MISERY INDEX, PART II

The state's medical examiners have seen a parallel rise in the number of
methadone-related deaths with the amount of methadone prescribed to treat
pain

Editor's Note: This week in part two of "The Misery Index", UTW reviews drug
overdoses documented by the state Medical Examiner's Office and the
increasing role methadone is playing in drug-related deaths, particularly in
Oklahoma.

Fifteen years ago, very few methadone-related deaths occurred in the state
of Oklahoma.

The Drug Enforcement Administration still spent a considerable amount of
time cracking down on doctors who prescribed narcotics to treat severe acute
or chronic pain, and medical schools for years tended to discourage students
from making narcotics widely available for pain mitigation.

Doctors generally were more afraid of going to jail than assisting patients
afflicted with brutal, incessant pain.

Since then, however, attitudes have shifted, and the DEA has become
enlightened to the needs of chronic pain sufferers enabling the wider
distribution of codein, Demerol, Dilaudid, oxycodone. . .and methadone.

Thousands of terminal patients in particular found relief, and the
conscientious consideration of chronic pain patients became an issue not of
mere medical ethics, but of human rights.

"When I trained, they taught me, you never prescribe narcotics for people
with chronic pain. Why? Because they're going to get hooked," said Ronald
Distefano, a state assistant medical examiner. "They're likely to take too
much and die just because the nature of chronic pain patients. . .[But] the
philosophy in medicine changed 180 degrees."

Methadone appeared at the top of the list as a popular drug for easing
everything from cancer symptoms to ceaseless back pain experienced by
millions of Americans. In the early '90s, pain management specialists had
initiated the use of methadone for treatment, but more recently, a wider
variety of practitioners have begun employing the drug.

Designed by the Germans during World War II, no patent on the drug is held
by a major pharmaceutical manufacturer making it attractively cheap and
easily dispensable by doctors and insurance outfits alike.

It carries a significant half-life sustaining relief from pain for much
longer periods of time, and taken alone it produces relatively little in the
way of a euphoric sensation compared to other controlled substances used to
treat pain.

But a high rate of methadone-related overdoses in Oklahoma suggests
patients, as well as recreational methadone abusers, are dangerously unaware
of the drug's nuanced pharmacology.

Between 2002 and 2003, the number of methadone-associated deaths in Oklahoma
jumped from 55 to 82, even while overall drug deaths were slightly lower
that year, according to numbers from the state medical examiner.

Incomplete preliminary numbers for 2004 put the number at 131, which means
methadone appeared in more than a fifth of drug deaths across the state.

An Urban Tulsa Weekly investigation revealed there are two very distinct
stories to methadone in Tulsa.

Last week we reported that the city's for-profit methadone clinics, charged
with administering substance-based treatment to drug addicts, have had
difficulty executing their mission during a time when approaches to treating
narcotics abuse nationally are changing.

But when it comes to methadone-associated deaths, the clinics tend to be
regulated enough to prevent diversion of the drug to recreational users.
Distefano discovered, as did the federal Substance Abuse and Mental Health
Services Administration, that methadone distributed for pain from physicians
was either not being taken according to the prescription, or was being
abused by experimenters.

This week in part two, UTW reviews drug overdoses documented by the state
Medical Examiner's Office and the increasing role methadone is playing in
drug-related deaths, particularly in Oklahoma.

Steel pillows

Randy Suffell's desk job is far from mundane.

After 20 years working as a funeral director, the Eastern Division of the
state Medical Examiner's Office, located at the OSU College of Osteopathic
Medicine off West 17th St., hired him as a family assistance coordinator.

Suffell works at the morgue, in other words. And two decades of learning how
to sensitively plan funerals with grieving families had prepared him for the
job.

"They wanted somebody who could keep our job and the families a little bit
separate, but still be very responsive and very empathetic to them." Suffell
said.

Of the 30,000 or so deaths in the state of Oklahoma each year, autopsies are
performed on a considerably small portion, and most autopsies are triggered
by legal requirements, including all drug overdoses.

Police and paramedics can only determine that a drug overdose has likely
taken place. The state's medical examiners dissect bodies completely, and
after sometimes as long as three months, the coroners conclude in an opinion
(they emphatically describe it as an opinion rather than a ruling) how an
individual has died.

Essentially, ME's come the closest to finding out exactly what's killing
people.

After a toxicology screening is conducted and just before the autopsy report
is issued, it's Suffell's job to call distraught families to tell them what
killed someone they love.

And lately, he's had to tell a lot families that methadone has played a
role.

