Tuesday, June 16, 2009

Unique aspects of methadone toxicity---the methadone toxidrome

James R. Roberts, MD, Professor of Emergency Medicine and Toxicology at the Drexel University College of Medicine, describes what I think we should call the methadone toxidrome:

The prescient clinician faced with a lethargic patient with pinpoint pupils can glance at the EKG and immediately pronounce methadone overdose.

Although the cardiac toxicity of methadone, unique among analgesics, has been known for at least 7 years and I first blogged about it here, it remains underappreciated. While Sid Wolfe clamors to ban Darvon the rising methadone body count continues to be ignored by consumer activists. All the while the pain treatment mafia rails against the evils of Demerol while promoting methadone as a reasonable analgesic.

Methadone’s cardiac issues first surfaced on a hospice which employed heavy use of methadone for terminal analgesia where otherwise stable patients, instead of gradually slipping away as expected, were dying suddenly. The same phenomenon has apparently been observed in methadone maintenance populations. To be sure, cardiac death can be the mode of demise in methadone overdose (the cardiac effects are not reversed by narcan, by the way) but not only that. Methadone can cause sudden cardiac death in ordinary therapeutic doses. And while the respiratory depressant effects of methadone, along with the analgesic effects, are blunted by the gradual development of tolerance the cardiotoxic effects are not. This is why patients on methadone may experience cardiac problems after years of stable use. Indeed, as dosages increase with the development of tolerance the cardiac risks can only increase over time.

Dr. Roberts seems to have gotten one thing wrong in this otherwise excellent article. He says:

No one appears to recommend routine EKG or continuing EKG follow-up in patients undergoing MMT or for those treated with methadone for chronic pain.

That was true until early this year when the American College of Physicians issued cardiac screening and safety monitoring guidelines for patients being prescribed methadone.


Anonymous said...

Your broad assumption about methadone's cardio toxicity has yet to be proven and your talking about it like it's a given? It never fails to surprise me how easily even DOCTORS can leave their rationality and objectiveness behind, when they hear the word "methadone".

YOur writing this entry as if your assumptions about methadone are a "known fact" and it's simply not true.

The first study you mention was very poorly done, only has 17 participants and everyone in it had a dose of 400mg or more. Hardly what most people reading your blog are going to think of when they read "ordinary therapuetic dose".

The recent rise in "body count" due to methadone has to do with OVERDOSES, not sudden cardiac death--and is usually in pain patients who took too much or in addicts who are not in a methadone program and they are almost ALWAYS poly drug...so bringing up the rise in methadone RELATED deaths is a poor choice. People will read your entry and believe that we have thousands of people dying because they took a small dose of methadone and their heart exploded. This is simply not the case.

Posting the comment from another site about a doctor knowing methadone is to blame immediately by looking at the EKG. First, the symptoms you mention (pinpoint pupils and lethargy) happen in any overdose situation. Second, overdoses are rarely due to one drug. Most overdoses coming into the ER have at least two drugs on board. I know this because I am the person in the lab running the drug screens. I think in the five years of overdose emergency room tox screens, I have seen ONE that methadone alone was to blame for an overdose. How can this doctor possibly say which drug is causing the blip on the EKG especially when you consider how many of these patients have amphetimines or cocaine in their system?

The other study you linked only had 22 patients on methadone. I recently had the pleasure of being in a conference with one of the Doctors who ran this study, and even she stated that all that can truly be concluded from her study is that MORE research into the usefullness of EKG's in particular patients on methadone, is needed.

To date there has been no proof that routine EKG's, for anyone on methadone, will even HELP--and it may actually hurt many patients because of the cost. Especially considering that there is no proof that RANDOM ekg's will diagnose or help prevent this phenomenon.

The most important thing to consider with ANY drug is if it's benefits outweigh it's risks. An opiate addict in methadone treatment has a far far greater risk of overdosing or dying from a disease caught by IV drug use--if methadone treatment isn't available to them--then they ever will ever risk from the very small risk of sudden cardiac death due to QT prolong.

As an emergency room doctor I am sure you have a very warped view of drug addiction and methadone treatment. You only see the tragedies....maybe you should do a little more research into the miracles. It might change the way you talk about this issue...because methadone treatment has enough stigma and prejudice and misinformation already. Just remember that anything you write about methadone may deter someone from seeking the treatment they need.

If you do nothing else after reading this message, at the very least you should read the responses to THE ANNALS when they published a crude list of guidelines (based on a very poor study) on this very issue

It's also worth noting that the Center for Substance Abuse Treatment forced Annals to retract the first guidelines and remove the agencies name from them....

Bren said...

The methadone advocates like arme that left a comment deny their own TORSADES patients. Ask how that makes them feel ? With methadone KILLING innocent victims by the thousands every year finally doctors and politicians have listened to the people of the United States.These advocates are so threatened from new regulations along with consideration of banning methadone they will say or do anything.Get it through your heads methadone causes serious side effects , it is an addiction in itself and is the #1 prescription opiate causing death on the market today. This poster is using their job description in claiming out right lies. One dose of methadone can kill whether it's from a clinic, doctor or diversion.Another false statement was made about poly drug use had to be involved NOT TRUE. How many autopsies and toxicolgy reports have you read ? I have known about methadone since the early 1970's and it has failed addicts miserably and it should never be prescribed as a pain medication. There are other safer alternatives in treating addiction.Everyday I work with families that have lost loved ones to this lethal drug and addicts seeking help. Our daughter died on April 5, 2006 from methadone alone prescribed as a painkiller within 8 hours of leaving the doctors office.She would be included in Your Body Count.

