Methadone maintenance treatment: the balance between life-saving treatment and fatal poisonings

Aim To determine the total mortality related to the Stockholm methadone programme during the period 1988 2000, both the mortality related to the treatment and fatal methadone intoxications in the Stockholm area during the same period. Methods The study comprised all individuals (n = 848) who had been in contact with the methadone programme in Stockholm during the study period, including those patients who had been discharged from treatment and those opiate users who had applied for but not received methadone treatment. All deaths that had been the subject of medico-legal examination at the Department of Forensic Medicine in Stockholm where methadone was found in blood or urine were also analysed during the same period. Results The mortality was lower among those opiate users who remained in maintenance treatment and 91% of the deceased individuals had died due to natural causes, in most cases related to HIV or hepatitis C, acquired before admission to the programme. Those who had been discharged from methadone treatment had a 20 times higher risk of dying from unnatural causes compared to the patients who remained in treatment. The majority died due to heroin injections ('overdoses'). Eighty-nine cases of fatal methadone intoxication were found, but in only two of these cases was there evidence of leakage from maintenance treatment. Conclusion The 'high threshold programme' is safe as long as the patients remain in treatment and there are very few deaths due to leakage from the programme. However, there is a high mortality among those discharged from the programme and only a minority of the heroin users in Stockholm had applied for treatment.