Addiction 2004 99: 846-854 (July)
Overdose deaths attributed to methadone and heroin in New York City, 1990-1998. Bryant WK, Galea S, Tracy M, Markham Piper T, Tardiff KJ, Vlahov D.
This comprehensive review of coroner's records yields important information on the relative harms of street heroin versus prescribed and street methadone in a large city during a period of continued increases in both 'markets'. This group from the New York Academy of Medicine quotes the origin of this study as suggestions that methadone was 'killing more people than heroin' (in the 1990s in England, where supervised dosing was exceptional). Some even advised that opioid maintenance treatment be reviewed or even withdrawn for this reason (Newcombe, 1996).
From 1990-98 the number of patients in NYC on methadone maintenance treatment (MMT) increased from 26,000 to 34,000 yet the number of deaths in which methadone was a contributor varied between 85 and 145 each year with no trend. Out of a total of 7451 overdose deaths reported during the 9 year study period, only 121 (1.6%) deaths were due to methadone alone. Another 900 (12%) were reported as due to methadone, in combination with cocaine (40%), heroin (30%), alcohol (41%). There was an overlap of 400 deaths in which both heroin and methadone contributed.
Heroin deaths increased from 300 to almost 700 per year in the first 4 years of the study period after which they levelled off and then dropped to around 500 annually in the last 3 years. These were more likely to be 'single drug' overdoses of which there were around 900, comprising 20% of all deaths attributed to heroin.
During most years of the study there were 3 to 6 times as many deaths from heroin as from methadone with an upward trend for heroin and no trend for methadone (p=0.16) from 1990 to 1998. Males accounted for 80% of the deaths with an even split of white, black and Hispanic at 33% each.
Considering the 5 boroughs of New York City, (Manhattan, Queens, Brooklyn, Bronx and Staten Island) this would appear to be up to 100 overdose deaths per million population annually overall. This compares with Australian figures of between 20 and 40 for the same period, up to 20 in the UK and as low as 2 in some European countries such as Holland and Switzerland. These figures seem to reflect the degree of 'zero tolerance' policy implementation, with lower mortality rates being seen with the introduction of harm reduction measures such as buprenorphine, methadone, injecting rooms, needle services and heroin prescription trials.
The authors report an 'intriguing' and unexplained finding that Staten Island had a much lower rate of overdose death (2.4% of the total). They recommend further study of how some areas, despite no shortage of drug users, report much lower fatality rates. They speculate on the possible effects of income levels and poverty by region.
The message from this study is that one can expand methadone treatment in an urban setting AND permit take-away doses (nearly all NYC MMT patients receive 'Sunday bottles') WITHOUT a corresponding increase in overdose deaths from methadone. Indeed, there is probably a corresponding reduction in the number of heroin overdoses, although this is harder to measure with the long time frames involved here.
Bryant WK, Galea S, Tracy M, Markham Piper T, Tardiff KJ, Vlahov D. Overdose deaths attributed to methadone and heroin in New York City, 1990-1998. Addiction (2004) 99: 846-854