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CDC Telebriefing on Vital Signs Report: Risk for Overdose from Methadone Used for Pain Relief — United states, 1999–2010

Tuesday, July 3, 2012 at 11:30 a.m.

OPERATOR: Welcome.  I would like to thank you all for holding and inform you that your lines are in a listen only in today's conference until a question-and-answer session.  At that time, to ask a question, press star-one on your touch-tone phone.  Today's call is being recorded.  If you have any objections, you may disconnect.  I'd like to turn to Llelwyn Grant.  You may begin. 

LLELWYN GRANT: Good morning.  My name is Llelwyn Grant, and I am the branch chief for CDC's News Media Branch.  I wish to thank you all for joining us for today's telebriefing on CDC's Vital Signs report on the risks for overdose from methadone use for pain relief in the United States, 1999 through 2010.  Today's report represents a series of Vital Signs reports that illustrates CDC's commitment to working 24/7 in saving lives and protecting people.  Here to discuss the Vital Signs report is CDC director Thomas R. Frieden, that's f-r-i-e-d-e-n.  Following his remarks, Dr. Frieden will be joined by Dr. Leonard Paulozzi, that’s spelled p-a-u-l-o-z-z-i, and Christopher Jones.  And that's -- Dr. Jones is a health scientist with the CDC's Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control.  And Dr. Paulozzi serves as a medical epidemiologist with the same division.  At this time I would like to turn it over to Dr. Frieden. 

THOMAS FRIEDEN: Good morning, everyone, and thank you very much for joining us.  Today's Vital Signs talks about the role of methadone in opiate overdoses in the United States, and I want to just set the stage with a couple of key concepts.  The first is that there's been a real change in how American doctors view pain relief.  For many years, policies were very restrictive and patients suffered unnecessary and avoidable pain.  Then 10 or 20 years ago, there was a real change, and doctors saw pain and pain relief and understood it as a key role for medicine.  What we're now seeing, however, is a dramatic increase in the number of deaths related to opiate painkillers.  And working with others throughout the federal government and the private sector, we've been working hard to try to reduce those deaths and identify the drivers of the increase in prescription opiate overdose deaths. 

Currently, deaths from prescription opiates kill more people than heroin and cocaine combined and cause more emergency department visits, as well.  I also want to be very clear that we're not talking about heroin substitutions.  We're not talking about methadone maintenance treatment programs in this data.  All of the evidence suggests that the increase in methadone deaths is related to the increased use of methadone to treat pain.  In fact, today in the U.S., there are probably more people who receive prescriptions for methadone for pain than there are people who receive methadone as part of a drug treatment program.  And there are two fundamental problems with the use of methadone for pain. The first is that methadone is riskier than other prescription painkillers.  It tends to build up in the body.  It can suppress breathing, and it's particularly dangerous when used with tranquilizers or other painkillers.  The second is that there has really been an overuse of methadone for pain.  And I'll go through that for a bit. 

There are about four million prescriptions written for methadone each year, and about 5,000 Americans die from methadone overdose each year.  In fact, methadone deaths are up about six fold from a decade ago.  Methadone accounts for about 2 percent of all prescriptions, but 30 percent, nearly one in three of all deaths from prescription opiates, and in fact, if you look at deaths in which there's just a single prescription opiate used, it's 39 percent.  The reason for this large increase over the past decade is in large part because methadone costs less per pill, and so an increased number of formularies have listed it as a preferred drug.  But methadone is risky.  People who take methadone can stop breathing.  It can cause irregular heartbeat and acts differently in different people's bodies.  So it's possible that someone can take just a small amount, but it may last for days in their system and cause serious health problems. 

Methadone should generally not be used for acute pain.  So someone who has an acute pain problem, methadone is not the right drug for them.  It may not work rapidly enough and it is not as safe as other alternatives for acute pain.  And for someone who does not have cancer but is in pain, it's unclear that methadone provides the benefit they may need for backache or headache.  The use of opiates -- any opiates and especially methadone for noncancer pain is potentially quite problematic because it does build up in the body and because there's limited evidence that it works for chronic noncancer pain.  There are lots of things that can be done to reduce the number of overdoses and deaths from methadone.  We did see a slight increase [editor’s note: “increase” should be “decrease” based on speaker’s response to the first question] in 2009 -- 2008 and 2009, and we think that's related to actions at both the Food and Drug Administration and the Drug Enforcement Administration took in changing the labeling in the case of the FDA and in reducing availability of higher dose forms of methadone in the case of the Drug Enforcement Administration.  But there's still more that all of us can do to reduce the burden of both opiate associated overdoses in deaths and methadone specifically. 

