Mortality associated with New South Wales methadone programs in 1994: lives lost and saved

Olaf H Drummer and John R M Caplehorn
Med J Aust 1999; 170 (3): 104-109.
Published online: 1 February 1999


Mortality associated with New South Wales methadone programs in 1994: lives lost and saved

John R M Caplehorn and Olaf H Drummer

MJA 1999; 170: 104-109
For editorial comment, see Ali & Quigley


Objectives: To estimate the effects of methadone programs in New South Wales on mortality.
Design and cases: Retrospective, cross-sectional study of all 1994 New South Wales coronial cases in which methadone was detected in postmortem specimens taken from the deceased. Cases were people we identified as patients in NSW methadone maintenance programs or those whose deaths involved methadone syrup diverted from maintenance programs.
Outcome measures: Relative risks of fatal, accidental drug toxicity in the first two weeks of treatment and later; the number of lives lost as a result of maintenance treatment; preadmission risks and the number of lives saved by maintenance programs, calculated from data from a previous study.
Results: There was very close agreement between this study's classifications and official pathology reports of accidental drug toxicity. The relative risk (RR) of fatal accidental drug toxicity for patients in the first two weeks of methadone maintenance was 6.7 times that of heroin addicts not in treatment (95% CI RR, 3.3-13.9) and 97.8 times that of patients who had been in maintenance more than two weeks (95% CI RR, 36.7-260.5). Despite 10 people dying from iatrogenic methadone toxicity and diverted methadone syrup being involved in 26 fatalities, in 1994 NSW maintenance programs are estimated to have saved 68 lives (adjusted 95% CI, 29-128).
Conclusions: In 1994, untoward events associated with NSW methadone programs cost 36 lives in NSW. To reduce this mortality, doctors should carefully assess and closely monitor patients being admitted to methadone maintenance and limit the use of takeaway doses of methadone.


Methadone maintenance greatly reduces heroin addicts' risk of death.1 A 15-year follow-up of patients in New South Wales showed methadone maintenance saved lives by reducing addicts' risk of fatal heroin overdose.1 When combined in a meta-analysis with the results of overseas cohort studies, the relative risk of death in methadone maintenance was a quarter that of addicts not in treatment (95% CI, 0.19-0.33).1 However, methadone maintenance is also a cause of death. Patients are at risk of fatal iatrogenic toxicity and other drug users may die from taking methadone syrup diverted from maintenance programs.2-6

Mortality associated with NSW maintenance programs was independently investigated. The first report from this project presented the case histories of the 13 patients who died in the first two weeks of treatment.7 It identified 10 probable cases of fatal iatrogenic methadone toxicity (ie, where prescribed doses of methadone either caused or contributed to fatal accidental drug toxicity).7 This, the second report, presents an estimate of the relative risk of fatal accidental drug toxicity in the first two weeks and later maintenance. It also presents estimates of the effect of admission to methadone maintenance on the risk of fatal accidental drug toxicity and of the number of lives saved by NSW maintenance programs in 1994.


This study was approved by the Human Research Ethics Committee of the Western Sydney Area Health Service and the NSW State Coroner.

In late 1995 the database at the NSW Health Department's Division of Analytical Laboratories was searched to identify 1994 coronial cases in which methadone was detected in postmortem specimens. These analytical laboratories receive specimens for toxicological analysis in all cases of sudden death referred to the NSW State Coroner. Autopsy, toxicology and police reports and the statements of family and friends, prescribers and other witnesses were collected from coronial files.

The methadone treatment histories of the deceased were extracted from data held by the NSW Health Department's Pharmaceutical Services Section. The Department also provided data on the number of people admitted to and treated with methadone maintenance in NSW in 1994.

Cases were grouped according to the source of the methadone: methadone syrup given as maintenance treatment; methadone syrup diverted from the maintenance program; and methadone tablets (Physeptone; Glaxo Wellcome, Boronia, Vic.) prescribed for pain relief. As the Sydney black market consists almost entirely of methadone syrup diverted from maintenance programs,8 illicit drug users who obtained methadone from an unknown source were classified as having taken diverted syrup.

