Methadone is successful as painkiller, but can be deadly

Rivals or passes tolls of Vicodin and OxyContin

By Erik Eckholm and Olga Pierce
New York Times News Service / August 17, 2008
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NEW YORK - With excruciating spinal deterioration, Robby Garvin, 24, of South Carolina, tried many painkillers before his doctor prescribed methadone in June 2006, just before Garvin and his friend Joey Sutton set off for a weekend at an amusement park.

On Saturday night Garvin called his mother to say, "Mama, this is the first time I have been pain free; this medicine just might really help me." The next day, though, he felt bad. As directed, he took two more tablets, and then he lay down for a nap. It was after 2 p.m. that Joey said he heard a strange sound that must have been Robby's last breath.

Methadone, once used mainly in addiction treatment centers to replace heroin, is today being given out by family doctors, osteopaths, and nurse practitioners for throbbing backs, joint injuries, and a host of other severe pains.

But it is implicated in more than twice as many deaths as heroin and is rivaling or surpassing the tolls of painkillers like OxyContin and Vicodin. "This is a wonderful medicine used appropriately, but an unforgiving medicine used inappropriately," said Dr. Howard A. Heit, a pain specialist at Georgetown University. "Many legitimate patients, following the direction of the doctor, have run into trouble with methadone, including death."

Federal regulators acknowledge that they were slow to recognize the dangers of newly widespread methadone prescribing and to confront physician ignorance about the drug. They blame "imperfect" systems for monitoring such problems.

In fact, a dangerously high dosage recommendation remained in the Food and Drug Administration-approved package insert until late 2006. The agency has adjusted the label and is now considering requiring doctors to take special classes on prescribing narcotics.

Between 1999 and 2005, deaths that had methadone listed as a contributor increased nearly fivefold, to 4,462, a number that federal statisticians say is understated since states do not always specify the drugs in overdoses. Florida alone, which keeps detailed data, listed methadone as a cause in 785 deaths in 2007, up from 367 in 2003. In most cases it was mixed with other drugs like sedatives that increased the risks.

The rise of methadone is in part because of a major change in medical attitudes in the 1990s, as doctors accepted that debilitating pain was often undertreated. Insurance plans embraced methadone as a generic, cheaper alternative to other long-lasting painkillers like OxyContin, and many doctors switched to prescribing it because it seemed less controversial and perhaps less prone to abuse than OxyContin.

From 1998 to 2006, the number of methadone prescriptions increased by 700 percent, according to DEA figures, flooding areas where it had rarely been seen.

But specialists say too few doctors understand how slowly methadone is metabolized and how greatly patients differ in their responses. Some prescribe too much too fast, allowing methadone to build to dangerous levels; some fail to warn patients of the potential dangers of mixing methadone with alcohol or sedatives, or do not keep in contact during the perilous initial week on the drug.

"Those problems were not soon recognized," Dr. Bob Rappaport, a division director at the Food and Drug Administration. He added: "Methadone is an extremely difficult drug to use, even for specialists. People were using it rather blithely for several years."

Dr. James Finch, an addiction specialist in Durham, N.C., said, "In the clinical and regulatory communities, everyone is trying to run and catch up with and deal with the causes of methadone overdoses."

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