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Diversion and Abuse of Methadone Prescribed for Pain Management
To the Editor: In late 2003-2004, the White House Office of National Drug Control Policy, the General Accounting Office, and several state authorities reported that diversion and abuse of methadone was emerging as a major problem in a number of metropolitan areas across the United States.1-4 In some states, it was asserted that methadone had surpassed controlled-release oxycodone as the most widely diverted and abused drug, an assertion reinforced by newspaper accounts.1-5 This increase in reported methadone abuse was attributed to the increase in licit and illicit exposure to methadone resulting from its inappropriate use as a safer alternative to drugs with greater potential for abuse. To examine the accuracy of these reports, we quantified information from an abuse and diversion surveillance system.
Methods
Purdue Pharma LLC has created the Researched Abuse Diversion and Addiction-Related Surveillance (RADARS) system, designed to obtain information on abuse of oxycodone and other prescription opiates. As part of this program, quarterly survey interviews were carried out with 237 drug diversion investigators (2002-2003) and 321 drug abuse experts (2003 only). For the studies reported in this article, these informants estimate that their catchment areas cover nearly 80% of the nation, including all urban and most rural areas, particularly areas in which abuse of prescription drugs has been endemic for decades (eg, Appalachia). For all cases in which abuse of methadone was reported, each informant was requested to fill out a case report form that included demographic data and whether the patient’s drug-seeking behavior met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for substance abuse and dependence. The accuracy of the number of abuse cases and diagnosis of substance abuse generated by the drug abuse experts was assessed by review of a sample of patient charts (>50) and by on-site interviews with 18 abusers at 12 sites. There was a 95% concordance between what was reported in questionnaires and our review.6
Results
Police investigators reported a total of 623 cases of methadone diversion during 2002 and 2003 (Figure), with a steady increase in the number of reports over the 2-year period. There was a 5-fold increase in rates of reported methadone abuse over the 4 quarters in 2003, expressed as cases per 1000 prescriptions (Figure). These reports of abuse and diversion were widespread and included many small cities, suburban areas, and rural areas in more than 47 states, including areas in which abuse of prescription drugs is widespread. Methadone tablets were the form of use indicated in more than 80% of these reports. During this time, the number of prescriptions for methadone increased from fewer than 1 million in 2002 to 2.6 million in 2003 (data purchased from IMS Health Inc).
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Figure. Methadone Abuse Cases per 1000 Prescriptions and Diversion Cases, 2002-2003
Rates were not applicable for diversion since a case frequently involves fake prescriptions and possession of 1 or 2 tablets, making rates based on legitimate prescriptions inappropriate. All of these data have been standardized using 150 informants/quarter as the baseline.
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Comment
Methadone clinics typically dispense maintenance doses in either wafer or liquid form and do not normally use externally filled prescriptions. The number of methadone clients has remained stable for the last decade. The marked increase in prescriptions for methadone suggests that methadone is now being increasingly prescribed for pain management. Given this, the predominant use of tablets suggests that methadone was being diverted from the analgesic market as a result of the increase in availability to patients and perhaps adjunctively to recreational or habitual drug abusers.
Two limitations of this study should be considered. First, while there is evidence to support the general accuracy of the surveillance system, there was not complete validation of all abuse cases. Second, while our data suggest increasing levels of methadone abuse, it must be emphasized that in terms of relative rates of abuse methadone does not rank as highly as other more commonly abused analgesics, including most prominently oxycodone, the abuse of which is at least 5-fold more prevalent.1, 4 Nevertheless, our data show that physicians who choose to prescribe methadone as an analgesic need to do so carefully and be aware of the possibility of diversion and abuse, a number of reports of fatal overdose,1-5 and the possibility that it may not be correct to assume that methadone is a much safer and less abusable alternative to other opiate analgesics.
Financial Disclosure: The authors received consultant fees from Purdue Pharma LLC during the time these studies were carried out.
Access to Data: Dr Cicero had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analyses.
Funding/Support: This research was supported in part by grants from Purdue Pharma LLC as a general study of prescription drug abuse. Purdue Pharma has extensive interests in opiate analgesics, the most important of which is oxycodone, and other long-acting analgesic preparations.
Role of Sponsors: Purdue Pharma LLC had no role in the design and conduct of the study; the collection, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript.
Theodore J. Cicero, PhD
cicerot{at}wustl.edu
Washington University School of Medicine
St Louis, Mo
James A. Inciardi, PhD
University of Delaware
Newark
1. Executive Office of the President, Office of National Drug Control Policy. Pulse Check: Trends in Drug Abuse, January 2004. Washington, DC: Office of National Drug Control Policy; 2004.
2. National Drug Intelligence Center. Information Bulletin: Methadone Abuse Increasing. September 2003. Available at: http://www.usdoj.gov/ndic/pubs6/6292/index.htm. Accessibility verified November 23, 2004.
3. Substance Abuse and Mental Health Services Administration. Methadone-Associated Mortality: Report of a National Assessment. Rockville, Md: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration; 2004. Publication 04-3904.
4. Substance Abuse and Mental Health Services Administration. Results From the 2002 National Survey on Drug Use and Health: National Findings. Rockville, Md: Substance Abuse and Mental Health Services Administration; 2003. NHSDA Series H22, DHSS publication SMA 03-3836.
5. Maimon A. Methadone abuse hits state hard. Louisville Courier Journal. May 9, 2004.
6. Cicero TJ, Adams EH, Geller A, et al. A postmarketing surveillance program to monitor tramadol (tramadol hydrochloride) abuse in the United States. Drug Alcohol Depend. 1999;57:7-22.
PUBMED
Letters Section Editor: Robert M. Golub, MD, Senior Editor.
JAMA. 2005;293:297-298.
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