An Investigation of Medical Examiner Cases in Which Methadone Was Detected, Harris County, Texas, 1987–1992

Abstract

In 1991, media reports of an increase in the number of deaths attributed to methadone toxicity in Harris County, Texas, raised public concern about the safety of methadone. This concern was heightened by publicity surrounding the closure of three Harris County methadone maintenance treatment programs due to their poor compliance with federal methadone regulations. In response to this concern, the Texas Department of Public Health requested that the Centers for Disease Control and Prevention (CDC) assist in an epidemiologic study to determine the extent of methadone-related mortality in Harris County during 1991 and to determine the role of methadone maintenance treatment in these deaths. We reviewed cases investigated by the Harris County Medical Examiner's Office from 1987 through 1992 in which methadone was detected by postmortem drug testing. The autopsy reports for cases occurring in 1991 were also reviewed by three independent forensic pathologists who were asked to determine the role of methadone in the death. In addition, we attempted to document Harris County methadone maintenance treatment program enrollment for each decedent. We identified 91 decedents in whom methadone was detected at the time of death, with the largest number of cases occurring in 1991 (n = 27). Other substances, including alcohol, were detected in 85% of the cases. The Harris County Medical Examiner attributed 11 of the deaths to methadone toxicity. No more than three cases per year from 1987 through 1992 were attributed to methadone toxicity. In contrast, 34 deaths were attributed to polydrug toxicity, the largest number occurring in 1991 (n = 11). There was good agreement between the results of the independent review and the opinions of the Harris County Medical Examiner. Only 20% of the decedents were found to have been enrolled in a Harris County methadone maintenance treatment program at the time of death. Four people died of drug toxicity shortly after enrolling in a methadone maintenance treatment program. We found an increase in the number deaths occurring in Harris County, Texas, in 1991 in which methadone was detected. We also found that methadone blood levels were higher among decedents identified for 1991 and 1992 than among those identified in the previous years studied. However, we did not find evidence that the cause of these deaths could be attributed solely to methadone toxicity. Instead, for all years studied, the use of multiple drugs was the leading cause of death among people in whom methadone was detected. This finding points out the difficulties involved in determining the role of methadone as a cause of death.

Methadone Death, Dosage and Torsade de Pointes: Risk-Benefit Policy Implications

“…In retrospective evaluations of post mortem toxicological investigations over a fi ve-year period in France (Pirnay et al 2004) and 1 1-year period in Germany (Grab et al 2003) a large proportion of methadone deaths were found to occur in combination with opioids, benzodiazepines or alcohol. Similar results have also been reported from the US (Barrett et al 1996), Australia (Capel hom & Drummer 2002), Switzerland (Parret et al 2000), and England, Wales and Scotland (Ghodse et al 2003;Griffith 2004;Seymour et al . 2003)…”

Interacciones de metadona con fármacos antiinfecciosos y sustancias de abuso

“…Este sector de población tiende a consumir todo tipo de drogas psicoactivas, con el consecuente riesgo de sobredosis por potenciación de sus efectos y/o aumento de sus niveles. Precisamente es el alcohol junto a las benzodiacepinas, una de las combinaciones encontradas con mayor frecuencia en las muertes relacionadas con la metadona (25,26). La trascendencia de esta combinación queda subrayada por el hallazgo de menores concentraciones plasmáticas de metadona con defunciones relacionadas con alcohol que en aquellas en que éste no estuvo presente, a pesar de que las primeras sólo constituyeron un 30% de los casos en este estudio (27).…”

Deaths Among Heroin Users in and out of Methadone Treatment

“…Methadone toxicity ranks high among the list of problems cited by opponents of methadone treatment (e.g., Marks, 1994;Newcombe, 1996), and periodic outbreaks of methadone-related deaths (Barrett et al, 1996;Drummer et al, 1992;Zimney & Luke, 1981) appear to lend credence to these critics. In contrast, standard substance abuse textbooks (Senay, 1994;Lowinson et al, 1992) often emphasize the safety of methadone in the treatment of opioid dependence.…”

“…Death directly attributable to methadone toxicity is, in fact, rare among patients on maintenance (Baden, 1970;Barrett et al, 1996;Chappel, Mays & Senay, 1973;Concool, Smith, & Stimmel, 1979;Des Jarlais, 1984;Greene, Luke & DuPont, 1974;Kreek, 1973;Manning et al, 1976;Texas Department of Health, unpublished). When such deaths do occur, they tend to happen during induction to maintenance, when assessment of patients' tolerance to opioids and concurrent use of other substances is especially problematic (Drummer et al, 1992).…”

“…When such deaths do occur, they tend to happen during induction to maintenance, when assessment of patients' tolerance to opioids and concurrent use of other substances is especially problematic (Drummer et al, 1992). The majority of deaths involving methadone occur among persons who are not enrolled in a treatment program (Baden, 1970;Barrett et al, 1996;Greene, Luke & DuPont, 1974;Nadler et al, 1975).…”