Doctors can follow guidelines in prescribing methadone and other prescription painkillers, including screening for substance abuse and other problems and making sure that they're providing the right drugs to the right patients as per guidelines.  Health insurers and health providers and individuals and states have a series of other actions that they can take to reduce the inappropriate use of methadone and also ensure that people who are in pain get effective treatment for that pain.  And the fact sheet that comes out with the CDC Vital Signs outlines some of those actions.  These include things like increasing use of prescription drug monitoring programs whereby doctors can check to see what other doctors have prescribed for the patients they're seeing and guidelines that doctors can follow. 

There are plenty of safer alternatives to methadone.  There are non-opiate alternatives, both pharmacological, physical therapy and other that can be effective in reducing noncancer chronic pain, and there are also safer opiates if opiates are needed to address pain relief.  We want to ensure that methadone remains available for appropriately treating addiction and pain and also address the thousands of overdose deaths involving methadone.  Methadone is riskier than other prescription painkillers, and it should only be used for pain when other drugs haven't been effective.  And we don't think it has a role in treatment of acute pain.  Improving the way methadone's prescribed will reduce the amount of diversion and nonmedical use and at the same time, we can make sure that patients have access to safe and effective treatments.  Thank you. 

LLELWYN GRANT: At this time, I believe we are ready to take some questions. 

OPERATOR: Thank you.  At this time, if you'd like to ask a question, please press star-one on your touch-tone phone.  You'll be prompted by our automated service to state your name to help our pronunciation.  Star-one to ask a question and star-two to withdraw your question.  And one moment, please.  Our first one comes from Mike Stobbe.  Your line is open, sir. 

MIKE STOBBE: Hi, thanks for taking the question.  Just wanted to ask, Dr. Frieden talked about the use of methadone and when it's appropriate and not appropriate.  And he specifically referred to noncancer chronic pain.  I was wondering, is methadone a -- an appropriate drug for cancer-related chronic pain?  I was wondering about that distinction you made. 

THOMAS FRIEDEN: Sure.  Let me first say I believe I misspoke and said that methadone deaths increased in 2008 and 2009.  I intended to say that methadone deaths decreased slightly in 2008 and 2009, but we're still seeing rates that are nearly six times higher than they were just a decade ago.  Methadone may have an important role in treating patients with cancer pain.  I'll turn it over to Chris Smith -- sorry, Chris Jones to comment. 

CHRIS JONES: We did see methadone use for patients with cancer-related pain.  Often times patients who are on higher doses of another opioid may develop tolerance to that opioid and sometimes switching them over to methadone in a cancer patient may allow them to continue to get pain relief.  I still think it's important that regardless of whether it's for cancer pain or noncancer pain, we have to make sure that the drug is prescribed appropriately and safely. 

MIKE STOBBE: Okay.  Thank you. 

LLELWYN GRANT: Next question --

OPERATOR: Salimah Ebrahim.  Your line is open. 

SALIMAH EBRAHIM: Hi, I'm calling from Reuters.  I'm just wondering in terms of the data collection, I mean, we're looking at sort of -- the study which ranges from 1999 to 2010, using 2009 data from 13 states.  I'm just wondering in terms of the practices how consistent has this data been -- you know, sort of collected in terms of the methodology in which it was collected.  Are we better at screening for and recognizing overdose now than we were a decade ago or in the 1990s?  I just wonder if you could speak to that because sometimes the way we screen for, you know, makes it appear that these overdoses are on the rise.  But not always the case. 

THOMAS FRIEDEN: It's very clear that these are real increases.  Data are consistent over time and across different states.  They're consistent year to year.  We're seeing -- we've seen a steady increase in prescription drug overdoses.  And it matches very closely the steady increase in prescriptions for opiates.  I don't know if Dr. Paulozzi or Dr. Jones wants to add anything to that. 

LEONARD PAULOZZI: This is Len Paulozzi.  I would agree that all indications whether it's emergency department data or mortality data, indicates increasing deaths overall for opioids and in particular, methadone.  Yes, there’s been some increase in use of specific testing but it really cannot account for the dramatic increases that have been seen in the last ten years. 

