Marteau coMplex
We were shocked to see the title of a
key article on the cover of last
month’s
DDN
,
Kill or cure: the dangers
of diverted methadone
.
DDN
’s
approach was more in keeping with a
tawdry tabloid splash rather than its
usually more balanced magazine.
Dave Marteau’s article (page 6) asks:
is it time ‘to reappraise our
relationship with the life-saving drug
methadone?’ He says he will discuss
the evidence and this is what we
want to challenge.
He starts with how methadone
reduces deaths by 50 per cent, reduces
HIV infection and how it has been
positively evaluated by NICE. Then it
seems as if Marteau does not know
that methadone and buprenorphine
are very different drugs. It is no
revelation that methadone is
potentially more dangerous than
buprenorphine. Thus they are in
different legal classes and schedules –
unusually a sensible use of the
classification system. But simply
saying methadone is more dangerous
than buprenorphine is like saying
insulin is more dangerous than oral
hyperglycaemic drugs and therefore
we shouldn’t prescribe insulin.
He references the Auriacombe
review of drug-related deaths in
France between 1994 and 1998,
which found buprenorphine was
safer. This was when buprenorphine
was first licensed and was first used
in primary care and prescribed to
people with less complex issues. This
is a very important point. Many of us
writing here are clinicians and have
between us many, many years of
experience. We will have cared for
thousands of patients with drug
problems and as a broad
generalisation, the more complex,
vulnerable, more likely to overdose
and sick patients were settled much
better on methadone and few of this
group did well on buprenorphine.
Keeping these patients in treatment is
the most important thing – especially
at the start. So using the medicine
that does this most successfully is the
obvious and right thing to do.
In his own study on which this
article is based,
The relative risk of
fatal poisoning by methadone or
buprenorphine within the wider
population of England and Wales
Marteau D, Macdonald R, Patel K. BMJ
Open 2015; 5:e007629
, they used
fairly simple drug-related mortality
data from two sources but posed
some complex questions. We feel
there is not nearly enough data to
make any recommendation on ‘safe
or unsafe’ prescriptions from this
paper. Marteau needs to recognise
that the nature of methadone – or
buprenorphine – related deaths is a
very broad church and association
does not necessarily imply causation
in all cases.
It is also an area where reporting
bias may feature. In the Bell study
there were 60 sudden deaths positive
for methadone (32 in treatment) and
seven buprenorphine-positive
decedents (none in treatment). Most
out-of-treatment deaths occurred in
people with known histories of drug
misuse, so is this a failure by drug
services to engage with people?
Might the diverted methadone
actually be keeping many people alive
who aren’t able to access treatment
or couldn’t manage daily supervision?
Also, isn’t it possible that those who
were in treatment were inadequately
dosed and self-treating with street
methadone? It’s notable that the
average dose of methadone across
the six years of the Marteau paper
was 46.6mg per day, way below the
accepted therapeutic dose – what
part did this play?
Using a single study, which like
any academic paper has weaknesses
as well as strengths, to suggest
blanket recommendations on policy
is indefensible. It’s a sensationalist,
self-aggrandising approach that does
an enormous disservice to public
health. Methadone has many
complex issues but it is a medication
that has saved many lives in this
country and around the world and
continues to do so. Of course the
issue of diversion is important and
should be dealt with, but this article
is at the very least unhelpful, and at
the worst dangerous, particularly in
this climate of rising poverty, social
exclusion and drug-related deaths.
We implore Marteau to think
seriously about the limitations of his
paper before recommending
potentially dangerous and unjustified
policy changes.
Dr Chris Ford, clinical director, IDHDP;
Dr Euan Lawson, deputy editor, British
Journal of General Practice;
Dr Clare Gerada, GP and ex-chair RCGP;
Dr Judith Yates, GP and chair IDHDP;
Dr Roy Robertson, professor of addiction
medicine, Edinburgh; Dr Garratt
McGovern, specialist GP, Dublin; Niamh
Eastwood, executive director, Release;
Dr Icro Maremmani, president, World
Federation for the Treatment of Opioid
Dependence; Dr Alex Wodak, emeritus
consultant, Alcohol and Drug Service,
St Vincent’s Hospital, Australia;
Dr Robert Newman, director, Baron
Edmond de Rothschild Chemical
Dependency Institute, US; Joycelyn
Woods, executive director, National
Alliance for Medication Assisted
Recovery, US; Dr Jasna Cuk Rupnik, MD,
Center for Prevention and Treatment of
Addiction of Illicit Drugs, Slovenia;
Professor Barbara Broers, vice-president
of the Swiss Society of Addiction
Medicine; Dr Herman Joseph, NAMA, US
Dave Marteau
responDs:
I am reassured that experts now all
seem to agree that methadone is
more dangerous than buprenorphine.
The published evidence to date
indicates that it is around five times
more lethal. Again, all seem to agree
that methadone diverted from the
treatment system is the main source
of these tragedies. A total of 2,366 of
our fellow citizens dying with
methadone in their systems in just
six years is hundreds, if not
thousands, too many.
I have already given my views on
this very important subject, so I (and I
imagine
DDN
) would welcome the
thoughts of other readers.
DDN is a non-partisan forum for
debate and all views are welcome.
Editor
reD alert
I work in an emergency accommoda-
tion facility, and I recently completed
a two-day trainer course on naloxone.
Now we have been told we cannot
store naloxone on the premises –
neither will they fund a kit for myself!
Red tape gone mad... again!
Jim Kirkwood, Glasgow
Letters and Comment
8 |
drinkanddrugsnews
| October 2015
DDN welcomes your letters
Please email the editor,
or post them to DDN, cJ wellings ltd, 57 High street, Ashford, Kent tN24 8sG. letters may be edited for space or clarity.
‘
Might the
diverted
methadone
actually be
keeping many
people alive who
aren’t able to
access treatment
or couldn’t
manage daily
supervision?’
