1 August 2004

Methadone and buprenorphine related deaths rare in Paris study

Addiction 2004 99: 978-988


A critical review of the causes of death among post-mortem toxicological investigations: analysis of 34 buprenorphine-associated and 35 methadone-associated deaths. Pirnay S, Borron SW, Giudicelli CP, Tourneau J, Baud FJ, Ricordel I.



Dear Colleagues,

This adds to the modest amount of published research on the major French 'experiment' with buprenorphine, starting in 1996. To add another variable, two years after the release of unrestricted buprenorphine prescription, methadone treatment also became available, albeit in a more structured manner.

This is a detailed report of 60 consecutive overdose deaths in Paris over a 5 year period from 1997 in which buprenorphine (34), methadone (35) or both (9) were found in the post-mortem toxicology. An exhaustive investigation of each case classified the relative contribution (if any) of the two drugs towards the death. Unfortunately as a retrospective study, the authors were not able to determine the subjects' treatment status.

Despite buprenorphine being prescribed at a rate about 8 times that of methadone in France, the numbers of deaths most likely attributable to each drug were about the same (12 versus 14). In these deaths, as in other reports, an average of about 4 other drugs (excluding nicotine) was found, and in one case there were 13 additional drugs! Alcohol, benzodiazepines and other opioids were the most common, sometimes in very high concentrations. Heroin (morphine) was also found in toxic levels in 5 buprenorphine cases and 6 methadone subjects. Other cases either had clear alternative causes of death (eg. homicide, suicide, burns, carbon monoxide, etc) or else the cause of death could not be determined (12 cases).

In 1995 there were ~500 opioid overdose deaths in France. This annual rate had reportedly dropped to 100 by 1999. During this period, Australian overdose deaths increased relentlessly. Due to its restricted status, methadone in France is generally reserved for the more difficult cases. The authors state: "From the beginning, methadone appears to have had the image in France of 'a drug of last resort' for the most desperate cases". Hence the higher per-patient death rates are probably a combination of the drug's higher toxicity as well as it being used in higher risk circumstances clinically in France.

When compared, the figure of 60 deaths in a five year period is reassuringly low. This is in stark contrast to 900 methadone overdose deaths reported in New York City over a 9 year period (Bryant and colleagues in last month's Addiction). The difference is so great that it would appear France is doing something right while America is doing something wrong. Treatment access is doubtless a factor, and one can only speculate about the contribution of so-called US zero tolerance or 'harm maximization' policies as being related to the marked differences in outcomes in what is essentially the same social phenomenon in two very large, sometimes very tough cities on opposite sides of the Atlantic. New York's Rockefeller laws, with long mandatory jail terms for relatively minor drug offences, seem not to have had the desired effect, yet it seems they are politically very hard to reverse. It is good to know that the US has finally introduced buprenorphine treatment but sad to learn that, like methadone, most of the people who need it either cannot afford it or it is simply find that it is not available in their neighbourhood.

Comments by Andrew Byrne ..



Pirnay S, Borron SW, Giudicelli CP, Tourneau J, Baud FJ, Ricordel I. A critical review of the causes of death among post-mortem toxicological investigations: analysis of 34 buprenorphine-associated and 35 methadone-associated deaths. Addiction (2004) 99: 978-988