Rob Calder is joined on the Addictions Edited podcast by Nicky Kalk and Caroline Copeland, to talk about their study of deaths related to methadone and buprenorphine during the COVID-19 pandemic, parallels between Hurricane Katrina and the COVID-19 pandemic for prescribing practices, and how to mitigate the risks of ‘life-saving’ treatments.

Dr Nicky Kalk is Consultant Addiction Psychiatrist for the Kings College Hospital Alcohol Care Team, a Visiting Clinical Lecturer at King’s College London, and Clinical Lead for the National Programme on Substance Abuse Deaths (NPSAD). Dr Caroline Copeland is a Lecturer in Pharmaceutical Medicine at the Institute of Pharmaceutical Sciences, King’s College London, where she is the Director of NPSAD.

Along with Dan Aldabergenov and colleagues, they published an article in the International Journal of Drug Policy in December 2022, which assessed the impact of the first COVID-19 lockdown on methadone- and buprenorphine-related deaths in England.

The data for Nicky and Caroline’s study came from NPSAD, which differs from other major datasets about drug deaths. It includes full toxicology reports, and records the dates that deaths occurred, rather than the dates that deaths were registered.

Deaths link to methadone versus buprenorphine

Recommended reading

Methadone and buprenorphine-related deaths among people prescribed and not prescribed opioid agonist therapy during the COVID-19 pandemic in England. By Dan Aldabergenov and colleagues. Published in the International Journal of Drug Policy (2022).

Death matters: understanding heroin/opiate overdose risk and testing potential to prevent deaths. By John Strang. Published in Addiction (2015).

Rob asked Nicky and Caroline what they would expect to see from the data in a ‘normal’ year in terms of deaths related to buprenorphine and methadone. They explained that there would be very few deaths due to buprenorphine (e.g. in the tens), but quite a lot more due to methadone (e.g. in the hundreds). Having said that, it would be rare to see methadone as the only substance involved in an overdose. Typically, they said, methadone-related overdoses are unintentional or accidental and involve other drugs such as heroin, benzodiazepines, and gabapentinoids.

So, why the disparity between methadone- and buprenorphine-related deaths? Nicky and Caroline suggested two reasons: firstly, methadone is “less safe” as a medication; and secondly, buprenorphine is less prone to being diverted to the illicit market, and therefore less likely to be used without the guidance of a prescribing doctor.

“Methadone is a less safe medication. Because it is a ‘full agonist’ at the mu-opioid receptor, it has more of an impact as a respiratory depressant than buprenorphine. So, we know that the way opioids kill you is that they suppress your urge to breathe … that’s how they do it. And we also know methadone stimulates those receptors fully. Buprenorphine is what I like to call the ‘Goldilocks drug’, in that it stimulates the receptors enough to get you out of withdrawal but not enough to put you in respiratory failure.”

Deaths during COVID-19

Rob asked about one of the key findings from their study – a large (64%) increase in methadone-related deaths at the start of the COVID-19 pandemic, compared with the same months the previous year.

COVID-19 introduced requirements to ‘social distance’, responsibilities to minimise clinical contact, a record number of staff absences, and the need to shield people with co-morbidities who would be particularly vulnerable to harm from respiratory infections (e.g. older people with opioid dependence). This constellation of factors started to make it very difficult (or even dangerous) for people who needed opioid substitution treatment to attend pharmacies on a regular/daily basis to receive their medication.

Nicky and Caroline explained that, during COVID-19, public health professionals made the judgement that the risks of requiring supervised daily consumption had started to outweigh the benefits. And consequently, many people went from receiving daily supervised doses to receiving a two-week supply of opioid substitution treatment.

“We know that opioid substitution treatment is a lifesaving treatment, and it’s really important that people have continued access to their supply.”

The change in practice was informed by the public health response to opioid prescribing during Hurricane Katrina – a Category 3 storm, which resulted in an enormous loss of life and billions of dollars worth of property damage. This event forced difficult decisions about whether to give people take-home supplies of medicine and how to verify treatment when records were not available.

Acknowledging the risks (as well as benefits) of methadone

Nicky and Caroline referred to an article in Addiction by Professor Sir John Strang (a trustee of the SSA). In this, he spoke about how methadone is a medical treatment that can save lives, but also pose a risk to life. Quoting from a book he edited on methadone-prescribing for opioid dependence, Professor Strang said, “Methadone heals and methadone kills: the challenge is to achieve the former without incurring the latter”.

They finished the podcast on this note by talking about ensuring that prescriptions are appropriate and that the context in which people take prescribed opioid substitution treatment is as safe as possible.

“I don’t want the methadone I prescribe to kill anybody. I care about that immensely and I really want to know … what the consequences of those decisions are – intended and unintended – because methadone-related deaths are different from heroin-related deaths. Doctors play a part in them, and pharmacists play a part in them, and that’s something that we have responsibility for.”

This article is based on a podcast episode available to download or stream here. Quotes have been condensed and edited for clarity.

by Natalie Davies

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