article smacks of ongoing bias against people using methadone
Dan Bigg, Chicago Recovery Alliance
31 October 2007
While the authors' discuss a few of the studies' weaknesses they minimize or entirely dismiss other significant and potentially lethal shortcomings thus perpetuating misunderstandings and myths. It is also unclear how much of the bias and noise in this study is from the fairly significant ways methadone for addiction treatment is practiced in the Canada versus the US. A discussion of this would have also avoided such confusion.
The authors describe the "triple-check" system of making up methadone doses as a perfect system of control, which is unknown by this author, and don't even bother to use their own checking system on doses before they leave the pharmacy thus missing a potentially critical source of error. In general, despite numerous competing explanations including creative and effective self-dosing patterns they conclude all sources for "discrepancies" in predicted versus "actual" dose is due to "tampering" by clients. I find this demeaning and scientifically naive, anti-methodical, and exposing a lethal bias against persons using methadone. The authors do not even make an attempt to ask clients about their explanations for differences in dose in a way which could elicit accurate information. It remains a blaring omission of explanation that one client returned with more methadone than they were given -- yet another example of the crazy silence this article covertly demonstrates with people using methadone.
None of the discussion in the article suggests alternative explanations which deviate from their "tampering" theory. Such narrow vision benefits no scientific pursuit and adds only bias and smear to a field greatly needing neither.
Finally, while I am sure some diversion of methadone treatment milligrams occurs I am even more sure that methadone used for addiction treatment is not the source for significant lethal street methadone even based on a study by the US Drug Enforcement Administration itself: http://www.deadiversion.usdoj.gov/mtgs/drug_chemical/2007/methadone_gfeussner.pdf
I am surprised the review process did not pick up on these limitations and/or outright bias of this article.
Competing interests
I have no competing interests or conflicts in this case.
A response to Mr. Bigg's..... Dr. David Teplin, Psy.D., C.Psych.
David Teplin, Ontario Addiction Treatment Centres
1 November 2007
While the authors' discuss a few of the studies' weaknesses they minimize or entirely dismiss other significant and potentially lethal shortcomings thus perpetuating misunderstandings and myths. It is also unclear how much of the bias and noise in this study is from the fairly significant ways methadone for addiction treatment is practiced in the Canada versus the US. A discussion of this would have also avoided such confusion.
Dr. Teplin: While we recognize that Canada and the US may have different practices with respect to MMT (Methadone Maintenance Treatment), this study makes it very clear that it was based on a Canadian MMT population, and more specifically, on MMT Guidelines for the Province of Ontario (p3). Once significant difference may be that many programs in the United States do not provide for take home doses (carries), which would significantly decrease potential for diversion. Many “functionally stable” patients in Ontario are given 5-6 take-home doses per week, thus increasing the risk of diversion.
The authors describe the "triple-check" system of making up methadone doses as a perfect system of control, which is unknown by this author, and don't even bother to use their own checking system on doses before they leave the pharmacy thus missing a potentially critical source of error.
Dr. Teplin: These statements are not accurate. On page 7 we stated, “....in order to try and minimize or avoid any discrepancy in prescribed and/or dispensed doses”. This is by no means described as a “perfect system of control”. Nowhere in our article does it mention that our own “checking system” was not used.
In general, despite numerous competing explanations including creative and effective self-dosing patterns they conclude all sources for "discrepancies" in predicted versus "actual" dose is due to "tampering" by clients.
Dr. Teplin: This statement is not accurate. On page 10, we stated, “...may have possibly tampered…” This is very different from the above statements.
I find this demeaning and scientifically naive, anti-methodical, and exposing a lethal bias against persons using methadone.
Dr. Teplin: This statement is inaccurate and quite to the contrary. On page 10 we stated, “Clearly, a major limitation with this pilot study was that the sample size was small, thus limiting the ability to generalize the findings to a broader office-based MMTP population. Another limitation was the lack of a control group. In addition, a much larger prospective observational study is strongly recommended in order to test such suppositions”. There was no intent to stigmatize, or “bias” any conclusions. The purpose of the MMTP is to provide as many patients as possible with a safe and effective treatment program, while at the same time assuring public safety.
The authors do not even make an attempt to ask clients about their explanations for differences in dose in a way which could elicit accurate information.
Dr. Teplin: This statement is inaccurate. On pages 8 and 9, we stated, “When followed up by their methadone prescribing physicians as to why such discrepancies may have occurred, patient explanations included using larger amounts of methadone than prescribed and then having to purchase methadone from the street to make up for the “short-fall”, or splitting their take home doses into multiple daily amounts (depending on symptoms and needs) and then trying to adjust the take home methadone doses to the original concentration when randomly asked to bring in the take home doses”.
