All men on methadone maintenance programmes should be having bone checkups. That was the conclusion of a past paper in the journal Addiction. Why? It looks like taking methadone long term for men, but not women, is associated with thinning of the bones potentially leading to increased fracture risk. This is likely to be part of methadone’s effect on the endocrine (gland) system in the body. It’s not the only effect as I wrote recently. Libido and sexual performance can also be impaired, probably through the same mechanism.
In this study, eighty-three people (48 men) were recruited. The average age was 48, the median duration of methadone use was 11 years and the median daily dose was 90mg. They compared the men to age matched controls and found that everywhere they looked, bones were thinner by 7-14% than they should have been. Given that these were men in early middle age the implications for future fractures are significant.
Actually we’ve suspected this for a few years with other researchers finding similar things. This paper was different though, for it called clearly for men on maintenance treatment to undergo “assessment of skeletal health”. Why is that of any interest? Well because in the UK there are around 170,000 people on methadone.
Let’s say three quarters are men, meaning 127,000 guys, generally younger chaps, now need to be screened for osteoporosis. We might reduce this if we only screened folk who had been on methadone for longer periods of time, but how long?
Screening is normally done through asking questions for risk factors and arranging a bone scan. Those found at risk would be recommended to start medication to reduce the risk. Clients would almost certainly need to be directed to their GPs in the first instance for assessment.
Not only this, but if this research had been accepted and had changed practice, all clients coming to treatment would need to be informed of this “new” risk. The paper was published in 2011. Did it change practice? No it didn’t. I wonder about the reasons for that. Cost? The paper was missed by most prescribers? Methadone patients don’t deserve high quality healthcare? Most would argue that’s clearly nonsense. So why does research like this not translate into what’s best for patients?
There are significant implications in this paper for our treatment system, both in terms of raising awareness, operationalisation, resource provision and cost of medication to prevent or treat osteoporosis. The costs of investigation and treatment may be substantial depending on what’s uncovered.
Another interesting finding reported here was that guys on methadone maintenance had lower testosterone levels than normal. That’s what’s thought to behind the accelerated loss of bone as testosterone is important in bone metabolism. Lower testosterone levels have been evidenced plenty of times since and no doubt this contributes to the relative lack of interest in amorous escapades that we see in clients on long term methadone – something I blogged about before.
What about other opioids? Is this a class effect? It looks like it might be. Again I am brought back to thinking about how honest we are with clients on medication. Do we talk about long term methadone side effects? Are patients fully informed? What is the balance of risks? How can we practice harm reduction on the harm reduction?
It looks like this paper was quietly forgotten – a bit like the bones of the guys on long term methadone.
Grey, A., Rix-Trott, K., Horne, A., Gamble, G., Bolland, M., & Reid, I. (2011). Decreased bone density in men on methadone maintenance therapy Addiction, 106 (2), 349-354 DOI: 10.1111/j.1360-0443.2010.03159.x