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Increase in Deaths Due to Methadone in North Carolina
To the Editor: Methadone traditionally has been used to treat opiate addiction, but in recent years has been used increasingly for management of chronic pain. In North Carolina, for instance, there was a 4-fold increase in the amount of methadone sold to pharmacies and hospitals between 1997 and 2001,1 probably reflecting the increased use of methadone for pain management. However, because the analgesic effect of methadone lasts less than 12 hours while its plasma half-life can last for up to 72 hours, frequent dosing can result in toxic levels.2-4 Thus, a few states have reported a recent rise in methadone-related deaths.5-6 However, these unpublished reports include deaths in which methadone only appears as a toxicological finding and contain limited information beyond the drugs involved. We examined deaths due to methadone in North Carolina between 1997 and 2001, and ascertained the manner by which methadone had been obtained.
Methods
We used medical examiner (ME) data to identify unintentional deaths due to methadone in North Carolina from 1997 through 2001. For deaths to be included in this report, the ME must have concluded that methadone was a primary cause of death and that the manner of death was accidental; these determinations were made using autopsy results, drug concentrations, and a review of clinical and historical information. The reporting of poisonings through North Carolina's centralized ME system has been standardized for more than 20 years.
We simultaneously surveyed all authorized North Carolina opiate treatment programs (OTPs) to determine which of the decedents had been receiving methadone therapy. This investigation was determined to be exempt from review by the institutional review board of the North Carolina Department of Health and Human Services.
Results
We identified 198 deaths due to methadone. Sixty-four percent were among males, 98% were among whites, and the mean age was 38.9 years. The number of deaths increased from 12 in 1997 to 80 in 2001. During this time the rate of deaths due to methadone per 100 000 population increased more than 5-fold, from 0.16 in 1997 to 0.98 in 2001. In 75% of cases, the ME concluded that methadone was the only drug that significantly contributed to death.
Additional information on the likely source of methadone was documented in the ME reports for 97 (49%) of the decedents. Of these, 73 (75%) had been prescribed methadone by a physician. The remaining 24 decedents (25%) were reported to have obtained methadone illicitly (eg, prescribed to a relative or friend, given at a party, or purchased "on the street"). When shown the list of decedents, OTPs reported that only 8 (4%) of them were clients at their time of death. We received responses from 100% of North Carolina OTPs.
Comment
We found a 5-fold rise in the number and rate of deaths due to methadone in North Carolina from 1997 through 2001. Much of this increase may be related to increased prescription and use of methadone.
Additionally, although there was a 4-fold increase in methadone retailing statewide during this period, the amount of methadone retailed to OTPs increased only 2.6-fold (J. Howard, Targeting and Analysis Unit, United States Drug Enforcement Administration, written communication, May 2003). Because only 4% of decedents were receiving methadone maintenance therapy for opiate addiction at the time of their death, it seems unlikely that this indication was directly associated with the increase in deaths due to methadone in our study.
Michael F. Ballesteros, PhD, MS;
Daniel S. Budnitz, MD, MPH
Epidemic Intelligence Service
Epidemiology Program Office
Centers for Disease Control and Prevention
Atlanta, Ga
Catherine P. Sanford, MSPH
Injury and Violence Prevention Unit
Division of Public Health
North Carolina Department of Health and Human Services
Raleigh
Julie Gilchrist, MD
Division of Unintentional Injury Prevention
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention
Georgina A. Agyekum, MPH
Public Health Prevention Service
Epidemiology Program Office
Centers for Disease Control and Prevention
John Butts, MD
Office of the Chief Medical Examiner
Division of Public Health
North Carolina Department of Health and Human Services
Chapel Hill
1. Department of Justice, Drug Enforcement Administration. Automation of Reports and Consolidated Orders System (ARCOS): Retail Drug Summary Reports, 1997 and 2001. Available at: http://www.deadiversion.usdoj.gov/arcos/retail_drug_summary/index.html. Accessibility verified May 27, 2003.
2. Shir Y, Rosen G, Zeldin A, Davidson EM. Methadone is safe for treating hospitalized patients with severe pain. Can J Anaesth. 2001;48:1109-1113.
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3. Fainsinger R, Schoeller T, Bruera E. Methadone in the management of cancer pain: a review. Pain. 1993;52:137-147.
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4. Inturrisi CE, Colburn WA, Kaiko RF, Houde RW, Foley KM. Pharmacokinetics and pharmacodynamics of methadone in patients with chronic pain. Clin Pharmacol Ther. 1987;41:392-401.
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5. Sorg MH, Greenwalk M. Maine Drug-Related Mortality Patterns: 1997-2002. Available at: http://www.state.me.us/ag/pr/drugreport.pdf. Accessibility verified May 27, 2003.
6. Florida Department of Law Enforcement. 2002 Interim Report of Drugs Identified in Deceased Persons by Florida Medical Examiners. Available at: http://www.fdle.state.fl.us/publications/examiner_drug_report.pdf. Accessibility verified May 27, 2003.
Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.
JAMA. 2003;290:40.
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