"The people I talk to, it's a very emotional call, because I'm giving them
terrible news," Suffell said. "It's horrible to call a mother and say her
25-year-old son died from the toxic effects of methadone, and she didn't
even know he was taking it. He got it from a friend, or he had a sore back
and his brother loaned him some of his. It just destroys people."

Suffell is not a doctor, but spending the entire day explaining what drugs
were found in an overdose victim's body gives him particular insight. He
says he makes methadone calls every single day, and indeed he'd made one
just before we sat down to talk.

A few weeks ago, he had to call a mother and explain that the few tablets of
her prescribed methadone she had given her son for a backache had killed
him. His body hadn't been tempered to tolerate the dosages.

Assistant medical examiner Distefano became alarmed when more and more
victims of drug overdose appeared at the morgue with methadone as a
prominent culprit.

He began distilling the numbers to find out just how the rate of
methadone-associated deaths was climbing. In an analysis he conducted for
the state Medical Licensure Board, he noted that since about 1997, overdose
rates that included methadone had steadily increased. He constructed a bar
graph that showed a parallel rise in the amount of retail methadone
distribution across the United States reaching just over 30,000 grams in
2002 from less than 1000 in 1994.

He then began to cross-reference Oklahoma's rates with numbers from other
cities around the country collected by the Drug Abuse Warning Network
(DAWN). He noticed that for cities in many other states, methadone was low
on the list of drugs associated with overdoses, and in some cases, they were
so low they didn't appear on the top-ten list at all.

The last time Oklahoma reported to DAWN in 2001, Oklahoma City showed
methadone among its top three mentions, while New Orleans, Dallas, Kansas
City, St. Louis and Denver ranked methadone significantly low among top
killers. Six cities didn't even rank methadone in the top ten in 2002, but
methadone was Oklahoma's number one mention that year.

Users in Oklahoma, he gathered, were likelier to abuse prescription drugs
compared with drugs that appeared prevalently in other cities.

And of all Oklahoma's autopsy files he reviewed, 65 percent of the victims
had no known prescription to methadone, strongly suggesting the drug was
diverted from someone who did.

"My whole issue was, 'Where's this methadone coming from?'" Distefano said.
"Everything I saw led me to believe it was for chronic pain."

What's important to understand about the DAWN numbers, however, is that
they're based on what drugs are appearing in medical examiners' reports from
major cities across the country.

As Suffell noticed, death certificates contained larger combinations of
drugs compared with what he had seen previously. DAWN's numbers include all
certificates in which methadone was mentioned in concert with other drugs.

A popular yet dangerous combination is methadone, alcohol and cocaine, but
abusers and patients alike have been known to combine the benzodiazepine
Xanax, often prescribed for anxiety, with methadone. The two are relatively
safe together if taken as prescribed, but patients not fully aware of how
dangerous they can become often fail to strictly follow their prescriptions.
For abusers, the two together produce a spectacular high in larger
quantities, but raise the risk of overdose.

The component of methadone that makes it particularly volatile is its
half-life. The drug builds in the system and takes a longer amount of time
than other drugs to filter out of the body. A second methadone tablet piles
on to the first rather than simply replace it.

"Methadone doesn't give you as much latitude to over-medicate as other
drugs," Suffell said. "So if they over-medicate with methadone, all of a
sudden they've got a toxic-level build up. Then when you combine it with
other drugs, it's a real problem."

But Distefano will be the first to say that the introduction of methadone as
a pain reliever was not a mistake on the part of the medical community or
regulators. While he'd rather the DEA not play God over the severe acute or
chronic pain of patients, the problem, it seems, is a failure on the part of
patients and abusers to regard how quickly methadone can become a killer if
not taken as prescribed.

Like just about everything in medicine, methadone is a double-edged sword.

Grey area

When the national press, including the New York Times, picked up on the
story of methadone-associated deaths describing the drug as "widely abused
and dangerous," the temptation was to immediately assume it was leaking onto
the streets from drug treatment clinics.

But in May 2003, following an investigation by the federal Substance Abuse
and Mental Health Services Administration, a report concluded that
methadone-associated deaths were largely generated from diversion or neglect
of the drug's prescription to pain patients.

"The conclusion we were able to draw is it wasn't methadone provided in
addiction treatment," said Nick Reuter, senior public health analyst for
SAMHSA. "When I talk to physicians throughout the U.S., the inexpensiveness
of methadone is a big factor in why doctors write for it. It's reimbursed
more readily through Medicaid."

