alone. The responsibility is, and should be, on the individual not to be a danger. No organization can prevent it, there is always another way a person destroy themselves if that is what they are looking to do. As for bad drug interactions, these are tragic, but again the responsibility is on the individual. That mixing meds can be dangerous is no secret or new information. Every bottle of pain killers I have ever seen has at least warning to this effect, plus one about not drinking. People need to take responsibility for their own health care and check into every prescription they get. Doctors are human, not gods.

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