It remains a blaring omission of explanation that one client returned with more methadone than they were given -- yet another example of the crazy silence this article covertly demonstrates with people using methadone. In this instance, the patient attempted to avoid negative consequences of diverted methadone, by adding and modifying his doses, to try and “normalize” the amount of methadone in the given dose, while in error, adding more methadone than was originally dispensed.
None of the discussion in the article suggests alternative explanations which deviate from their "tampering" theory. Such narrow vision benefits no scientific pursuit and adds only bias and smear to a field greatly needing neither.
Dr. Teplin: This statement is not accurate. On page 7 we stated, “It is possible however, that spillage can occur after point of dispensing once the doses are in the patients’ hands”.
Finally, while I am sure some diversion of methadone treatment milligrams occurs I am even more sure that methadone used for addiction treatment is not the source for significant lethal street methadone even based on a study by the US Drug Enforcement Administration itself:
Dr. Teplin: This again points to the likely significant differences between US and Canadian (as well as other countries’) treatment programs, diversion patterns and risks. Perhaps some of the articles used in this paper would shed some additional light on the matter, for those who wish to explore this issue further. Some of these references are as follows:
Seymour, A., Black, M., Jay, J., Cooper, G., Weir, C. & Oliver, J. (2003). The role of methadone in drug-related deaths in the west of Scotland. Addiction, 98(7):995-1002.
College of Physicians & Surgeons of Ontario. (2005). Methadone Maintenance Guidelines.
Bell, J., & Zador, D.A. (2000). A risk-benefit analysis of methadone maintenance treatment. Drug Safety, 22(3): 179-190
Zador, D.A., & Sunjic, S.A. (2002). Methadone-related deaths and mortality rate during induction into methadone maintenance, New South Wales, 1996. Drug & Alcohol Review, 21: 131-136.
Heinemann, A., Iwersen-Bergmann, S., Stein, S., Schmoldt, A. & Puschel, K. (2000). Methadone-related fatalities in Hamburg 1990- 1999: Implications for quality standards in maintenance treatment. Forensic Scientific International. 113:449-55.
Green, H.B., James, R.A., Gilbert, J.D., Harpas, P.B., & Byard, R.W. (2000). Methadone maintenance programs-A two edged sword? The American Journal of Forensic Medicine and Pathology, 21(4): 359-361
Fountain, J., Strang, J., Gossop, M., Farrell, M. & Griffiths, P. (2000). Diversion of prescribed drugs by drug users in treatment: Analysis of the UK market and new data from London. Addiction. 95(3): 393-406.
Competing interests
I am one of the co-authors of this published article.
Harm Reduction Journal
article smacks of ongoing bias against people using methadone
31 October 2007
While the authors' discuss a few of the studies' weaknesses they minimize or entirely dismiss other significant and potentially lethal shortcomings thus perpetuating misunderstandings and myths. It is also unclear how much of the bias and noise in this study is from the fairly significant ways methadone for addiction treatment is practiced in the Canada versus the US. A discussion of this would have also avoided such confusion.
The authors describe the "triple-check" system of making up methadone doses as a perfect system of control, which is unknown by this author, and don't even bother to use their own checking system on doses before they leave the pharmacy thus missing a potentially critical source of error. In general, despite numerous competing explanations including creative and effective self-dosing patterns they conclude all sources for "discrepancies" in predicted versus "actual" dose is due to "tampering" by clients. I find this demeaning and scientifically naive, anti-methodical, and exposing a lethal bias against persons using methadone. The authors do not even make an attempt to ask clients about their explanations for differences in dose in a way which could elicit accurate information. It remains a blaring omission of explanation that one client returned with more methadone than they were given -- yet another example of the crazy silence this article covertly demonstrates with people using methadone.
None of the discussion in the article suggests alternative explanations which deviate from their "tampering" theory. Such narrow vision benefits no scientific pursuit and adds only bias and smear to a field greatly needing neither.
Finally, while I am sure some diversion of methadone treatment milligrams occurs I am even more sure that methadone used for addiction treatment is not the source for significant lethal street methadone even based on a study by the US Drug Enforcement Administration itself: http://www.deadiversion.usdoj.gov/mtgs/drug_chemical/2007/methadone_gfeussner.pdf
I am surprised the review process did not pick up on these limitations and/or outright bias of this article.
Competing interests
I have no competing interests or conflicts in this case.
A response to Mr. Bigg's..... Dr. David Teplin, Psy.D., C.Psych.
1 November 2007
While the authors' discuss a few of the studies' weaknesses they minimize or entirely dismiss other significant and potentially lethal shortcomings thus perpetuating misunderstandings and myths. It is also unclear how much of the bias and noise in this study is from the fairly significant ways methadone for addiction treatment is practiced in the Canada versus the US. A discussion of this would have also avoided such confusion.
