Victoria's heroin recovery program has contributed to a shameful number of deaths as patients prescribed "takeaway" doses of methadone abuse the system, a coroner says.
Methadone given to patients trying to ween themselves off heroin killed at least 21 "third persons" who were not involved in the opioid replacement therapy (ORT) program in 2010 and 2011.
But the true number of deaths over that period could be as high as 63, at a rate of more than two per month.
Coroner Jacinta Heffey said methadone was now widespread in the community and too readily finding its way into the hands of vulnerable people it was never meant for.
"The number of deaths of third parties occasioned by the abuse of the system by the people for whom it was designed is shameful and deserves a robust rethinking," she said on Tuesday.
Ms Heffey handed down her findings into the ORT program following the death of a 16-year-old, who died from combined drug toxicity, which included methadone, in May 2010.
The girl was not on the ORT program and Ms Heffey determined that she either traded for or stole a bottle of methadone from an ORT patient.
Ms Heffey found ORT patients were often too easily prescribed "takeaway" dosing which allowed them to take methadone into the community for unsupervised use.
She said many on the program believed it was simply a "rite of passage".
She quoted addiction medicine specialist Dr Matthew Frei, who described the expectation that patients would be eligible for takeaway dosing after a month as "the genie that has got out of the bottle in Victoria".
"It could persuasively be argued that the pendulum has swung too far in favour of minimising harm to participating clients, taking shortcuts to attract them into and retain them in the program and to respond to their particular needs," Ms Heffey said.
"As a result of this process, third parties have been able to access a dangerous drug, which in too many cases, has ended in their deaths."
Chief among Ms Heffey's 15 recommendations was a review of the Victorian Department of Health's takeaway methadone dosing and a data collection process which measures the number of takeaway patients and the number of doses prescribed.Ms Heffey said unless her recommendations are implemented, "it is certain that there will be more tragic deaths like this one".