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There's much in favour of MXL on a theoretical basis. Like methadone, its oral, and once a day dosing, which means it can be supervised, but unlike methadone, it contains morphine, which give the same effect as diamorphine, which theoretically could be an advantage to some. the main drawback is that its not licenced for treatment of addictions. Urine testing is more complicted, instant tests won't differentiate it from heroin , the urine has to be sent to the lab, with a request to test for 6-MAM (Monon-acetyl morphine, a metabolite of diamorphine) to detect continuing heroin use, and this usually takes a day or two. Therefore it can't be a first line option. I have prescribed it in a few cases. in the first case I attempted, the patient was stable on methadone for many years, but suddenly started to experience daily withdrawals, MXL was an alternative to increasing the methadone dose. It worked a treat, and this patient has now functioned very well on it for a few years now. In another case it was used to help a patient stop heroin injecting - it was prescribed on a 3 month trial basis, and toxicology confirmed that heroin use had ceased - again a satisfied customer for a couple of years now. A third was on injectable methadone, and really wanted diamorphine, but it was at the time of the shortage and moving to another area to get on a trial would have been the only way to get it. This person was coming to the end of the road with their one and only vein and hated im injecting, so it made sense to try a transfer to oral medication. This person had one relapse but is stable again now. As far as I know, none have ever tried to inject the tablets, and all were given it on a supervised basis for the first few weeks.
My main concern is diversion, and I am always very clear at the outset that I would have to cease prescribing if this seemed to be happening. I worry that if it became widely available on the streets we might see people going to GPs for it who might lack awareness of its abuse potential, and/or get it from other patients who are prescribed for genuine licenced indications, bringing about similar problems we see in relation to benzos.
The patients are aware that the forumlation of the tablet is what makes it last the whole day so they have to take them whole, and cannot break them up. There is some limited evidence from Europe on efficacy as substitute rx, and I believe there may be a trial ongoing at the Maudsley, though I have not managed to establish anything about this despite emails. (If anyone knows more, please let us know!). I would be very interested to hear of others' experiences, in particular any cases where it has been injected.
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