We used two parallel classifications of cause of death -- that on the official pathologist's report, and our own. In our classification, we initially established cause of death independently of one another, with one of us (O H D) blind to the official cause of death. Cases were first categorised as "accidental drug toxicity" and "other". The "other" category included suicides, deaths from natural causes and trauma, and deaths in which drug toxicity was considered to have contributed to a death from natural causes. The "accidental drug toxicity" cases were further categorised into "methadone" and "other drug or drugs" on the basis of whether or not methadone was considered to have either caused or made a significant contribution to the death.

There were no simple criteria for establishing the contribution of methadone to deaths involving other drugs. However, as deaths to which methadone contributed closely resembled cases of fatal methadone toxicity,2,3,7 a relatively confident decision could be made after a thorough examination of the documentary and toxicological evidence and the autopsy report.2,7,9-12

Police statements and photographs of the deceased at the scene of death provided some assistance. A brownish, frothy oedema fluid was often observed coming from the deceased's mouth or nose (see Box 1).7 Witnesses' statements provided a guide to likely tolerance and chronologies of ingestion and of the development of symptoms and signs of toxicity.2,7 These statements were particularly useful in cases involving methadone as death usually occurred some hours after the drug was taken,14 and some time after the development of coma (see Box 1).2,3,7,10,11

Postmortem blood methadone concentration was helpful but not definitive, as fatal concentration varies widely with tolerance11,12 and the blood concentration of methadone increases after death.15 Moreover, the postmortem increase in blood methadone concentration varies unpredictably from one part of a cadaver to another.16

The autopsy findings were remarkably consistent in cases of fatal drug toxicity involving methadone, with the immediate cause of death being pulmonary oedema secondary to hypoventilation.2,7,10,11 As methadone toxicity usually causes a gradually worsening hypoventilation, the hypoxia and resulting pulmonary hypertension are generally prolonged and severe, and significant quantities of water and electrolytes, large proteins and red blood cells leak from the pulmonary capillaries into the air spaces. Consequently, brownish oedema fluid was often observed in the large airways and the lungs were unusually heavy (see Box 1). Microscopic examination of lung specimens often showed areas of patchy bronchopneumonia and other evidence of prolonged hypoventilation and suppression of the cough reflex.2,7,10


Statistical analysis We used published estimates of NSW methadone patients' risks of death after leaving treatment as approximations of 1994 NSW methadone patients' risks before admission to treatment.1Rates were adjusted for age, as the risk of death was significantly higher for those aged 20-29 years compared with those aged 30-39 years.1 Weighted average risks were calculated in the knowledge that, in 1994, 68% of NSW maintenance patients were at least 30 years of age.17 We assumed half of those admitted to maintenance were aged 20-29 years and half 30-40 years.

The 95% confidence intervals of mortality rates were calculated by dividing the estimates by significance factors taken from a published table.18 The standard errors of the relative risks were estimated using the binomial approximation of the Poisson distribution.19


Methadone was detected in postmortem material from 89 NSW coronial cases in 1994. These cases comprised 41 methadone maintenance patients (38 registered with the NSW Health Department and three with the Queensland Health Department), one neonate being breastfed by a NSW methadone maintenance patient, 29 cases considered to have involved methadone syrup diverted from the NSW methadone program, and 18 cases considered to have involved methadone tablets.

In 18 of the 29 cases involving diverted methadone syrup, either a bottle used to dispense methadone syrup (5 cases), a statement from a witness (10 cases), or both (3 cases), indicated that the maintenance program was the source of the methadone. In the remaining 11 cases, it was assumed methadone syrup was obtained from the black market.8 In 16 of the 18 cases involving methadone tablets, either a statement from the prescribing doctor (8 cases), a tablet bottle (4 cases), or both (4 cases), indicated the source of the methadone. The remaining two people had professional access to methadone tablets and committed suicide.

