Diverted methadone implicated in another death

Multiple coroners have made recommendations for tightened access to unsupervised dosing and better education on storage, with further investigation encouraged in latest case

A 71-year-old Victorian woman died in early 2019 from combined drug toxicity after she ingested her daughter’s methadone, a coroner has found.

Toxicological analysis of post mortem samples detected the presence of methadone, codeine, diazepam, nitrazepam, venlafaxine, metoclopramide and paracetamol.

There was no current Department of Health and Human Services (DHHS) permit in the name of the deceased for the use of methadone and she had never been prescribed the drug.

However investigations revealed her daughter was being treated with methadone through her GP. The deceased’s daughter was prescribed 60 milligrams daily of liquid methadone, and was allowed up to two takeaway doses with each supervised dose.

She was also the deceased’s full-time carer and would take her methadone with her and place it in the fridge when she stayed at her mother’s house.

In handing down her findings this week, Victorian Coroner Audrey Jamieson said there was not enough evidence to conclude the deceased intended to end her own life.

She expressed concern that consumption of diverted methadone has been commonly encountered in the state’s coronial investigations. Coroner Jamieson covered another case involving diverted methadone just last month. The scenario has also occurred in other states, such as these two cases covered in AJP involving Tasmanians who died after consuming diverted methadone.

“Over the past decade methadone has consistently been one of the most frequent contributors to overdose death in Victoria, playing a role in more fatal overdoses than drugs that attract far more public attention, such as methamphetamine and oxycodone and codeine and alprazolam,” said the Coroner.

“Consumption of diverted methadone, as occurred in the death of [the woman], is a common theme Victorian coroners encounter in their investigations. Reducing methadone diversion and non-clinical use of methadone is essential to reducing Victoria’s overdose death toll, and coroners have repeatedly made recommendations aimed at addressing this.”

Many Victorian deaths have related to takeaway doses not being stored safely and securely, leading to another person accessing the drug and overdosing—such as in the current case, she said. Coroners have made multiple recommendations that the DHHS improve policy and education around methadone safe storage to combat this.

Another common scenario is where a person has been dispensed unsupervised methadone and sells, trades or gifts it to another person who fatally overdoses. Coroners have, again, made multiple recommendations that the DHHS tighten access to unsupervised methadone dosing and doctors conduct better assessment of patient suitability for unsupervised methadone dosing.

Coroner Jamieson encouraged the Medicines and Poisons Regulation Unit within the DHHS to consider the circumstances of the death in light of their current Policy for Maintenance Pharmacotherapy for Opioid
Dependence, and whether there are any safeguards for unsupervised methadone dosing not described in the policy which might reasonably have prevented this death from occurring.

What are the numbers?

A recent analysis by the Coroners Prevention Unit (CPU) requested by Coroner Jamieson found there were 4365 overdose deaths investigated by Victorian coroners between 2010 and 2019.

The CPU found that, in 2019 alone, methadone contributed to 74 overdose deaths in Victoria.

“Methadone remained the most frequent contributing opioid to Victorian overdose deaths in 2019, and opioid involvement in Victorian overdose deaths generally remained at its highest level in a decade despite several interventions such as the implementation of SafeScript, rescheduling of codeine, and oxycodone reformulation,” said the Coroner. SafeScript became compulsory in the state from 1 April this year.

Evidence suggested diverted methadone had contributed to 19 deaths in 2019, which Coroner Jamieson said was “a substantial number”.

However, the proportion of overdose deaths involving methadone is increasingly higher among people who were prescribed the drug as opposed to those for which no permit is held.

For example, in 2010 more than half (56.4%) of methadone-involved overdose deaths were in people for whom there was no evidence of a permit. In 2019, this proportion had more than halved to 25.7%. Therefore, most deaths are now occurring among people who were prescribed the drug, the CPU concluded.

“Among [opioids], methadone remained (for the tenth straight year) the most frequent contributor to overdose deaths. This finding is consistent with the risk profile of the drugs,” said the CPU.

“Methadone is associated with a particularly elevated overdose risk because it has a long half-life of action; there is wide variation in how it affects individuals; its respiratory depressant effects can last well beyond the experience of its subjective (analgesic and euphoric) effects; and its respiratory depressant effects are additive with the effects of most other central nervous system depressants.”

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  1. Irvine Newton

    As a member of the DHHS Drugs of Dependence Advisory Group, I contributed to the decision to “liberalize” the availability of methadone take away doses. As it became apparent following that decision that there were increasing numbers of methadone related deaths, I and others started to doubt the wisdom of that change. Eventually, the group moved to tighten the provisions again. But has anything changed? 74 deaths in 2019 would suggest otherwise.
    So where is the real problem? Many clients are committed to their treatment and treat their take away doses with respect and the care they require. Take away doses represent a valuable, indeed essential element of their efforts to have a “normal” productive lifestyle.
    The problem then is with those who are not so committed and responsible. The Policy guidelines give equal responsibility to both prescribers and pharmacists to decide such things as who should have take away doses and who should not. Often, pharmacists have a much better understanding of clients’ behaviors and attitudes than their prescribers; we see clients face to face much more often than the GP. So pharmacists should be providing input and making their opinions known before such important decisions such as take away provision are made. Will my client store the doses safely and do they understand what that means? Will they use them responsibly? Are they likely to use them to facilitate a healthy lifestyle or are they likely to divert them? Take away doses are a privilege, not a right, so is there a genuine need?
    Pharmacists have an essential role and helping prevent deaths is one of those!

    • Peter Allen

      there are two quite separate causes of death, invoking two responses.

      Patients who overdose are the difficult one. But “no benzos” should be the rule.

      Stealing a patient’s dose must be prevented, and a safe is not feasible.
      I had some risky patients purchase a small toolbox plus a padlock, holding upto six bottles fir storage in the fridge.

      Bunnings $10 Craftright metal toolbox.

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