DEATH STALKS INCREASED METHADONE USE IN STATE

in Oregon from the use of methadone, a narcotic painkiller and heroin
substitute, have quadrupled in four years, health officials said Monday.

The rising toll reflects a sharp increase in use and abuse of the low-cost
opiate by chronic pain patients, they say.

Last year, 103 Oregonians died of methadone-related causes, compared with
23 in 1999. That is more deaths than caused by any other narcotic,
including heroin.

"We're seeing essentially a mini-epidemic of methadone deaths," said Dr.
Stuart Rosenblum, co-medical director of the Pain Management Center at
Legacy Emanuel Hospital & Health Center.

Methadone, a long-acting narcotic, was approved in 1972 by the federal Food
and Drug Administration specifically for treatment of heroin addiction. In
recent years, it has been used increasingly for chronic pain.

More of Oregon's methadone-related deaths occurred in patients treated for
pain than in heroin addicts, said Dr. Mel Kohn, state epidemiologist.

Oregon ranks fifth among states in methadone distribution per capita for
heroin addiction and chronic pain. Use rose five-fold in Oregon between
1997 and 2001 -- in part because the Death With Dignity Act legalizing
doctor-assisted suicide prompted widespread attention to end-of-life care,
including pain management.

Insidious, complex drug Another factor: Methadone is by far the cheapest
painkiller in its class. Health insurers, including budget-strapped state
Medicaid programs such as the Oregon Health Plan, have a clear incentive to
encourage doctors to prescribe methadone before other, more expensive
painkillers.

Drugs such as OxyContin, a newer painkiller, cost between $3 and $4 a pill,
Rosenblum said. Methadone costs about 10 cents a pill.

But methadone is a tricky drug to prescribe, with potentially insidious
effects. The effects develop more slowly -- without the obvious "high" of
many opiates -- and last longer. That means patients may be tempted to
boost their dosage prematurely -- and dangerously.

"It's a two-edged sword," Rosenblum said. "Methadone is a very effective
drug that can give people back their lives. But it also takes careful,
educated use."

It's an extremely risky drug for patients to take without close medical
supervision. Compared with other drugs in its class, including heroin and
morphine, methadone has "by far the most complex pharmacology," Rosenblum said.

"Some patients do better on methadone; some do better on OxyContin," Kohn
said. "It's not a simple thing." Both drugs, he noted, have been linked
with abuse and fatal overdoses.

Jumps in methadone-related deaths have been reported in other states as
well, including Florida, Maine and North Carolina.

"Treating heroin addiction and chronic pain are very important things to
do," Kohn said. "We don't want to stop doing that."

But doing so requires tough medical judgment calls.

Price pressure Jeff McClelland, who has been disabled by partial paralysis
and chronic pain since a car crash in 1995, recently got caught in that bind.

McClelland is on the Oregon Health Plan, which refused to continue paying
for his painkiller of choice, MS Contin, until he tried the much cheaper
methadone last month.

"It was a horror story for 20 days," said McClelland, 40, who uses a
wheelchair and has chronic pain in his neck, shoulders, back and legs.

Methadone caused him severe side effects, including shortness of breath,
headaches and panic attacks.

"My body would clench up," he said. "I felt like I was a junkie. I had to
take Valium to be able to take methadone."

After numerous phone calls by McClelland and an appeal by Rosenblum, his
doctor, the health plan agreed to pay for a new prescription of MS Contin.

Rosenblum worries that the cost factor is pressuring many primary care
doctors, with little or no experience in prescribing methadone, to choose
the drug for their pain patients.

Until recently, methadone was considered a second-line drug in pain
treatment, used only after patients tried other long-acting opioids, such
as morphine or Fentanyl, or short-acting ones, such as Percocet or Vicodin.

Methadone's effect on individual patients is highly variable. In some, the
main effect of a dose lasts 20 hours; in others, more than 150 hours.

Danger of mixing Like many other medications, methadone is more dangerous
when taken in combination with alcohol or other drugs. A majority of
Oregon's reported methadone-related deaths involved patients with a history
of abusing other drugs.

State health officials advise doctors to "start low and go slow" when
prescribing methadone.

The Oregon Board of Medical Examiners, which regulates medical practice in
the state, requires a doctor prescribing methadone to discuss its risks
with the patient. The patient must sign a form acknowledging receipt of
that information.

Among other steps being considered, Kohn said, is "some kind of little red
flag" that a pharmacy computer would raise electronically with every
methadone prescription to remind the doctor to ask the patient about other
medications being taken.

He also warned family members to be alert to symptoms of methadone
overdose: excessive drowsiness and louder-than-usual snoring.

Long-acting opioid painkillers were one of the first classes of medication
investigated for the Oregon Health Plan's preferred drug list, which began
last August. The state will not pay for unlisted drugs for health plan
patients unless the doctor requests an exception for the prescription.

Drug of first resort Most commercial health insurance plans have similar
lists of cost-effective drugs that doctors are encouraged to prescribe
before trying expensive alternatives.

The state Health Resources Commission considered nine long-acting pain
relievers and looked at 37 published studies. It found no evidence to
support one drug as safer or more effective than the others.

With all nine drugs deemed comparably effective, price became the key to
getting on the preferred list. State Medicaid officials chose long-acting
morphine as the benchmark drug, based on its low wholesale price. Methadone
is cheaper, but it was rejected as the first-line drug because of its
tricky dosing and its stigma from use in addiction treatment.

Two other drugs, MS Contin and OxyContin, were left off the list because of
their high price.

Judgment calls, such as those required to prescribe methadone, are simply
part of practicing medicine, said Dr. Steven DeLashmutt, an internist in
Baker City and a member of the Health Resources Commission.

"You prescribe one drug, and if that doesn't work, you find others to use,"
he said. "You have alternatives.

"It's just that you try methadone first."