Commentary: decline in methadone-related deaths probably relates to increased supervision of methadone in UK.

Morgan et al. report a number of important findings, but of greatest interest to providers of drug treatment services is probably that methadone-related deaths dramatically declined from 1997 onwards. Deaths per thousand methadone treatment patient-years varied little between 12 and 13/year between 1993 and 1997 but then plunged by three-quarters between 1997 and 2004 to a low of 3.1 deaths per thousand in 2004. Furthermore, this impressive achievement occurred in the context of greatly increased expansion of methadone treatment and despite the finding that heroin-related deaths essentially continued to increase over the same time period. For some time in the 1990s in Britain, repeated claims that ‘methadone kills more drug users than heroin’ were made, and refuted. By 2003, Hickman et al. reported that trends in methadone-related deaths in England and Wales from 1993 to 1998 had not increased at a greater rate than heroin deaths. The present authors amplify the findings of Hickman et al. by their report of a precipitous decline in methadone deaths while heroin deaths continued to increase and they also demonstrate a strong association between heroin and methadone death rates and seizures of heroin and methadone. Their study should finally knock on the head the ‘methadone kills more people than heroin’ myth once and for all. Morgan et al. correctly hesitate to attribute the reduction in heroin-related deaths to improvements in methadone treatment availability. They theorize that changes in the underlying characteristics of the heroin-using population or, less likely, reduced availability of street heroin may also account for this. What could have led to such a healthy change? The most obvious coinciding changes have been the increased supervision of methadone treatment (i.e. the introduction of a system of supervised swallowing of prescribed methadone), and to a lesser extent reduced prescription of methadone tablets and ampoules (highly divertible and injectable sources of methadone), changes to methadone treatment consistent with current recommended best practice in the management of drug-dependent persons. What other explanation could there be? Fewer persons in methadone treatment since 1997? The data, however, indicate the converse, that more drug users are in treatment than ever. National Treatment Agency data show that numbers in treatment have more than doubled since 1998. Lower doses of prescribed methadone in recent years? The most recent prescribing data indicate that if anything, mean methadone doses have increased in the last decade, by about a fifth. Increasing provision of supervision? This has changed greatly and in the direction of the change in overdose deaths: since the mid-1990s, supervised consumption of prescribed methadone has become widespread rising from nil in England in 1995 to just under 40% of all methadone prescriptions by 2005. The reported reduction of methadone seizures since 1998 appears to be strong evidence of the impact of increased supervision of doses. The remarkable decline in methadone deaths is good news for providers of methadone treatment. Training, accreditation and/or licencing are not required of doctors in order to prescribe methadone mixture in Britain, as mentioned by Morgan et al. Yet, the extraordinarily encouraging findings of the reduction in methadone deaths coinciding with the expansion in continuous professional development initiatives in the drug treatment field, and the development and dissemination of national clinical guidelines specifically emphasizing adequate supervised doses alongside best practice models of shared care partnerships between primary care and specialist drug treatment services, indicate that Britain’s methadone prescribers have never been better informed or supported to deliver safe and effective methadone treatment. We are left in little doubt that the outstanding finding of Morgan et al. of a large decline in methadone-related deaths is most likely related to the introduction of supervised consumption of methadone. Whatever the explanation for the reduction in methadone deaths in this country, it is only a good news story for heroin users in treatment, their carers and families, the drug treatment field, policymakers, the general public and for methadone treatment itself.