Controlling the Abuse of Illicit Methadone in Washington, DC Mark H. Greene, MD;

Barry S. Brown, PhD; Robert

L.

DuPont, MD

Methadone hydrochloride has been found to be medically safe when administered in the setting of a well-organized heroin addiction treatment program. The abuse of illicit methadone, outside the therapeutic setting, has aroused considerable controversy, particularly with regard to the public health hazards of primary methadone addiction, overdose, abuse, and childhood poisoning. We attempted to document the nature and extent of these negative aspects of the diversion of methadone into the illicit drug market, using data collected between 1969 and 1974 in the District of Columbia. The data illustrate the severe problems created by the widespread availability of illicit methadone, and document that, with the appropriate controls, the large-scale use of methadone in addiction treatment is feasible with minimum risk of methadone addiction and overdose in the community.

Methadone, high

a

synthetic narcotic,

was

originally

introduced as an alternative to opiate analgesics with addiction potential. It subsequently was found to possess a number of properties that led Dole et al to test its utility in treating heroin-dependent individuals.1 Today, methadone hydrochloride is widely used in the treatment of heroin addiction. In the setting of a well-or¬ ganized treatment program, methadone appears to be "medically safe, with minimal side effects and no toxicity" for the addict treated with it.2 As drug abuse has emerged as an issue with significant political and racial overtones, debate has grown regarding the dangers of using methadone. Early research docu¬ menting the abuse potential of methadone has been cited in this regard,15 as well as the occurrence of methadone overdose,68 childhood poisoning,9 methadone abuse,10·11 and diversion of methadone by patients in treatment into the illicit drug market.1013 It has been stridently claimed, although poorly documented, that methadone is an un¬ mitigated menace to the community. Many people now be¬ lieve that the use of methadone in addiction treatment is followed, of necessity, by a flood of illicit methadone in the streets of their city, with concomitantly high rates of methadone-overdose deaths and primary methadone ad¬ diction (addiction to methadone prior to addiction to her¬ oin or other opiates). In spite of this controversy and the social importance of this issue, there has been no system¬ atic attempt to verify the nature and extent of these neg¬ ative aspects of the use of methadone in addiction treat¬ ment.

This report summarizes Washington, DCs experience following the introduction of methadone as an addictiontreatment tool, documenting the problems encountered as a result of methadone diversion (diversion of methadone Accepted

for publication Oct 21, 1974. From the Bureau of Epidemiology, Center for Disease Control, US Public Health Service, Atlanta (Dr. Greene); the Bureau of Research and Development, Narcotics Treatment Administration, Department of Human Resources, Government of the District of Columbia, Washington, DC (Dr. Brown); and the Special Action Office for Drug Abuse Prevention, Executive Office of the President, Washington, DC (Dr. DuPont). Reprint requests to the Special Action Office for Drug Abuse Prevention, 726 Jackson Place NW, Washington, DC 20506 (Dr. DuPont).

intended for therapeutic use in heroin addiction treat¬ ment programs into the illicit drug market), and the re¬ sults of control measures designed to reduce these prob¬ lems. The data suggest that, given appropriate controls, it is feasible to use methadone on a large scale in addiction treatment while simultaneously minimizing the risk of methadone addiction and overdose in the community. METHODS The data were collected through the activities of the Narcotics Treatment Administration (NTA), the District of Columbia's large, multimodality addiction treatment program established in late 1969.,4 By the end of 1973, NTA had treated in excess of 15,000 heroin users. Approximately 80% of these patients received methadone, 60% in a detoxification program and 20% in a main¬ tenance program.

The NTA Drug Abuse Surveillance System provided data on methadone-related deaths, methadone seizures made by the DC Metropolitan Police, and urine screening for methadone at two different sites. Details of this data-collection system have been

previously reported.1516 Briefly, data on methadone-related deaths were collected begin¬ ning in 1969 with an improvement in the system occurring in July 1971 with the establishment of a medical examiner system in the District of Columbia. Data have been collected in a uniform fash¬ ion since that time with no change in the system for classifying drug-related deaths.6 Cases reported as acute methadone-overdose deaths all had positive toxic reactions to methadone and no other apparent cause of death. Deaths due to homicide, suicide, acci¬ dent, and natural causes were excluded. Cases included in this re¬ port include those in which methadone was the only drug detected, as well as cases in which both methadone and morphine were de¬ tected, since our data indicate that methadone plays the critical role in these latter cases.6 The DC Metropolitan Police Narcotics Squad tabulated all sei¬ zures of illicit drugs on a monthly basis. Methadone seizures are reported here as a percent of all illicit drugs seized. Police enforce¬ ment policy and data collection procedures were unchanged dur¬ ing the course of the study period. Urine testing for methadone was performed at two locations. First, heroin addicts enrolling with NTA were tested at NTA's Central Medical Intake Unit. An average of 250 patients were tested each month. Second, urine specimens were obtained from arrestees newly incarcerated in the DC Superior Court Central Lockup, a holding facility in which arrestees await arraignment. An average of 85% of the 1,000 individuals incarcerated each month underwent this urine drug-screening procedure. These two testing programs represent different samples of the total popu¬ lation of individuals using methadone. There is some overlap be¬ tween the two samples since one third of NTA program admis¬ sions are referrals from the criminal justice system. However, the NTA admission data include predominantly voluntary referrals, and the Superior Court data include individuals who are not re¬ ferred to the treatment program. The NTA's Bureau of Research performed a series of five sur¬ veys ("methadone diversion surveys") between January 1972 and December 1973 on addicts entering treatment. Sample sizes ranged from 100 to 150 consecutive individuals encountered at

Downloaded From: by a UNIVERSITY OF ADELAIDE LIBRARY User on 12/01/2017

NTA's Central Medical Intake Unit. With minor variations, the questionnaire instrument was used in all surveys. Detailed data on each respondent's experience with illicit methadone were same

sought.

