10 June 2013

Two articles indirectly support opiate maintenance in community practice.

Opiate-Dependent Patients on a Waiting List for Methadone Maintenance Treatment Are at High Risk for Mortality Until Treatment Entry. Peles E, Schreiber S, Adelson M. J Addict Med 2013 7;3:177-182

Criminal behavior in opioid-dependent patients before and during maintenance therapy: 6-year follow-up of a nationally representative cohort sample. Soyka M, Träder A et al. J Forensic Sci 2012 57;6:1524-30

Dear Colleagues,

A diaspora of twelve methadone clinics across Israel had no waiting lists until 2002. The waiting time increased from seven months in 2003 to almost two years by 2008. These veteran authors describe outcomes for opiate dependent citizens while not in treatment. From state records we learn mortality and cause of death for both groups plus an older ‘control’. ‘The mortality rate during the 2 years on the waiting list was higher (5.0/100 person years) for the 225 non-admitted applicants than for the 358 admitted (0.42/100 person years, P < 0.0005) …’. Of those seeking treatment 40% were never admitted and 21 of 24 deaths in the period occurred in those who were on the waiting list. There is much more in this article but the ‘message’ is the same as Gronbladh (1990), Caplehorn (1994), Blix (1999), Clausen (2008) that maintenance treatment lowers a very high mortality (and morbidity) dramatically.

In Germany over 2000 opiate dependent patients were followed for six years after joining maintenance therapy (see ref). There was a criminal conviction rate (ever) of 85%. Follow-up at six years was available for 71% finding progressively reducing rates of both acquisitive and drug related crime. In the final year only 18% had any ‘legal problems’ as defined by EuropASI subscore.

Unlike Germany and most other western countries, neither Israel nor the United States allow methadone treatment in regular medical practice and community pharmacy. The restriction of this simple treatment to specialised clinics limits patient numbers to the capacity of the clinics and prevents expansion of treatment in the most efficient sector of the health care system.

As in many American clinics, the main Israeli facility had 330 ‘slots’. New admissions are restricted by the large number of long-term recipients with no alternative if they wish to remain on methadone treatment. Thus in 2002 in Israel and much earlier in America (about 1985) the numbers of patients on methadone was effectively frozen. If this occurred in any other field of medicine there would be an outcry, especially a condition which affected so many individuals directly and indirectly.

Written by Andrew Byrne ..


Grönbladh L, Öhlund LS, Gunne LM. Mortality in heroin addiction: impact of methadone treatment. Acta Psychiatr Scand (1990) 82:223-227

Caplehorn JRM, Dalton MSYN, Cluff MC, Petrenas A. Retention in methadone maintenance and heroin addicts' risk of death. Addiction 1994 89:203-7.

Clausen T, Anchersen K, Waal H. Mortality prior to, during and after opioid maintenance treatment (OMT): a national prospective cross-registry study. Drug Alcohol Depend 2008;94:151–157

Clinic web page: http://methadone-research.blogspot.com/