Is methadone too dangerous for opiate addiction?

Editor—Luty et al's enthusiasm for buprenorphine over methadone risks losing baby and bath water.¹ Some patients fare well on one drug yet poorly on the other, so a choice is needed, as in depression, arthritis, or hypertension. The references cited do not support the assertion that buprenorphine is at least as effective as methadone in maintenance treatment. Most randomised control trials have showed adequate methadone doses (60-100 mg/day) to be associated with modestly higher retention rates and lower illicit opiate use than buprenorphine, with low dose methadone (20-30 mg/day) clearly giving poorer results than adequate doses.²

What randomised trials can tell us about dose-response relations in methadone maintenance is limited, and the use of randomised trials of non-equivalent medications has ethical limitations. Furthermore, a finding of “no significant difference” is often loosely interpreted to mean clinical equivalency, which it is not.³ There is other clinical evidence of a dose-response relation in methadone maintenance treatment, extending to doses above 100 mg/day.⁴

Luty et al point out the risks of unsupervised dispensing of methadone. However, they assume that reducing availability of methadone will reduce overdoses, despite strong contrary evidence that increased methadone availability actually reduces overdose rates.⁵

This is not an either/or situation. Better outcomes in addiction treatments are likely to be achieved by increasing the range of treatments available. The answer is not for methadone to be replaced by a more expensive and sometimes less effective alternative but for appropriate supervision of dispensing of opioid replacement treatment, with take-home doses for people who have demonstrated stability in treatment.