SALIMAH EBRAHIM: Great. 

LLELWYN GRANT: Next question, please. 

OPERATOR: Again, if you'd like to ask a question, please press star-one.  Our next one comes from Deborah Kotz.  Your line is open. 

DEBORAH KOTZ: Hi, there.  Thanks for taking my question.  Just wondering how many of those deaths, the 5,000 deaths that you have, how many of those are attributed to accidental overdoses and how many intentional?  Do you have that data? 

THOMAS FRIEDEN: A very small portion are intentional or suicide.  The great majority are unintentional overdoses.  I don't know if Dr. Jones or Dr.  Paulozzi would like to put a proportion on it. 

CHRIS JONES: It's approximately 20 percent that are suicide.  Maybe 10 percent that are undetermined intent, and the remainder are unintentional overdoses. 

THOMAS FRIEDEN: It also varies by location.  So some jurisdictions have found even larger -- even smaller proportions are intentional.  But in general, the bottom line is the great majority of them are unintentional. 

DEBORAH KOTZ: and is there any reason for -- or indications as to which patients are more at risk of having an accidental overdose?  Are they being written in higher doses than the FDA recommends? 

THOMAS FRIEDEN: Dr. Paulozzi? 

LEONARD PAULOZZI: This is Len Paulozzi -- yes.  In general, the men and people of middle age are at greater risk for prescription painkiller overdoses, including those for methadone.  A lot of studies of prescription painkillers in general indicate that a greater daily dose is associated with a greater risk of dying.  So there's a lot of factors related to it, including the daily dose.  Also has to do with the characteristics of the patient, whether they are misusing the drugs or using it as directed.  Whether they're combining it with other drugs and/or alcohol.  And a lot of those details are not available in data about the deaths. 

LLELWYN GRANT: Next question, please. 

OPERATOR: Next question will come from Timothy Martin.  Your line is open, sir. 

TIMOTHY MARTIN: Hi, thanks for taking my call.  My question.  I'm wondering -- it's a two-parter.  Can you guys talk about when you started seeing this transition from methadone being used as a medication to treat heroin addiction or drug addiction, and sort of being used for pain?  And the second part of my question is, to what extent if at all is methadone being used to help addicts wean themselves off of other painkillers? 

LEONARD PAULOZZI: We started seeing reports of deaths increasing from methadone around 2002.  The first report was an investigation in North Carolina.  And some of the individuals according to anecdotal data may be using methadone to self-treat, to take themselves off of heroin or other prescription opioids.  But we don't have any quantitative data on that. 

TIMOTHY MARTIN: Okay.  The second part is, is this being used to help people who are really addicted to, say, oxycodone or hydrocodone, to help them wean off of those types of medications? 

LEONARD PAULOZZI: Methadone when used in treatment programs is very effective in treating addiction to heroin or prescription painkillers such as oxycodone, hydrocodone. 

TIMOTHY MARTIN: Okay.  Thank you. 

LLELWYN GRANT: Next question, please. 

OPERATOR: Next question comes from Peggy O'Farrell from Dayton Daily News.

PEGGY O’FARRELL: Hi, thanks for taking my question.  You had talked about working more with states to help track what doctors are doing and help doctors know how many painkiller prescriptions patients might be on.  How many states actually have those programs up and running, and what is CDC doing if anything to help get those programs established? 

THOMAS FRIEDEN: Nearly all states have prescription drug monitoring -- this is Dr. Frieden.  Nearly all states have prescription drug monitoring programs.  They operate differently in different states, and one of the things that we do is to help states identify how those programs can be more effective, more real time, more accessible to doctors, more routinely used.  And we are seeing that where they are more used there is -- there are less risky prescriptions being written by physicians.  States can also develop and promote the use of safe prescribing guidelines for methadone and other drugs and we've seen some states like Washington state begin to make real progress on the prescription drug opiate problem.  So we think this is an area where states have a lot that they can do.  CDC spends a lot of it’s time and effort supporting state and local governments- that’s core to our mission. We embed staff in state and local governments to provide resources and technical support.  We investigate problems along with states.  And so this is certainly an area where we're working closely, and we're encouraged by some of the innovation and some of the commitment that we're seeing around the country. 

