Methadone death, dosage and torsade de pointes: risk-benefit policy implications

Methadone maintenance treatment (MMT) for opioid dependency has consistently shown important heath, social and legal benefits. What started as a small experimental program in Lexington, Kentucky has grown and expanded substantially over 35 years. Its practice is now well established both in specialized centers and in the broader community. In society, methadone deaths represent an important issue of public safety: methadone diversion to and ingestion by nontolerant individuals outside of treatment. Within treatment, methadone deaths occur most commonly in the early stabilization period (due to issue of tolerance), in periods of transition, or among certain individuals who abuse other substances (opioids, benzodiazepines, or alcohol). Research suggests moderately high methadone dosages help improve patient retention. Results from pharmacodynamic, kinetic and stereospecific studies continue to support the importance of individualizing dose. For some patients, much larger doses may be necessary to fully achieve all pharmacotherapy goals of treatment. Practitioners must be cautious however as certain patients on higher dosages are predisposed to torsade de pointes and increased mortality. Policymakers have a responsibility in their decision-making to balance the quality of life benefits for patients within MMT with the risks of increased mortality both for individuals within treatment and the general public.