Anonymous said...

On January 4, 2007 our son died of a methadone overdose. The clinic he went to would only allow you to come in and take the liquid form and then drink water and show you did not hold it in your mouth. The toxicology report showed no other drugs in his system. He was on his third day of treatment. When he died he hadn't even digested all of that day's dose, which means he died within four hours of leaving the clinic. I was with him the first hour then left for work when he went to bed (we had to go very early in the morning the only hours the clinic was open). His father was off work that day and knew he had had trouble sleeping so he didn't bother him assuming he was finally getting some sleep. His methadone blood level per the autopsy was 1.38. There were no signs of any allergic reaction. I would like to know how this could happen and why the methadone clinics are not held accountable for "accidently" overdosing a patient. I know methadone helps a lot of people, but I do believe that clinics should be made to monitor their patients more closely as required by some states so that these "accidents" don't happen. My son went to the clinic for help because he wanted to change his life and ended up not living at all.

Anonymous said...

Methadone can cause an overdose, and at the same time it saves lives, and guess what - it is not going anywhere. Methadone maintenance treament programs will not be banned. Those who are concerned that it is such a toxic drug that kills so easily, this is simply not true. It is a very complicated issue, and most people in general, including nurses and physicians, are not fully educated on this issue. Methadone, as with ANY medication, reacts with person to person on an individual basis. Just because you know someone or have heard of someone who overdosed on methadone does not mean that it is going to effect everyone the same way, or even that it should be banned. There is an incredible lack of knowledge and sensitivity to this issue, even with doctors who prescribe it. How many people die from driving cars? Obesity? Smoking tobacco? Should these all be banned? The reason methadone maintenance is not going anywhere is the fact that it saves too many lives, and prevents too much crime. There are many more ways that it benefits society than harms it. I agree that physicians and nurses who work with patients on methadone need to acquire a tremendous amount education pertaining to this medication, moreso than most any other medications that exist. Methadone patients need very special attention that they do not often recieve in these drive thru style clinics that prescirbe it. Perpetuating myths and stigma related to methadone only increases the lack of ability to control the substance socially and medically. In other words, If you judge something and cast it out as "bad" (subjective) instead of researching and evaluating its benefits and how to better approach the administration of these benefits (objective) then you are creating even more complexity of the subject (methadone).

James said...

I would like to say that after a couple of very painful surgeries I became addicted to opiates. I began methadone

maintenance as a way to get off of narcotics altogether as well as to assist with the dehabilitating effects of withdrawal.

I began at a low dose - 20 mg a day. I did not do any other drugs, and my dose was increased to 50 mg per day, and when I

felt I was stable and had no more cravings I began to go down 1 mg a week. The maintenance program was difficult due to all

the demands made by the government on the clinic, and made it very difficult to stay in the program, but I did, and now I

am off of methadone and I can safely say that it did save my life. I could have turned to buying illegally and facing a

life of criminal activities and the threats that this type of lifestyle imposes. Of course I recieved a great amount of

negativity from other doctors when I went for other medical problems to the point I can say my other medical needs were

simply not met based on the doctors' own stigma of methadone. But this is only because it has been around for such a short

amount of time (since WW II), and there is so many rumors about it. Some of which were "Methadone rots your teeth" - (often

people confuse methadone for "meth" or "crystal meth") - "Methadone was named after adolph hitler so it must be bad" (not

true at all, I cant even begin to go into how off this rumor is), "if someone takes methadone with any other pain or nerve

medications they will die" (only if the doctors and patient do not understand and follow the rules", there were about 600

mehtadone patients at the clinic at one time, some made it through the program and some didnt because to put it simply they

still wanted to get high and they would continue to do other drugs illegally, mainly benzos cause this problem. Noone ever

died from their prescribed dose or suffered any health problems because of it. I have never used or been addicted to

heroin, but another rumor is that it is a step down from heroin (whatever that means) or that it is more difficult to get

off of than heroin. I find this very difficult to believe. Of course a patient can not go cold turkey and just stop taking

it on a daily basis, they do have to wean off from it at a pace they are comfortable with. Patients were drug tested

weekly, and if any drugs came up on their tests including even THC they were immediately put on a detox program. Those are

not fun because a patient will certainly face withdrawal and once again seek drugs illegally. If there truly are people who

die from taking a prescribed dose from a methadone program, I can only speculate that their health was not monitored

closely enough and that this would be a problem of that specific clinic and not methadone treatment in general. Some

clinics do overprescribe, and this can cause health problems and even death. From what I have seen, patients at

ridiculously higher doses than 50 - 60 mg per day are the ones who complained they were still withdrawing and experiencing

craving to the doctor in order to get a higher dose with hopes of possibly getting yet another high. Literally the second

day I dosed I noticed I wasnt even "buzzing", and by the third day on no "buzz" at all. And yes, these doctors and clinic

owners are smart people, you cant beat them, they have too much info, too much to contribute to their local societies, and

they are in the business of making money. Isnt that what America is all about these days? Unfortunatley we do not live in a

society that is educated on most any drugs, let alone one that is as unique as mehtadone.