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Accidental death from take home methadone maintenance doses: A report of a case and suggestions for prevention
Child Abuse & Neglect 35 (2011) 1–2
Contents lists available at ScienceDirect
Child Abuse & Neglect
Letter to the Editor Accidental death from take home methadone maintenance doses: A report of a case and suggestions for prevention Keywords: Overdose Methadone Storage Neglect
Background Methadone, a synthetic opioid receptor agonist, is used for the treatment of opioid withdrawal and dependence. It occupies the opioid receptor and prevents withdrawal while permitting opioid addicts to change their behavior and discontinue their opioid use. The drug must be administered daily. Federal law allows for select individuals to take home and keep methadone for their therapy at home. There are currently approximately 260,000 individuals eligible for methadone to take home a 30-day supply of such methadone. Federal regulations specify the labeling of the medication containers and the use of child resistant containers. No regulations specifically require methodology for safe storage of containers (US Public Health, 2009). To the methadone naïve individual, particularly a small child, even the content of 1 container, even if only partially full, could prove fatal if ingested. Over 30,000 exposures to methadone were reported to poison control centers between January 2000 and December 2008 (American Association of Poison Control Centers, 2009). There were 684 deaths reported. Of the individuals exposed, 2,186 were under 6 years of age and 20 of these died. Only 1 child reached an ER alive, all the rest were dead on arrival. We report a case of a childhood death from an unintentional exposure to take home methadone.
Case report A 2½-year old African-American male child was noted to be fine when the mother checked on him at 11:30 at night. At around 4 in the morning, he climbed into his mother’s bed and slept with her. His mother noticed that he was making strange sounds breathing and then stopped breathing. Emergency medical services (EMS) responded to a call from the home and upon arrival found him to be asystolic and apneic. He was intubated and advanced pediatric life support was instituted and he was transported to an emergency room (ER). Upon arrival in the emergency room he was apneic and asystolic and actively being resuscitated. There was return of vital signs and he was transported to the pediatric intensive care unit. A “urine tox screen” was obtained and was positive for methadone. He remained unresponsive, his radionuclide brain flow study revealed the absence of cerebral perfusion and he was removed from life support. All specimens obtained while the patient was alive were sent to the regional medical examiner (RME) for confirmation of the tox screen. Post mortem examination was unrevealing for any other cause of death. The RME toxicology laboratory confirmed the presence of methadone in both blood and urine. Investigators from the RME located an open and empty bottle of methadone under the child’s bed. The bottle did not demonstrate any evidence of forceful opening. Multiple full and open bottles of methadone were found in a shaving kit and in a cardboard box. The containers were properly labeled as per existing regulation and the full ones had their child resistant caps intact. The medication “belonged” to both the grandmother and grandfather; each qualified for take home of a month supply of methadone. 0145-2134/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.chiabu.2010.08.003
2
Letter to the Editor / Child Abuse & Neglect 35 (2011) 1–2
Discussion/conclusion The case we present clearly represents a tragedy in preventive medicine. If we are to continue to allow take home methadone therapy, then we must do it more carefully. We propose a linked educational and engineering approach. We do not believe that either alone will suffice; they need to work in tandem. At the core of the “engineering in” safety would be the use of a lockable container to store the medicine. Such containers are readily available and can take the form of a simple fishing tackle or tool box with a lock attached to a specially designed lockable medicine cabinet. The client would be required to bring the lock box with the empty daily dose containers to the treatment center to exchange the used dosage containers for new ones and to insure the use of the lock box. Purchased in bulk, 1 such lockable medicine box could be purchased for approximately $6.00 (B. Lateerf, personal communication). Even when multiplied by a factor representing the number of registered methadone maintenance clients, the total economic impact would seem negligible on a national basis. Further, in line with engineering safety, the placing of the methadone into solution is also an accident waiting to occur, as even a small remnant may contain enough methadone to poison a small child. It is a handy tool to use to insure that the dose has been ingested if dispensed at the treatment facility, but it seems absurd to use that form of dispensing in the home of a client deemed responsible enough to keep a month’s supply at home. There is increasing interest in providing access to naloxone in the community to treat opioid overdoses pre-hospital and outside of the usual emergency medical system. If the results of the pilot programs in several cities is any indication of effectiveness, then the provision of naloxone in any home with substantial supplies of methadone would seem judicious. All of these engineering efforts will only be effective if there is intense, targeted, education on how to store and use the medication and what to do if someone seems to have overdosed. Requiring evidence of knowledge of rescue breathing and cardio-pulmonary resuscitation techniques would also be a possible mitigation technique for accidental exposures. With the marked increase in reports of “accidental” overdose deaths from prescription opioids and other sedative hypnotics, and the evidence that individuals seek prescription medications from family and friends’ medicine cabinets, the use of lockable medicine cabinets may be seen as a preventive approach for these cases as well. These suggestions are not fool proof, but they would seem to be a good start. References United States, Title 42: Public Health §8:12 federal opioid treatment standards. electronic Code http://ecfr.gpoaccess.gov/cgi/t/text-idx?c=ecfr&sid=0ff8339b2448e734fd172509105. June 2009. Data supplied by the American Association of Poison Control Centers (2009) from the National Poison Data System.
of
Federal
Regulations,
e-CFR.
Steven M. Marcus a,b,∗ New Jersey Poison Information and Education System, Department of Preventive Medicine & Community Health, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA b Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA a
∗ Corresponding
author address: c/o NJPIES @ UMDNJ, 140 Bergen Street, Suite G1600, PO Box 1709, Newark, NJ 07101-1709, USA.