We excluded the three Queensland maintenance patients, the neonate and all cases involving methadone tablets, leaving 67 cases in the study.  

Methadone maintenance patients Box 2 shows that, of the 38 NSW maintenance patients, 13 died in the first two weeks after admission, and 25 died later in treatment. We and the official pathologists concluded that 12 of the 13 fatalities in the first two weeks of maintenance and six of the 25 deaths later in treatment were caused by accidental toxicity. Three of six deaths from accidental drug toxicity among established maintenance patients were caused by heroin, one by dextromoramide, one by the combined effects of heroin and dextroproxyphene, and one involved injected methadone syrup.  

Diverted methadone syrup Box 2 shows that, for the 29 cases involving diverted methadone, we concluded methadone contributed to 26 of 27 deaths from accidental drug toxicity compared with 24 of 26 on the official pathologists' reports. One death which we classified as accidental drug toxicity was officially attributed to bronchopneumonia with methadone intoxication as a contributing factor. In another case, we concluded injected, diverted methadone contributed to a death which was officially attributed to acute heroin poisoning.

Witnesses' statements or autopsy reports indicated that methadone syrup was injected in 16 of the 26 cases we classified as accidental drug toxicity to which diverted methadone contributed. One of the 10 cases involving oral ingestion of diverted methadone was that of an infant who either took or was given some of his mother's syrup.  

Relative risks of accidental drug toxicity We concurred with official pathologists' conclusions that 12 patients died of accidental drug toxicity during the first two weeks of maintenance treatment in NSW in 1994 (see Box 2). To calculate the rate of fatal accidental drug toxicity, we estimated the total time patients spent in the first two weeks of maintenance treatment. In 1994, 4449 people were admitted to methadone maintenance in NSW. Assuming all new admissions stayed at least two weeks in treatment,20,21 patients spent approximately 170.5 person-years in the first two weeks of maintenance. Using this estimate as the denominator, the rate of fatal accidental drug toxicity in the first two weeks of maintenance was 70.4 deaths per thousand per year (Box 3).

We also agreed with official pathologists' conclusions that six NSW methadone patients died from accidental drug toxicity after being in maintenance treatment for at least two weeks (Box 2). An approximation of the total time methadone patients spent in treatment in NSW in 1994 was derived from the average of the number in treatment at the beginning and end of the year (7975 and 9038, respectively).22 The 170.5 person-years spent in the first two weeks' maintenance were subtracted from the average of the totals, 8506.5, to estimate the total time spent in later maintenance -- 8336 person-years. When this was used as the denominator, the rate of fatal accidental drug toxicity in later maintenance was 0.72 deaths per thousand per year (Box 3).

When combined with the previous estimate, the risk of fatal accidental drug toxicity in the first two weeks of treatment in NSW in 1994 was estimated to have been 97.8 times the risk later in maintenance (95% CI RR, 36.7-260.5 times). Based on the results of a previous study,1 the rate of fatal accidental drug toxicity for addicts on the street was estimated to be 10.4 per thousand per year. Using this estimate, the risk of fatal accidental drug toxicity in the first two weeks of methadone maintenance in NSW in 1994 was 6.7 times the risk before admission (95% CI RR, 3.3-13.9 times).  

Lives saved by NSW maintenance programs The age-adjusted approximation of the expected mortality from all causes among heroin addicts was 15.5 deaths per thousand per year (95% CI, 11.0-21.9 deaths).1 Using this estimate, 132 deaths would have been expected to occur in 8506.5 person-years (95% CI, 93-187 deaths). As 64 people either died while receiving maintenance (38) or from the toxic effects of diverted methadone (26), NSW methadone programs are estimated to have saved 68 lives in 1994 (95% CI, 29-123 lives saved). To save one life approximately 125 patients needed to be given methadone maintenance for a year (95% CI, 69-293 patients).

