Loss of tolerance and overdose mortality with detoxification

Editor—Strang et al reported the death rate after inpatient detoxification but not treatment status before admission, which may be an important factor.¹ Addiction services should record these outcomes through monitoring adverse events. Detoxification can be inappropriately recommended to patients when there is an expectation in the service to encourage alternatives to long term methadone prescribing. A safer option may be detoxification followed by rehabilitation in a therapeutic community, but this is not always realistic.

In Liverpool like other cities the only drug related deaths have occurred in users participating in the methadone programme, with users of street opiates seeming to have less risk.² Prescriptions of injectable methadone approached 10%, and untutored patients frequently self administered into the femoral vein and artery. Over 30% developed complications resulting in amputation, compartment syndrome, deep vein thrombosis, and post-thrombotic syndrome, whose sequelae are leg ulcers that require a considerable amount of resources to manage. Intensive urine testing for methadone to ensure compliance does not prevent illicit trading. Methadone is an easily marketable product, and large scale prescribing had unforeseen consequences on the greater community.³ Harm reduction measures using syringe exchange schemes have also proved to be flawed.⁴

All too often philanthropic general practitioners become overwhelmed without understanding the necessity for extensive organisational support.⁵ The tiresome litany of general practitioners being investigated for methadone related deaths bears testimony to this.

Treatments pose a greater threat to public health than the underlying problem. Other than managing the inevitable physical complications of drug misuse, the medical establishment has nothing to offer drug users. Their interests are best served by deconstructing the current medical models of addiction treatment to allow response from the community through non-statutory helping agencies. Policy makers will find it difficult to persuade the conventional psychiatric based services to undergo this exigent fundamental reform.