Contents lists available at ScienceDirect
Child Abuse & Neglect
Letter to the Editor Accidental death from take home methadone maintenance doses: A report of a case and suggestions for prevention Keywords: Overdose Methadone Storage Neglect
Background Methadone, a synthetic opioid receptor agonist, is used for the treatment of opioid withdrawal and dependence. It occupies the opioid receptor and prevents withdrawal while permitting opioid addicts to change their behavior and discontinue their opioid use. The drug must be administered daily. Federal law allows for select individuals to take home and keep methadone for their therapy at home. There are currently approximately 260,000 individuals eligible for methadone to take home a 30-day supply of such methadone. Federal regulations specify the labeling of the medication containers and the use of child resistant containers. No regulations specifically require methodology for safe storage of containers (US Public Health, 2009). To the methadone naïve individual, particularly a small child, even the content of 1 container, even if only partially full, could prove fatal if ingested. Over 30,000 exposures to methadone were reported to poison control centers between January 2000 and December 2008 (American Association of Poison Control Centers, 2009). There were 684 deaths reported. Of the individuals exposed, 2,186 were under 6 years of age and 20 of these died. Only 1 child reached an ER alive, all the rest were dead on arrival. We report a case of a childhood death from an unintentional exposure to take home methadone.
Case report A 2½-year old African-American male child was noted to be fine when the mother checked on him at 11:30 at night. At around 4 in the morning, he climbed into his mother’s bed and slept with her. His mother noticed that he was making strange sounds breathing and then stopped breathing. Emergency medical services (EMS) responded to a call from the home and upon arrival found him to be asystolic and apneic. He was intubated and advanced pediatric life support was instituted and he was transported to an emergency room (ER). Upon arrival in the emergency room he was apneic and asystolic and actively being resuscitated. There was return of vital signs and he was transported to the pediatric intensive care unit. A “urine tox screen” was obtained and was positive for methadone. He remained unresponsive, his radionuclide brain flow study revealed the absence of cerebral perfusion and he was removed from life support. All specimens obtained while the patient was alive were sent to the regional medical examiner (RME) for confirmation of the tox screen. Post mortem examination was unrevealing for any other cause of death. The RME toxicology laboratory confirmed the presence of methadone in both blood and urine. Investigators from the RME located an open and empty bottle of methadone under the child’s bed. The bottle did not demonstrate any evidence of forceful opening. Multiple full and open bottles of methadone were found in a shaving kit and in a cardboard box. The containers were properly labeled as per existing regulation and the full ones had their child resistant caps intact. The medication “belonged” to both the grandmother and grandfather; each qualified for take home of a month supply of methadone. 0145-2134/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.chiabu.2010.08.003
2
Letter to the Editor / Child Abuse & Neglect 35 (2011) 1–2
Discussion/conclusion The case we present clearly represents a tragedy in preventive medicine. If we are to continue to allow take home methadone therapy, then we must do it more carefully. We propose a linked educational and engineering approach. We do not believe that either alone will suffice; they need to work in tandem. At the core of the “engineering in” safety would be the use of a lockable container to store the medicine. Such containers are readily available and can take the form of a simple fishing tackle or tool box with a lock attached to a specially designed lockable medicine cabinet. The client would be required to bring the lock box with the empty daily dose containers to the treatment center to exchange the used dosage containers for new ones and to insure the use of the lock box. Purchased in bulk, 1 such lockable medicine box could be purchased for approximately $6.00 (B. Lateerf, personal communication). Even when multiplied by a factor representing the number of registered methadone maintenance clients, the total economic impact would seem negligible on a national basis. Further, in line with engineering safety, the placing of the methadone into solution is also an accident waiting to occur, as even a small remnant may contain enough methadone to poison a small child. It is a handy tool to use to insure that the dose has been ingested if dispensed at the treatment facility, but it seems absurd to use that form of dispensing in the home of a client deemed responsible enough to keep a month’s supply at home. There is increasing interest in providing access to naloxone in the community to treat opioid overdoses pre-hospital and outside of the usual emergency medical system. If the results of the pilot programs in several cities is any indication of effectiveness, then the provision of naloxone in any home with substantial supplies of methadone would seem judicious. All of these engineering efforts will only be effective if there is intense, targeted, education on how to store and use the medication and what to do if someone seems to have overdosed. Requiring evidence of knowledge of rescue breathing and cardio-pulmonary resuscitation techniques would also be a possible mitigation technique for accidental exposures. With the marked increase in reports of “accidental” overdose deaths from prescription opioids and other sedative hypnotics, and the evidence that individuals seek prescription medications from family and friends’ medicine cabinets, the use of lockable medicine cabinets may be seen as a preventive approach for these cases as well. These suggestions are not fool proof, but they would seem to be a good start. References United States, Title 42: Public Health §8:12 federal opioid treatment standards. electronic Code http://ecfr.gpoaccess.gov/cgi/t/text-idx?c=ecfr&sid=0ff8339b2448e734fd172509105. June 2009. Data supplied by the American Association of Poison Control Centers (2009) from the National Poison Data System.
of
Federal
Regulations,
e-CFR.
Steven M. Marcus a,b,∗ New Jersey Poison Information and Education System, Department of Preventive Medicine & Community Health, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA b Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA a
∗ Corresponding
author address: c/o NJPIES @ UMDNJ, 140 Bergen Street, Suite G1600, PO Box 1709, Newark, NJ 07101-1709, USA.