To adjust for possible bias, we assumed that up to three of the 11 cases classified as involving diverted methadone syrup may have actually involved methadone tablets. When added to the two cases involving diverted methadone syrup in which there were differences in the official and study classifications of cause of death (Box 2), the number of lives saved may increase by up to five. Consequently, the upper limit of the confidence interval increased to give an adjusted 95% CI of 29 to 128 lives saved.

If all 10 cases of fatal iatrogenic methadone toxicity7 and 26 deaths to which diverted syrup contributed had been avoided, NSW maintenance programs would have saved 104 lives in 1994 (adjusted 95% CI, 65-164 lives saved), making them up to 53% more effective at saving lives (adjusted 95% CI, 37%-124%).


We found that, in NSW in 1994, the risk of fatal accidental drug toxicity in the first two weeks of methadone maintenance was nearly seven times the risk before admission to treatment. A previous report suggested that this excess mortality was primarily the result of iatrogenic methadone toxicity.7 However, the risk of fatal accidental drug toxicity later in maintenance was approximately one-hundredth the risk in the first two weeks of treatment and less than one-tenth the risk before admission.

As there was complete agreement between our classification and that of official pathologists, our estimate of the relative risk of fatal accidental toxicity in the first two weeks and later maintenance is unlikely to have been significantly affected by misclassification of causes of death. Further, in estimating that NSW methadone programs saved 68 lives in 1994, we allowed for the difference between our opinion and that of the official report on the role of diverted methadone in two cases when calculating the upper limit of the adjusted 95% confidence interval (29-128) for the number of lives saved by NSW maintenance programs.

Another consideration in estimating the number of lives saved is that mortality among patients discharged from maintenance is only an approximation of preadmission risk. If the real risk on the streets was higher than our estimate, NSW methadone programs would have saved more lives and admission to maintenance would not have caused such a dramatic increase in the risk of fatal accidental drug toxicity. Conversely, if the real risk was lower, the reverse applies.

Our estimates of the number of lives saved and the increase in the risk of fatal accidental drug toxicity associated with admission to maintenance are approximations only. However, as our estimated 71% reduction in mortality is very similar to that observed in the US during the early 1970s, in Sweden during the 1980s, in Germany in the 1990s and Australia during the 1970s and 1980s,1 they are probably reasonably accurate.

Previous Australian studies have also identified mortality associated with methadone programs. Eighteen people died from methadone toxicity in Western Australia in the years 1975 to 1980. However, there were virtually no such deaths after WA maintenance patients were required to take their methadone under supervision.23 In South Australia, nine maintenance patients died from drug toxicity in the years 1984 to 1994, while 12 other people died from the toxic effects of diverted methadone syrup.22 The number of deaths per 1000 SA maintenance patients was approximately 75% of that observed in our study. Our finding that diverted methadone syrup contributed to 26 deaths in NSW in 1994 is supported by the results of a previous investigation which suggested that diverted methadone syrup was involved in up to 100 deaths between July 1990 and December 1995.6

The WA experience23 suggests the number of deaths from diverted methadone syrup is related to the number of takeaway doses dispensed to maintenance patients for consumption on subsequent days. In 1994, two-thirds of private sector patients received four takeaway doses a week, with some programs giving five or six a week to newly admitted patients.24 Although the NSW Health Department argued against such practices, there was no policy enforcement.24 To minimise the diversion of methadone syrup from maintenance programs, the NSW Health Department should monitor and ensure compliance with its current policy which strictly limits the number of takeaway doses available to recent admissions while giving stable, long-term patients access to generous takeaway privileges.

