Fatal methadone overdose

Editor–We had grandiose plans for our study of methadone related deaths1–until we realised that the local drug rehabilitation community was more interested in bidding for a forthcoming contract to provide a methadone maintenance programme to Manchester Health Authority. Our most informative contact refused to be acknowledged in print for fear of dismissal for revealing “commercially sensitive” information about the nature of certain bids. For these reasons, we limited ourselves to studying coroners' records. We freely admit that this approach has drawbacks: for example, coroner's records depend on appropriate referral of cases, and they are limited to subjects who died within the boundaries of individual jurisdictions rather than those resident there at the time of death.

We know that there are major difficulties in interpreting methadone concentrations after death,2 and the identification of fatal methadone overdose requires much more than matching a postmortem blood concentration with a predetermined criterion: it takes into account other findings made on naked-eye, histological, and toxicological examination, as well as considering anything known about the clinical circumstances. We explained this to members of Drugs North West, so we were surprised to read an accusation by John Merrill and colleagues that we have exaggerated our statistics on deaths caused by methadone3 and amazed that they ignore our observation that many of our subjects were killed by diverted methadone; in these subjects the concentrations appropriate for habitual users may be invalid. If Merrill and colleagues think the pathological diagnoses are wrong, what do they think is going on? Does Manchester really have an epidemic of some mysterious disease that kills young people, leaving no visible trace, affecting only those who have recently taken methadone? In any case, with few exceptions, methadone concentrations in our subjects were much higher than those discussed in Merrill and colleagues' letter: subjects investigated by the toxicological service at Manchester Royal Infirmary showed mean concentrations of 1057 µg/1 in users of diverted methadone and 2730 µg/1 in habitual users. Incidentally, Merrill and colleagues have overlooked a conflict of interest, which is that part of their client base is resident within the jurisdiction of the City of Manchester coroner.

We agree that effective services should be available to all who are dependent on opiates, but we do not think that the way forward is to stick one's head firmly in the sand, ignoring deaths caused by diverted methadone. It is clear that sloppy practices persist in the prescription, dispensation, and storage of methadone,4 5 and these now require urgent attention.