Oklahoma, for example, has a real-time prescription drug monitoring program which gets the information on the system almost immediately when the prescriptions are written.  Other states are doing more and more to reach out to doctors who may have problematic prescribing to either educate them if it's an information gap or to take regulatory action if doctors are essentially selling prescriptions, and similarly to identify patients who may be in need of treatment and encourage them to get treatment or if the patients are using medication refills as a way of selling prescriptions to take appropriate action there, as well. 

LLELWYN GRANT: Next question. 

OPERATOR: Again, if you would like to ask a question, please press star-one.  Our next one comes from Salimah Ebrahim from Reuters please go ahead. 

SALIMAH EBRAHIM: Sorry.  Second question here.  The press release touched on cost.  And I believe methadone is about a quarter of the cost of oxycontin and other like drugs.  Just wondering what the conversation that you'd like to see sort of with hospitals -- yes, you can tell doctors to be cautious and hospitals to be cautious, but when it's that much cheaper, it's really attractive price point.  So what do you -- what are you gentlemen thinking to be done in terms of that conversation? 

THOMAS FRIEDEN: I think that using methadone for pain is pennywise and pound-foolish.  Because although it may cost a couple dollars less per pill, the result is many more emergency department visits and a much higher societal cost in deaths and addiction and other problems that can be avoided.  So first is to use opiates only when necessary for pain.  And the second is to use opiates that are safer.  And part of the challenge is to work with insurers and others so that it is not necessarily the case that methadone would be the preferred drug.  With methadone accounting for nearly one out of three opiate deaths, the costs in terms of societal costs and human costs of saving a dollar or two on a pill are  too great to be risked. 

LLELWYN GRANT: We have time for two more questions, please. 

OPERATOR: If you would like to ask a question, press star-one.  Our next one comes from Mike Stobbe from the Associated Press.  Your line is open. 

MIKE STOBBE: Thanks, I'll go again, too.  I wanted to ask, is the pendulum swinging back?  In the '90s you all described and others have described that physicians shifted from oxycodone to methadone, and that use increased.  Just recently after all these FDA warnings and physician education efforts, do you have any data suggesting that the pendulum shifting back and physicians are -- are switching from methadone to oxycodone or hydrocodone? 

THOMAS FRIEDEN: I think the bigger pendulum shift is from -- on pain management.  And where we need to be is a middle ground where we're addressing patients' needs in an integrated fashion, identifying the sources of pain, trying a whole host of -- non-opioid pharmacological interventions as well as non-pharmacological interventions to help patients live with more functionality and less pain.  And understand that there are limits to any medication, and there are risks to any medication, particularly to prescription opiates.  Within the class of prescription opiates we may be seeing lower doses of methadone being used.  We have not seen a shift as far as we can tell from methadone overdoses to overdoses of other prescription opiates.  But I think the broader issue is the need to be careful in our prescribing of opiates, at the same time we preserve the fundamental importance of pain control for patients.  I don't know whether Dr. Jones or Dr. Paulozzi would like to add to that. 

LEONARD PAULOZZI: This is Len Paulozzi.  I would just add that the amount of methadone declined in recent years, but the number of prescriptions has not declined through 2009.  So there's no indication that doctors are prescribing it less often.  It's just that they are probably prescribing it at somewhat lower dosages. 

LLELWYN GRANT: Okay.  We have time for one final question. 

OPERATOR: At this time, I show no further questions.  But again, if you'd like to ask a question, please press star-one. 

THOMAS FRIEDEN: As we close, I would just like to thank everyone for their attention and reiterate that methadone is now accounting for about one third of opiate overdoses, and that we think that there are many safer alternatives to methadone for chronic noncancer pain.  We have seen a slight decrease in recent years, and we think this shows it's possible to make further substantial decreases in the number of people who overdose and die from methadone.  Thank you all very much for your interest. 

LLELWYN GRANT: I wish to thank everyone for participating in today's telebriefing.  For more information about the Vital Signs report on methadone, please visit www.CDC.gov/VitalSigns.  For more information about prescription drug overdoses in the United States, please visit www.CDC.gov/homeandrecreationalsafety/poisoning.  A transcript will be available this afternoon.  For follow-up questions, call the main press office at 404-639-3286.  This concludes our media telebriefing.  And thanks again for joining us. 

OPERATOR: At this time, this concludes this conference.  You may disconnect, and thank you for your attendance.  

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