METHADONE GROWS AS KILLER DRUG

PORTLAND, Me. -- Methadone, a drug long valued for treating heroin
addiction and for soothing chronic pain, is increasingly being abused by
recreational drug users and is causing an alarming increase in overdoses
and deaths, federal and state officials say.

In Florida, methadone-related deaths jumped from 209 in 2000 to 357 in 2001
to 254 in just the first six months of 2002, the latest period for which
data are available.

"Out of noplace came methadone," said James McDonough, director of the
Florida Office of Drug Control. "It now is the fastest rising killer drug."

In North Carolina, deaths caused by methadone increased eightfold, to 58 in
2001 from 7 in 1997 -- an "absolutely amazing" jump, said Catherine
Sanford, a state epidemiologist.

In Maine, methadone was the drug found most frequently in people who died
of overdoses from 1997 to 2002. It was found in almost a quarter of the
deaths. In the first six months of last year, methadone killed 18 people in
Maine, up from 4 in all of 1997. Dr. John H. Burton, medical director for
Maine Emergency Medical Services, said hospital emergency rooms were seeing
"a tidal wave" of methadone-related cases.

The increase in methadone overdoses and deaths has floored many drug
experts because methadone, which does not provide a quick or potent high,
has long been considered an unlikely candidate for substance abuse. It can
be hours before a user feels any effect, and it works more like a sedative
than a stimulant.

And because methadone is considered such an important and affordable tool
for treating addiction and pain, health and law enforcement officials are
facing a quandary: how to stop methadone abuse without curtailing its
valuable uses -- and especially without driving addicts back to drugs like
heroin.

"We've got years of experience with methadone and suddenly we've got this
problem," said Dr. H. Westley Clark, director of the federal Center for
Substance Abuse Treatment. "We realize that lives are being lost and we're
trying to stop that. But we're trying not to do quick fixes that will cause
us more problems."

The surge in methadone abuse appears linked to several factors, including
the growing abuse of heroin and OxyContin, a powerfully addictive
prescription painkiller. Health and law enforcement officials are reporting
that some of these addicts are turning to methadone when they cannot get
the other drugs.

At the same time, methadone has become more available. Physicians are
increasingly prescribing it for pain relief, in part because law
enforcement officials have been cracking down on OxyContin, and more
methadone clinics have sprung up to treat the growing number of heroin addicts.

"The availability of methadone for treatment and pain has put people who
would not normally be in a position to divert drugs in that position," said
Sgt. Scott J. Pelletier, who works for the Maine Drug Enforcement Agency
handling drug cases in Portland and Cumberland County, where methadone
caused at least 30 deaths in 2002, according to the state medical
examiner's office.

In most states with increased methadone deaths, the methadone being abused
appears to be tablets prescribed for pain. These are sold or sometimes
given to addicts by people who have stolen them from patients or, in some
cases, by the patients themselves. Addicts either swallow the tablets or
grind them into powder that can be inhaled or turned into liquid and injected.

In Maine, however, and to a lesser degree in a few other states, the
authorities say much of the methadone has been the liquid form used in drug
clinics and spread, in some cases, by clinic patients. Many clinics across
the country, following federal guidelines designed to make methadone
treatment more accessible, have stopped requiring patients to take all
their daily doses at the clinic, and instead are allowing them to take home
doses of methadone once a week or more.

In Chicago, "kids are now coming from suburbia and they're buying methadone
on the street," said Dr. Ernest C. Rose, a specialist in drug addiction who
works for several methadone clinics there.

"In the inner city, you can get 80 milligrams of methadone for $20 to $30,
which is a lot cheaper than a heroin habit would be. We do see a lot of
methadone getting diverted out here on the street from the clinic, and we
have to watch our clients very carefully because it's a secondary source of
income for a lot of them."

There are no national figures for methadone deaths or overdoses. But the
federal Drug Abuse Warning Network reported that in 2001, 10,725 people
turned up in emergency rooms after having abused methadone. That is nearly
double the number of such visits in 1999.

Experts say those attracted to methadone fall mostly into two categories:
people already addicted to other opiates, and naive, sporadic drug users
who have often never tried methadone before.

"Most people who are addicted for any period of time aren't out chasing the
buzz anymore," Dr. Rose said. "Most of them are trying to keep their sick
off, and methadone will do that."

Naive users might be "people who are just at a party and someone will give
them some methadone," said Dr. Burton, the emergency medicine specialist in
Maine. "They might mix it in with a beer or with some other drug. They take
it thinking it's just like any other drug and will give them a buzz, and
they end up either dead or deeply unconscious."

Methadone's delayed narcotic effect and its lack of a potent high are
important reasons the drug can be so dangerous, experts say.