A serious problem with iatrogenic methadone toxicity was identified in Victoria, where 10 deaths occurred among newly admitted methadone patients in the last six months of 1989.2 As Victorian methadone programs treated fewer than 1200 maintenance patients in this period, the rate of iatrogenic methadone toxicity was many times that observed in our study. It is noteworthy that, during 1989, the number of Victorian maintenance patients and programs increased rapidly and a number of inexperienced and poorly trained prescribers entered the field.2,3 Persons with minimal or no tolerance were prescribed initial, daily methadone doses of 50-70 mg, with fatal results.2

Two recent British studies, from Sheffield and Manchester, have similarly identified significant numbers of deaths from iatrogenic methadone toxicity early in maintenance treatment.4,5 These problems also arose after the relaxation of admission criteria and during a period of rapid increase in the numbers of maintenance patients and the involvement of new, inexperienced prescribers.4,5

While the official criteria for admission to methadone maintenance in NSW have not changed since 1988,25 they were not being implemented in 1994.26 Statements made by its Chairman in 1996 indicate that the NSW Medical Committee had not been applying the official admission criteria for some time.26 This is significant because, under the NSW Poisons Act, the Medical Committee advises the NSW Health Department on applications from doctors to prescribe methadone maintenance to addicts.

There were also problems with prescriber training. Since 1993, the NSW Methadone Prescribers' Accreditation Program has used the Methadone prescribers' manual as its course material.27 Contrary to NSW Health Department policy,25 the "Manual" states heroin users need not have a history of physiological dependence on opioids to be eligible for maintenance treatment.26,27 We urge the NSW Health Department to revise its Methadone prescribers' manual,27 review prescriber training and to ensure compliance with its current admission criteria for maintenance treatment.25,26

In 1994, Victorian and Queensland methadone prescribers were required to examine new patients during the first days of maintenance for signs of toxicity.28,29 Unfortunately, the NSW Health Department did not, and still does not, have a similar policy. Indeed, many private practitioners in NSW are only available to see maintenance patients one day a week (see Box 1), and the day-to-day supervision of patients attending public clinics is left to nurses working in busy dispensaries.

The first two weeks of methadone maintenance will always be the "danger period" owing to the difficulty in determining a safe and effective starting dose. There is wide variation in opioid-na•ve individuals' response to and ability to metabolise and excrete methadone,30 and applicants' self-reports of recent drug use are an unreliable measure of tolerance.7 Given this uncertainty and variability, it is not possible to define safe, effective starting doses of methadone.

We recommend prescribers be made aware of the risks, signs and symptoms of methadone toxicity and be required to examine newly admitted patients every day for the first one to two weeks of maintenance. People seeking methadone maintenance should be required to give written consent after being warned about the dangers of misleading their doctor and of the use of other drugs, particularly benzodiazepines.7,31 We believe that the forthcoming NSW methadone maintenance treatment clinical practice guidelines will address these issues.

We strongly recommend the establishment of independent, expert committees to investigate methadone-related deaths in States and Territories with maintenance programs. These committees should be modelled on those used to monitor anaesthesia-related deaths.


For their advice and generous assistance, we thank the NSW State Coroner at Glebe, the Westmead Court, the Division of Analytical Laboratories, and the Pharmaceutical Services Branch of the NSW Health Department, and the Drugs of Dependence Unit, Queensland Health Department. We also thank Professor Geoffrey Berry of the Department of Public Health and Community Medicine, University of Sydney, who assisted with the statistics and presentation of results.


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(Received 22 Sep 1997, accepted 18 Oct 1998)

Authors' details

Department of Public Health and Community Medicine, University of Sydney, NSW.
John R M Caplehorn, MB BS, MPH, PhD Student.

Victorian Institute of Forensic Medicine, Melbourne, VIC.
Olaf H Drummer, PhD, Head of Scientific Services, and Associate Professor, Department of Forensic Medicine, Monash University.

Reprints: Dr J R M Caplehorn, Department of Public Health and Community Medicine, Building A27, University of Sydney, Sydney, NSW 2006.

