Methadone overdose deaths in Australia

by Alex Wodak & James Bell

Over the last few years in Australia, there has been a steady increase in the number of deaths attributed to methadone toxicity. This mainly involves patients recently commencing this treatment, often within the first week. A series of deaths were investigated by the Coroner in the southern state of Victoria.

An account of these deaths was published in an international forensic journal and a letter to the Lancet. The Coroner was very critical of training methods of medical practitioners prescribing methadone. Subsequently, a number of deaths attributed to methadone have occurred in New South Wales. Coronial enquiries are underway. It is likely that the majority of cases will be confirmed as methadone deaths. Why has this happened? In Victoria, it was obvious that most of the deaths involved medical practitioners who had received little if any advice about the unusual pharmacology of methadone. Many patients were started on unrealistically high doses (e.g. 70 mg) or were prescribed increments which were too large (e.g. 10 mg) or too frequent (e.g. more than twice a week). Guidelines were produced and these have become more conservative over time. All guidelines now recommend starting at 40 mg or less and also warn against increments greater than 10 mg per week or more than 5 mg twice a week. New guidelines are expected to recommend an initial starting dose of 35 mg or even 30 mg. Another problem has been that of disseminating these guidelines. Prescribers who have been practising in this field for some years without problems continue to prescribe doses which are now realised to be hazardous. However, some fatal cases have occurred even among prescribers who have attended courses where the dangers of excessive starting doses of methadone have been discussed. Another problem has been that liberal take-away policies, intended to encourage rehabilitation, improve the attractiveness of treatment and reduce the costs of unnecessary bureaucracy, unfortunately resulted in substantial diversion. Some of the deaths have been attributed to ‘grey market’ methadone. An additional cause of death was young children unscrewing bottles of parental methadone and dying from an overdose. Most take-away methadone in Australia is now provided in special screw top bottles which cannot be opened by infants. As always in drugs and drug policy, a sense of balance is of critical importance but difficult to achieve. All of us working in this field need no reminders about the immense benefits which can accrue to individuals and their communities when heroin dependent drug users can readily obtain treatment in well run methadone programmes. Few of us would have realised, until recently, that these programmes are not without cost. There can be little doubt that the balance of benefits and costs in Australia, as elsewhere, remains strongly favourable. However, as committed harm reductionists, we must all do what we can to ensure that deaths from methadone are reduced to an absolute minimum. What is even harder is ensuring that this is achieved without making methadone programmes so rigid and unattractive that our patients prefer the street heroin programme run by criminals and disgraced ex-policemen.

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