Statistical tests of significance employed in evaluating the data included 2, Student t test, the Pearson Product Correlation Coef¬ ficient (r), and the Mann-Whitney U Test. Trends were demon¬ strated by means of a linear regression line fit by the method of least square. Significance of trends was tested by applying the Student t test to the slope (b) of the linear regression line. HISTORICAL BACKGROUND

The following is a brief summary documenting the growth of the methadone-abuse problem in Washington, DC, and those measures instituted to control this problem. The Growth of Methadone Abuse Fall 1969.-Methadone introduced in the District of Columbia on a small scale by private physicians and public programs January 1970.-District of Columbia's first methadone-overdose

fatality February

1970.-The NTA established-large-scale government high-dose methadone maintenance used (mean, 100 mg/day; maximum, 160 mg/day; supervision of take-home med¬ ication inadequate Fall 1970.—Beginning of large-scale methadone sales by DC pri¬ program;

vate

physicians

Winter 1970,-Start of education campaign regarding the nature of methadone March I971.-Accidental methadone-poisoning death of a 2-yearold child Winter 1971.—Heroin shortage in the streets of Washington January to February 1972.—Fourteen fatalities related to meth¬ adone overdose March 1972.-First NTA methadone diversion study-methadone readily available in the streets of Washington; NTA an impor¬ tant source of methadone reaching the streets

Control Measures March I971.-Intensified education campaign regarding dangers of unsupervised methadone use; introduction of child-proof, unit-dose methadone medication bottles; introduction of lockboxes for NTA patients to store home medication March 1972.-Suspension of methadone prescribing by DC private physicians and pharmacists May 1972.—Introduction of noninjectable liquid methadone prepa¬ ration by NTA September 1972.-Improved NTA clinic security (narcotics safes and alarms) October 1972.—Conviction of local physician for prescribing meth¬ adone for profit (lost license, $150,000 fine, and 15 to 45 years in

prison)

February 1973.-Introduction of more stringent take-home crite¬ ria; decrease in maximum number of doses of take-home medi¬ cation from four to two; decrease in maximum dispensed dose of methadone from 160 mg to 80 mg16 March 1973.-Last of the methadone-for-profit physicians closed down; introduction of computerized methadone accounting by NTA July 1973.-Decrease in maximum take-home dose of methadone from 80 mg to 60 mg

RESULTS

These control

introduced gradually be¬ in methadone use be documented as follows:

measures were

tween mid 1971 and mid 1973.

associated with this effort

can

Changes

Downloaded From: by a UNIVERSITY OF ADELAIDE LIBRARY User on 12/01/2017

Methadone-Overdose Deaths

There were no known opiate-overdose deaths related to methadone prior to 1970. As depicted in Fig 1, there were 17 such deaths (2.2 per 100,000 general population in the District of Columbia) in 1970. The death rate rose to a peak of 51 deaths (6.7 per 100,000) in 1972, and decreased to 14 deaths in 1973 (1.8 per 100,000). The declining death rate was first observed in the fourth quarter of 1972. Fur¬ thermore, of the 14 deaths in 1973, only three occurred during the last six months of the year. There were two methadone-related deaths in the first six months of 1974. This represents an annualized methadone-overdose death rate of 0.5 per 100,000, over 90% decrease from the peak death rate of 7.7 cases per 100,000 observed during the first six months of 1972. Police Methadone Seizures

There has been a steady decline in the number of meth¬ adone seizures made by the DC Metropolitan Police since early 1972 (Fig 2). Although the number of methadone sei¬ zures has been small, there were one third as many such seizures in the first quarter of 1974 compared to the first quarter of 1973. This is a statistically significant down¬ ward trend (r -.71, -2.88, < .05). It is of interest to note that there has never been a seizure of a large quantity of methadone in the District of Columbia. Typi¬ cally, only one or two doses of the medication have been found at any one time. This suggests that methadone is not part of the underworld drug distribution network; rather, the distribution chain is very short, most fre¬ quently directly from a patient to a friend. Such a distri¬ bution pattern, unlike that of heroin with its multilevel system, is not readily susceptible to police intervention. =

=

Methadone-Urine

Screening Of the two sites at which testing is performed, the data obtained from the arrestee population at the DC Superior

Court seem to be the more reliable index of illicit meth¬ adone use prevalence. This is because these data are ob¬ tained from individuals who did not know their urine might be tested at the time they made their decision to take a particular drug. The fact that they happened to be arrested provided the opportunity of obtaining a urine sample for drug screening. In the data reported here, ar¬ restees who were receiving methadone from an official treatment program were eliminated from the sample. As indicated in Fig 3, the percentage of urine specimens found to contain illicit methadone has decreased from a peak of 8.4% during the first quarter of 1972 to 2.7% in the second quarter of 1974. This decline is statistically signifi¬ cant

(r -.88, =

t

=

-5.46,

Controlling the abuse of illicit methadone in Washington, DC.

Methadone hydrochloride has been found to be medically safe when administered in the setting of a well-organized heroin addition treatment program. Th...
949KB Sizes 0 Downloads 0 Views