A report has come out this week on deaths caused by methadone overdose — specifically, overdose on methadone prescribed for pain relief. The report excluded methadone prescribed as a treatment for addiction — probably, if I had to guess, because in addiction treatment methadone is much more tightly controlled on a per-patient basis, since overdose is a recognized danger.
I think this is yet another symptom of the failure to properly integrate addiction care into the vast and varied field of pain management. They are so often considered two separate things, when in fact, a huge percentage of all patients being treated for pain are using methods which, uncontrolled, can lead to addiction. A vast majority of my addiction patients get addicted in this way — through pain treatment, originally for a surgery, accident, or other injury. Most people know about methadone in the context of addiction (methadone maintenance), and when they hear that it is causing overdose deaths, it will probably be addiction treatment that takes backlash. While methadone can be an ineffective and even harmful treatment for addiction (which is why I prescribe buprenorphine instead), the providers dispensing it for addiction treatment are well aware of their patients’ symptomatic tendencies to overmedicate. In pain relief, however, it would not surprise me at all to learn that methadone, like all the opiates that came before it, is being prescribed without proper regard for its dangerous and addictive properties.
Because methadone is used as a treatment to keep addicted people off of other opiates, physicians may assume that it is a “safe” alternative to narcotics. While it may be safer than street drugs, it is still a dangerous drug in its own right, and cannot be prescribed as an alternative to other commonly abused painkillers, like Oxycontin and Percocet.
Methadone is a complicated drug to dose and monitor correctly. It is not just another off-the-shelf opioid. Its overuse by inexperienced and untrained physicians is the reason for the overdoses and deaths, not its use as a treatment for opioid dependence by adequately trained physicians. I’m glad to at least see that physicians are being instructed not to use it “until all other opiates have failed to work”, but this is at most a first step in the right direction. Addiction care, both preventative and intervention-based, must be integrated fully into pain management in order to protect patients and physicians alike. It is also my personal hope that buprenorphine will soon replace methadone as the maintenance-based addiction therapy of choice; my own reasons for prescribing buprenorphine are that it is much safer, much more difficult to overdose on, and, in my experience, more effective at helping patients feel free of their addictions. I think it is absurd that buprenorphine has not yet become the standard; tragedies like the overdose deaths in the linked report would be greatly reduced by its widespread adoption. But even where buprenoprhine is not adopted, the improperly regulated prescription of methadone cannot continue.