"By the time they've actually overdosed, no one is with them to see what's
happening," said Kimberly Johnson, director of the Maine Office of
Substance Abuse.

Joseph Haddock, an analyst for the Justice Department's National Drug
Intelligence Center, said some people, unaware of the drug's delayed
effects, "take methadone, don't get the effect that they want, take more
methadone, still don't get that reaction, and they take more methadone, so
they end up overdosing."

How large a dose can cause an overdose can vary widely. Methadone is often
taken in combination with alcohol or other drugs, which may make it more
harmful. Typically, experts say, pills prescribed for pain are about 5 or
10 milligrams each, meaning several pills might be needed for an overdose.
Liquid for addiction treatment usually ranges from 50 to 500 milligrams.

While methadone has been available as a pain medication since World War II,
many physicians have only recently begun to prescribe it, said Dr. Edward
C. Covington, director of the chronic pain rehabilitation program at the
Cleveland Clinic in Ohio and a past president of American Academy of Pain
Medicine.

The change, he said, is partly the result of a new consensus that chronic
pain should be treated and a wider awareness that methadone is a legal and
effective way to do so.

Doctors wary of prescribing OxyContin because of warnings from the police
about the potential for abuse have also turned increasingly to methadone,
Dr. Clark and others say. Dr. Covington and other experts say some doctors
also prefer methadone because it is far cheaper than OxyContin, it does not
generate as much of a high as other drugs, and its effects are slower,
seemingly making it less likely to be abused.

But methadone is also complicated to prescribe. Doses are often difficult
to calibrate, Dr. Covington said, because of the way the drug accumulates
in fatty tissues and is slowly released in the body.

"Methadone is probably one of the very few drugs that I've seen doctors
almost kill patients with," he said. "It's that hard to use when you first
start to use it. If it's on the street, we're going to be seeing some deaths."

Officials in several states are pressing for electronic monitoring of
prescriptions filled by pharmacies, which can indicate whether patients are
getting identical prescriptions filled in different places.

Dr. Andrea G. Barthwell, the White House drug czar's deputy director for
demand reduction, said her office wants to educate physicians better about
methadone and root out unscrupulous doctors who help patients who are
abusing or selling the drug. Prosecutors in Virginia, Florida and elsewhere
are bringing charges against such doctors.

Grappling with methadone used in addiction treatment may be even more
difficult. For three decades, many health experts have praised methadone
for pulling addicts away from heroin. While those addicts usually remain on
methadone for long periods and may never be able to function without it,
many lead productive lives, experts say.

To make methadone more accessible, the Substance Abuse and Mental Health
Services Administration in 2001 relaxed its policy on distributing it. In
the past, patients who reliably took their methadone each day could earn
the privilege of taking as many as six days' worth of doses home. The new
rules lengthened that to 31 days, a boon for people who had to travel long
distances to clinics.

But while experts like Dr. Barthwell, a past president of American Society
for Addiction Medicine, consider patients who earn 31-day take-home
privileges to be highly unlikely to sell their methadone, they worry more
about another policy that allows clinics to close on Sundays and to send
even new patients home with a "Sunday bottle" of methadone.

"Some of these people exchange their Sunday bottle for other drugs or
money," Dr. Barthwell said. "It may be their only source of currency until
they are on a stabilizing dose" of methadone and are functioning well
enough to get a legitimate job.

In Maine, state officials and law enforcement authorities said that
take-home methadone -- which typically comes in stronger doses than
methadone tablets prescribed for pain -- had caused most of the deaths. In
some cases, Sergeant Pelletier said, clinic patients would "stockpile" a
small amount of each take-home dose and sell the methadone, trade it for
other drugs or give it to a friend addicted to other drugs.

What is more, the vast majority of the people who died in Maine were not
clinic patients themselves.

Maine's methadone clinics are cooperating with state officials and have
agreed to tighten procedures. Dr. Marc Shinderman, the operator of CAP
Quality Care in Westbrook, said his clinic was now open every day. Longtime
patients are permitted to take home at most only two weeks' worth of methadone.

More programs are available to educate patients about the consequences of
letting others sample their methadone. Dr. Shinderman's clinic requires
that people return empty bottles of take-home methadone, and is switching
as many patients as possible to tablets, which the clinic says it hopes
will be less likely to lead to overdose.

Dr. Shinderman said he was "mystified" about why so many of the deaths in
Maine were attributed to methadone from clinics.

"Methadone has been around a long time and diversion has been around a long
time," said Dr. Shinderman, who also operates clinics in Chicago. "It's a
kind of a puzzle. People should be somewhat sophisticated about methadone."