1: A case of fatal iatrogenic methadone toxicity

This 1995 NSW case highlights the danger of daily doses of 30-40mg methadone in non-tolerant individuals and presents a classic history of fatal iatrogenic toxicity. The deceased had clear, early signs of methadone toxicity: somnolence; unsteady gait; vomiting; and a general feeling of being unwell. The terminal events were also typical: prolonged coma following sleep; very slow, deep, irregular, noisy breathing; brown pulmonary oedema fluid coming from the mouth or nose.

Six weeks before his death, the 19-year-old man was admitted to hospital with hypothermia, pneumonia, right brachial plexus neurapraxia, rhabdomyolysis and acute renal failure after a heroin overdose. He reported using amphetamines for six months and heroin for two weeks. Liver function test and echocardiogram findings were normal, and at discharge three days later his serum creatinine level had fallen from 0.18mmol/L to 0.10mmol/L (upper normal limit, 0.12mmol/L).

He was referred to a short-stay, residential program and told the admitting officer he had had problems with alcohol for five years, cannabis for seven years and amphetamines for one year, but had only used heroin six times. While he was considered suitable for admission to a drug-free rehabilitation program, this was delayed pending full recovery of his arm.

However, he was advised not to wait to enter this program as he was facing trial for a criminal offence. Soon after, the deceased apparently told a general practitioner and a methadone prescriber he had been using heroin daily for a year. He was prescribed 30mg methadone, with the dose to be increased by 5mg every day for six days and then reviewed.

The deceased vomited several times after receiving his second dose (35mg). The next morning, he was difficult to rouse, had trouble walking and urinating and kept falling asleep. His father was unable to contact the methadone prescriber, who was on holiday, and the nurses at the private methadone clinic did not seem to have recognised the seriousness of the situation.

By late afternoon he felt much better and travelled by public transport to receive his last dose of methadone (35mg) at 1830. That evening he seemed well, was in a very good mood and ate a large dinner. However, he was still having difficulty urinating. He went to bed at 2245. Around 0645 the next morning his father was unable to wake him, he was breathing deeply, noisily and irregularly and had brown fluid coming from his mouth. After about fifteen minutes he stopped breathing and died.

At autopsy, the body weighed 72kg. No "track" or recent injection marks could be identified. The lungs weighed 960g (right) and 860g (left) and were described as "very oedematous and congested". The heart and liver were macroscopically and microscopically normal. The postmortem blood methadone concentration was 0.32mg/L. No other drugs were detected in blood, bile or urine samples. The investigating pathologist determined the cause of death was methadone toxicity. The Deputy NSW State Coroner determined the fatal toxicity was caused by the administration of three daily doses of methadone (30mg, 35mg and 35mg).13

At the inquest, the deceased's methadone prescriber said he did not physically examine methadone patients and had not rejected an applicant for maintenance in the past two years. He routinely saw methadone patients only one day a week at a private methadone clinic.13

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2: Causes of death determined in this study and in official pathologists' reports for 38 patients in New South Wales methadone maintenance programs and 29 people whose deaths involved methadone diverted from maintenance programs

Accidental drug toxicity
Methadone*Other drug(s)Other causes of death

Methadone maintenance patients
Death in first two weeks
This study
Official report
Death after two weeks
This study
Official report
Diverted methadone
This study
Official report
This study
Official report

*Methadone either caused or contributed to the death.

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3: Rates of fatal accidental drug toxicity and relative risks of fatal accidental drug toxicity and sudden death from all causes for patients in New South Wales methadone maintenance programs in 1994


Deaths from accidental drug toxicity
In first two weeks' maintenance
after two weeks' maintenance
First two weeks' maintenance v.
out of treatment* 
First two weeks' maintenance v.
after two weeks' maintenance 
Out of treatment* v.
after two weeks' maintenance 
Deaths from all causes
Out of treatment* v.
all maintenance 
Out of treatment* v.
after two weeks' maintenance 

*Calculated from approximations derived from previously published data.
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Received 24 September 2018, accepted 24 September 2018

  • Olaf H Drummer
  • John R M Caplehorn



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