Heroin, long Oregon's leading cause of fatal drug overdoses, has been dethroned--by methadone, a synthetic drug originally developed to help junkies kick the habit. Last year, methadone killed 103 Oregonians, two more than succumbed to heroin.
Oregon health officials are now investigating the sharp spike in methadone overdoses, which have soared by more than 400 percent since 1999--a wave of death that may be caused by the drug's increasingly muscular role in treating chronic pain, as opposed to its traditional duty in fighting heroin addiction.
"We are looking into this," says state epidemiologist Dr. Mel Kohn. "This is a problem we are concerned about."
The amount of methadone prescribed in Oregon has surged since 1997, according to the U.S. Drug Enforcement Agency. That's because it has several advantages over other drugs like morphine, OxyContin and Vicodin in the treatment of chronic pain.
Pain experts say methadone is highly effective, long-lasting and cheap--a pill costs as little as 10 cents, compared to $2 to $4 for OxyContin.
Because it doesn't produce a euphoric rush, methadone is also less likely to suck patients into addiction. "The patients don't get intoxicated," says Dr. Stuart Rosenblum of the Legacy Emanuel Pain Management Clinic. "It's got low abuse potential."
OxyContin, in particular, has suffered of adverse publicity in recent years with headlines describing the drug as "hillbilly heroin." As a result, some doctors have been reluctant to prescribe it. "People are somewhat afraid of OxyContin," says Dr. Brett Stacey, director of the pain-management clinic at OHSU.
In addition to its virtues, however, methadone also packs a lethal punch. While all narcotics hold the potential for overdose, pain experts say methadone is particularly dangerous. "There's no doubt. It's the easiest [pain drug] to make a mistake with," Stacey says.
Unlike other painkillers, methadone remains in the system for a long time. Its "half-life" (the period required for the body to eliminate 50 percent of the drug) ranges from 12 hours to as many as 150 hours. "That's a pretty broad range," says Kohn. "It's pretty easy to see how insidiously you might build up to lethal levels."
"It builds up in your body," says Rob Boggs, an investigator at the medical examiner's office. Victims, he says, "go down to take a nap, and they die."
The current investigation began in October after Dr. Larry Lewman of the State Medical Examiner's Office reported a suspicious increase in the number of overdose victims winding up on his gurney. "I said, 'something's wrong,'" he told WW.
The deadly power of methadone was demonstrated last month when music fan Nick Baccelleri suffered a fatal overdose in Multnomah county jail (see "What Killed Nick Baccelleri?," WW, April 16, 2003). Baccelleri, 41, was serving time for a drunk-driving conviction. But health workers at the jail did not let him take his OxyContin prescription for chronic back pain and switched him to methadone instead. He was found dead in his cell less than 48 hours later.
Handled properly, pain experts say, methadone is an excellent painkiller. "It is an important and useful tool in the pain-management armamentarium," says Rosenblum.
But methadone can be dangerous for two kinds of patients: those with a history of drug abuse, who may be tempted to take too much; and those with compromised liver or kidney function, whose bodies may not be able to eliminate the drug fast enough.
Pain experts say some of the overdoses stem from deliberate overuse by patients. But they also blame ignorance on the part of some doctors. "We are finding overdose deaths because of improper prescribing," says Carol Misrack of the State Pain Management Commission.
But doctors say they are under pressure from health plans to keep costs down. "Dollars are a serious issue, and methadone is by far the cheapest drug," says Rosenblum. "There's been a strong, strong push toward methadone."
For example, Central Oregon Independent Health Services, an HMO serving low-income Medicaid patients, has recently designated methadone as the only long-acting painkiller it will pay for, effective this September.
As a result of HMO pressure, many family physicians--who may not be familiar with the drug's quirks--may be turning to methadone without fully realizing its deadly potential.
"This drug is very potent," says Rosenblum. "Start low, and go slow."