Dr. Teplin: While we recognize that Canada and the US may have different practices with respect to MMT (Methadone Maintenance Treatment), this study makes it very clear that it was based on a Canadian MMT population, and more specifically, on MMT Guidelines for the Province of Ontario (p3). Once significant difference may be that many programs in the United States do not provide for take home doses (carries), which would significantly decrease potential for diversion. Many “functionally stable” patients in Ontario are given 5-6 take-home doses per week, thus increasing the risk of diversion.
The authors describe the "triple-check" system of making up methadone doses as a perfect system of control, which is unknown by this author, and don't even bother to use their own checking system on doses before they leave the pharmacy thus missing a potentially critical source of error.
Dr. Teplin: These statements are not accurate. On page 7 we stated, “....in order to try and minimize or avoid any discrepancy in prescribed and/or dispensed doses”. This is by no means described as a “perfect system of control”. Nowhere in our article does it mention that our own “checking system” was not used.
In general, despite numerous competing explanations including creative and effective self-dosing patterns they conclude all sources for "discrepancies" in predicted versus "actual" dose is due to "tampering" by clients.
Dr. Teplin: This statement is not accurate. On page 10, we stated, “...may have possibly tampered…” This is very different from the above statements.
I find this demeaning and scientifically naive, anti-methodical, and exposing a lethal bias against persons using methadone.
Dr. Teplin: This statement is inaccurate and quite to the contrary. On page 10 we stated, “Clearly, a major limitation with this pilot study was that the sample size was small, thus limiting the ability to generalize the findings to a broader office-based MMTP population. Another limitation was the lack of a control group. In addition, a much larger prospective observational study is strongly recommended in order to test such suppositions”. There was no intent to stigmatize, or “bias” any conclusions. The purpose of the MMTP is to provide as many patients as possible with a safe and effective treatment program, while at the same time assuring public safety.
The authors do not even make an attempt to ask clients about their explanations for differences in dose in a way which could elicit accurate information.
Dr. Teplin: This statement is inaccurate. On pages 8 and 9, we stated, “When followed up by their methadone prescribing physicians as to why such discrepancies may have occurred, patient explanations included using larger amounts of methadone than prescribed and then having to purchase methadone from the street to make up for the “short-fall”, or splitting their take home doses into multiple daily amounts (depending on symptoms and needs) and then trying to adjust the take home methadone doses to the original concentration when randomly asked to bring in the take home doses”.
It remains a blaring omission of explanation that one client returned with more methadone than they were given -- yet another example of the crazy silence this article covertly demonstrates with people using methadone. In this instance, the patient attempted to avoid negative consequences of diverted methadone, by adding and modifying his doses, to try and “normalize” the amount of methadone in the given dose, while in error, adding more methadone than was originally dispensed.
None of the discussion in the article suggests alternative explanations which deviate from their "tampering" theory. Such narrow vision benefits no scientific pursuit and adds only bias and smear to a field greatly needing neither.
Dr. Teplin: This statement is not accurate. On page 7 we stated, “It is possible however, that spillage can occur after point of dispensing once the doses are in the patients’ hands”.
Finally, while I am sure some diversion of methadone treatment milligrams occurs I am even more sure that methadone used for addiction treatment is not the source for significant lethal street methadone even based on a study by the US Drug Enforcement Administration itself:
Dr. Teplin: This again points to the likely significant differences between US and Canadian (as well as other countries’) treatment programs, diversion patterns and risks. Perhaps some of the articles used in this paper would shed some additional light on the matter, for those who wish to explore this issue further. Some of these references are as follows:
Seymour, A., Black, M., Jay, J., Cooper, G., Weir, C. & Oliver, J. (2003). The role of methadone in drug-related deaths in the west of Scotland. Addiction, 98(7):995-1002.
College of Physicians & Surgeons of Ontario. (2005). Methadone Maintenance Guidelines.
www.cpso.on.ca/Publications/MethadoneGuideNov05.pdf
Bell, J., & Zador, D.A. (2000). A risk-benefit analysis of methadone maintenance treatment. Drug Safety, 22(3): 179-190
Zador, D.A., & Sunjic, S.A. (2002). Methadone-related deaths and mortality rate during induction into methadone maintenance, New South Wales, 1996. Drug & Alcohol Review, 21: 131-136.
Heinemann, A., Iwersen-Bergmann, S., Stein, S., Schmoldt, A. & Puschel, K. (2000). Methadone-related fatalities in Hamburg 1990- 1999: Implications for quality standards in maintenance treatment. Forensic Scientific International. 113:449-55.
Green, H.B., James, R.A., Gilbert, J.D., Harpas, P.B., & Byard, R.W. (2000). Methadone maintenance programs-A two edged sword? The American Journal of Forensic Medicine and Pathology, 21(4): 359-361
Fountain, J., Strang, J., Gossop, M., Farrell, M. & Griffiths, P. (2000). Diversion of prescribed drugs by drug users in treatment: Analysis of the UK market and new data from London. Addiction. 95(3): 393-406.
Competing interests
I am one of the co-authors of this published article.