5 May 2003

BMJ article. More deaths in ‘successful’ detox cases.

Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. Strang J, McCambridge J, Best D, Beswick T, Bearn J, Rees S, Gossop M. BMJ 2003 326:959-960

Dear Colleagues,

Concerned about the excessive overdose mortality in England in heroin users, Strang had the excellent idea of looking prospectively at detox candidates. This showed that out of 137 inpatient detox subjects 5 (3.6%) had died within a year. This is within the reported ranges for opioid dependent populations not in maintenance treatment (2 - 7%pa). Three deaths were overdoses and the other 2 may have been drug related (infection and renal failure in relapsed patients). However, and most importantly, these Maudsley researchers managed to contact and interview most of their survivors (103, 78% at a mean of 9 months). This confirmed strong associations with death vs. survival (1) living alone (80% vs 16%) and the possibly related matters of (2) spending longer in detox (25 vs. 15 days) and (3) completing 28 day detoxification (100% vs 67%). Consistent with other studies, all deaths were male and were more likely in intermittent users cf. regular heavy users. Sadly, of the 71% who were prescribed methadone the mean reported daily dose was approximately 29mg (sd ~23mg). Professor Strang's own recommendations are for a minimum of 60mg to be effective. These patients may have been offered inadequate and therefore ineffective methadone treatment. Such a situation may have seen patients who were not "ready" for detoxification applying for it.

Is it disappointing that despite follow-up questionnaires, we are not told what proportion of detox patients remained opioid-free at 9 months, although we are told that only 37 (27%) achieved complete abstinence and became what these researchers call 'lost tolerance' (LT) category. All 5 deaths came from this small group, thus yielding a mortality amongst 'successful' detox subjects ('completers') of 13.5% at one year (and 3 were dead within four months).
There have now been at least five good studies showing apparently increased mortality in heroin addicts who have detoxed from opioids including prison discharges (references below). Each adds to the now very worrying literature on overdose deaths.

There can be few who could be more deterred by legal sanctions against heroin use than recently released prisoners. Yet it is these very people who are at very high risk of both drug use and complications from that use, including risk of death (up to 14 fold in one study). It is believed that the reduced tolerance of people who have undergone any form of detoxification (including 'rapid detox') may render them at higher risk from overdose on illicit drugs of unknown strength.

We know that overdose cases are more likely to be occasional users, live alone, be male and, paradoxically, to have completed detoxification. These authors find the latter outcome 'counterintuitive' but also concede that reduced tolerance and unknown strength of street drugs could be a cause.

This study should not be taken to mean that detox should not be offered, but it demonstrates that it is not an evidence-based intervention and needs to be patient-instigated when other options have been unsatisfactory or inappropriate. Detoxification should never be compulsory since this is known to result in increased death rates as found in rigorous Swedish research.

Education about not injecting alone, using supervised facilities where available and using smaller quantities have the potential to avoid most overdoses.

comments by Andrew Byrne ..

this item: http://bmj.com/cgi/content/full/326/7396/959

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Kakko J, Svanborg KD, Kreek MJ, Heilig M. 1-year retention and social function after buprenorphine-associated relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. (2003) Lancet 361:662-668

Grönbladh L, Öhlund LS, Gunne LM. Mortality in heroin addiction: impact of methadone treatment. Acta Psychiatr Scand 1990; 82: 223 - 227.
Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study Strang J, McCambridge J, Best D, Beswick T, Bearn J, Rees S, Gossop M. BMJ (2003) 326: 959-960

Darke S, Hall W, Kaye S, Ross J, Duflou J. Hair morphine concentrations of fatal heroin overdose cases and living heroin users. Addiction (2002) 97:977-984