Drug Diversion and Abuse: Methadone: Friend or Foe?
Although methadone is often legitimately prescribed as a painkiller, it continues to be abused—pharmacists should remain aware.
John Burke, commander of the Warren County, Ohio, drug task force and retired commander of the Cincinnati Police Pharmaceutical Diversion Squad, is a 40-year veteran of law enforcement. Cmdr Burke also is the current president of the National Association of Drug Diversion Investigators. For information, he can be reached by e-mail at linkEmail('burke','choice.net');, via the Web site www.rxdiversion.com, or by phone at 513-336-0070.
As this piece is being written,concerns over methadoneseem to have swelled, asreports of abuse have become morewidespread. This has been building fora few years now, as the drug has seena surge in prescribing due to its lowcost and, I believe, the thought that ithad relatively low abuse potential.
Manufacturers of the 40-mg methadonetablet, as of January 1, 2008, havedecided to withdraw this strength fromthe retail market and make it availableonly in health facilities and clinics thataddress substance abuse. This was inresponse to a recommendation by theDrug Enforcement Administration andis not currently mandated by theagency. My office is in the process ofconcluding a criminal case with a physicianwho was illegally prescribing the40-mg tablet, and a single pill was beingsold at $40 to $45 on the street insouthwest Ohio.
Methadone is a Schedule II drug, sowhen prescribing is increased significantly,it is clear why the abuse of thedrug also would increase, due to themere fact that more of the productexists for potential diversion. This is thecase with most controlled substances,as you might guess. It is important topoint out that the vast majority ofincrease in abuse of methadone occurswith the drugs that are being prescribedby physicians and dispensed inretail pharmacies. The liquid form ofmethadone, commonly used in clinicsto address substance abuse, is mostlynot the potential culprit. Some abusewill always exist in the clinics, mostlyinvolving the practice of allowing somepatients to take home a supply to preventthem from having to visit the clinicevery day. Again, diversion from thissource appears to be relatively lowacross the United States.
Instead, improper prescribing hasbeen reported as a larger problem anda potential cause of many of themethadone overdose deaths. Methadonehas a slow onset and long halflife,placing those who want to get highin potential peril. As they take their initialdose and do not attain the highthey were looking for, they increase thedose over several days and run the riskof overdose and even death.
So with all of these problems, whydo we not just get rid of methadonealtogether—the world would be a betterplace, right? Some groups, likethose supporting the Web site www.harmd.org, would very much like to dothat—very similar to a few radical folkswho still want to ban oxycodone(OxyContin) from the market.
The problem with banning methadoneand other prescription drugpainkillers is that, every day, they servea vast number of patients who desperatelyneed legitimate pain relief. Estimatessuggest that less than 10% ofthe individuals who ingest controlledsubstances are abusing them. If mymath is correct, this means that over90% of those individuals who are prescribedcontrolled substances needthem and take them as directed.
The other point that sometimes doesnot seem politically correct when dealingwith parents whose children havedied while taking these drugs is thatmany of them were either taking thedrug that was not prescribed to them,abusing what was prescribed to them,or involved in some sort of criminalbehavior that allowed them to obtainthe prescription medications. I havetremendous sympathy for these parents,but it does not justify not tellingthe entire truth. We have all made decisionsin our life that we wish we couldrescind. I continue to be an avid legitimatepain-patient advocate, but it worriesme whenever these types of situationsarise.