SAMHSA noted that methadone deaths involved one of three scenarios:

Illicitly obtained and excessively consumed by abusers;

Illicitly obtained and mixed with other prescription medications and alcohol
to produce a greater high;

An accumulation of methadone to harmful serum levels in the first few days
of treatment for addiction or pain, before tolerance is developed.

SAMHSA strove to quell concerns about the drug stating "methadone continues
to be a safe, effective treatment for addiction to heroin or prescription
painkillers," and, "while deaths involving methadone increased, experiences
in several states show that addiction treatment programs are not the
culprits."

Reuter reiterated that the respected National Institutes of Health had
issued a consensus report in 1997 stating methadone maintenance was the most
effective treatment for opiate addiction.

Dr. William Yarborough, as associate professor of medicine at the University
of Oklahoma Schusterman Center in Tulsa, further argues that reporters need
to lend more context to the issue of methadone in their coverage.

Yarborough explained that the last time he saw data in 2000, 18,000 people
in the United States had died from the toxic effects of NSAIDs - drugs like
Ibuprofen and Celebrex - more than the number of drug abuse deaths.

"They're very good drugs for some things, but because they're not narcotics,
doctors just hand them out for pain and they have lots of side effects,"
Yarborough said. "Why do we not have policemen with guns out visiting
doctors offices wanting to know how many of these you're prescribing?"

The very word "narcotic" elicits stigma, and Yarborough says doctors have
been criminally charged when death has occurred specifically from the
prescription of narcotics, as opposed to deaths stemming from the
prescription of other drugs.

Yarborough also said, as has the state licensure board, that there are key
differences between dependency and an actual addiction to narcotics.

"That's a nuance most people don't understand," he said. "The hallmark of
addiction is loss of control."

Non-addicted patients, however, are dependent on relief from pain.

As Yarborough noted in last week's story, addiction is a brain disease, and
while some patients and abusers can sustain large doses of painkillers for
long periods of time without becoming intensely addicted, others afflicted
with the disease of addiction can struggle with many forms of it throughout
their entire lives repeatedly relapsing.

Additionally, pain sufferers and addicts treated long term with methadone
are capable of withstanding large doses of drugs, often regardless of body
weight.

The licensure board confirms Yarborough's assessment in a March policy memo
explaining, "Physicians should recognize that tolerance and physical
dependence are normal consequences of sustained use of opioid analgesics and
are not the same as addiction."

Still, accepting escalating deaths rates associated with methadone as a
natural consequence of the increased use of the drug is difficult.

While the abuse and neglect of legally prescribed narcotics is an ongoing
concern, Yarborough says the press is less likely to report on pain
sufferers whose lives have dramatically improved as a result of methadone.

The best anyone can hope for is an improvement in patients' understanding of
methadone's composition and volatility, and the continued efforts of doctors
to prevent methadone from being diverted into the hands of abusers.

Hippocratic oath

Last Friday, Distefano made a presentation on methadone to about 40 primary
care physicians at the Downtown Doubletree for an OSU-sponsored event.

He reminded the crowd of how circumstances used to be for pain sufferers in
the United States.

"I used to see people dying in the hospitals, but the doctors didn't want to
give them too much [narcotics], because they didn't want to get in trouble,"
he told the crowd.

The licensure board's Intractable Pain Act gave doctors more flexibility
when it came to diagnosing and prescribing narcotics for pain, even with
drug dosages higher than what the FDA recommends. The Act recognizes that a
single pain threshold does not exist for each individual.

The battle, however, is insuring that patients, even in the face of
temptation, avoid taking too much methadone as if it were merely aspirin.
But for chronic pain patients, Distefano said, "compliance is not their
strong suit."

He says that people tend to have rapidly changing tolerances to the drug.
Leaving a treatment program and returning shortly afterward means starting
all over in terms of building tolerance.

Fifty milligrams can be fatal in non-tolerant adults, he said.

The state licensure board memo from March reminds physicians to incorporate
safeguards against diversion of methadone by keeping clear documentation of
who is prescribed methadone for pain and noting whether or not it's truly
working to alleviate the pain.

But, the memo states, "the Board recognizes that the use of opioid
analgesics for other than legitimate medical purposes poses a threat to the
individual and society and that the inappropriate prescribing of controlled
substances . . . may lead to drug diversion and abuse by individuals . . . "

A doctor can be overheard as he's leaving the Doubletree ballroom. "I used
to think it was a pretty safe drug," he says.

Yet, at the end of Distefano's presentation, he comes nowhere near
suggesting to the crowd that methadone should be outlawed.

"The ones who need it truly should get it," he said. "But you have to be
careful with it."