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Comments on the treatment and management of methadone patients in private care in B.C.

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Introduction

It is a commonplace that civil liberties organizations are often called upon to defend the rights of those who promote or are involved in unpopular causes or activities. Some of these groups and individuals have quite legitimately earned their public disfavour (pornographers, purveyors of hate literature and the like), but others, for instance narcotic-addicted persons, deserve a more sympathetic public assessment. It is beyond doubt now that people who are addicted to narcotics suffer from a chronic medical condition, yet it is rare that they are treated with the same standards of decency and compassion that we think appropriate to the treatment of any other medical condition. Their unattractiveness is at once the cause of this situation and the reason that few others are willing to defend their interests against often remarkably unfair and arbitrary practices. The figure of the “desperate drug addict” finds a different and perhaps more appropriate meaning in this context. Against these odds, the BCCLA has been successful in recent years in turning back a number of addiction treatment proposals that have represented serious threats to civil liberties. In the late 70s, we prevented the institution of a compulsory treatment scheme for narcotic addiction that was truly Orwellian in its scope and ambition. More recently, the brief included here was instrumental in preventing implementation of a proposal that would have eliminated treatment of methadone patients by private physicians and confined their care to a highly restrictive government treatment program. It is not difficult to see behind these comments to the depth of misunderstanding and prejudice that make proposals like these possible—and that will continue to produce others like them until there is a change in perception of the plight of narcotic-addicted persons.

The Joint Advisory Committee on the Treatment Uses of Methadone was established in February 1985 to advise the Ministry of Health on the treatment and management of methadone addicts in B.C. Representatives from the B.C. Medical Association (2), the B.C. College of Pharmacists (1), the B.C. College of Physicians and Surgeons (2), and the Ministry of Health, Alcohol and Drug Programs (3) participated on the Committee. On August 1, the Joint Advisory Committee (JAC) approved a brief four-page report which recommended discontinuing all private prescription of methadone and that all treatment of methadone patients be conducted within Alcohol and Drug Program (ADP) clinics. This report was later approved by the governing bodies of each of the participating agencies, although the BCMA will be reconsidering its position shortly, and the College of Physicians and Surgeons will be considering the ethical issues involved in transferring patients to clinics. The JAC Report subsequently formed the basis for the changes that are presently being introduced to methadone treatment programs in B.C.

The concerns that led the JAC to adopt a clinic treatment approach for methadone patients are:

  1. A perceived need for a body of current data to be generated on methadone treatment so that rational decisions can be made on future use of methadone in B.C.
  2. A general skepticism over the usefulness of methadone as an aid to the social rehabilitation of narcotic addicts.
  3. A need for better management of patient care. Concerns were expressed over “double-doctoring” and continued multiple drug use by patients, and that a number of patients were not being properly screened to determine whether they have a narcotic dependency, thus creating new addicts.
  4. Lack of adherence to and difficulty enforcing protocols for treating methadone patients, including faulty initial assessment of addicts, unsupervised and infrequent urinalysis testing, prescription of excessive dosages of methadone, and use of methadone for non-opiate addiction. Implicit here (and explicit in our discussions with JAC and ADP officials) is the claim that there is significant abuse of methadone and other narcotic prescribing privileges by private physicians, thus creating new addicts and increasing the availability of illicit methadone and other narcotics.
  5. A need to check escalating health costs.

Hardly a shred of concrete evidence is adduced in this Report to support these points. Many of the JAC’s concerns are not well-founded, and this will be demonstrated below. However, even if these concerns are valid, they do not establish a convincing case for withdrawing methadone patients from private treatment, given the probably adverse social consequences of such action.

Criticisms of the JAC report

There are two major omissions in the JAC’s Report. First, it does not show any evidence of having considered alternate methods of treatment for methadone patients—nor does it give any indication why such alternatives, if they were considered, were discounted. The JAC was certainly not presented with an “either/or” situation and some explanation is called for, especially in light of the number of requests and proposals that have been made by private physicians and the BCMA for the ADP to work cooperatively with physicians to permit better management of methadone patients.1 Second, the Report offers no discussion or consideration of the possible indirect costs of returning methadone patients to clinic care. Methadone patients’ almost universal antipathy toward the strict, relatively low dosage treatment offered by clinics in B.C. will prevent many, perhaps up to one-half, from going to treatment centres.2 These individuals’ narcotic addiction will rapidly destabilize, and existing research shows that many will seek drugs through the illicit market and become involved in criminal activity to support their addiction (e.g., prostitution, trafficking, minor fraud, breaking and entering, theft, robbery, and so on).3 It is hard to speculate on the reasons that the JAC avoided dealing with these issues in its Report, although some answers are suggested below.

The following criticisms can be made about the issues and concerns that are directly addressed by the report:

1. Need for current data

There are literally hundreds of research studies and reports on the management and treatment of persons who receive methadone for narcotic dependency. This research is extensive, often well-designed, and can be applied to our situation here in B.C.4,5 There is generally no need to go beyond this research to make rational decisions about which methadone treatment models should be used in B.C.

On the other hand, we can support the objectives of the JAC and Ministry of Health officials who wish to have precise information on the number of addicts in B.C., amounts of methadone being prescribed, treatment regimens, etc. But clearly there are other ways of obtaining this information than by forcing patients to receive treatment at government-sponsored clinics. The proposal that we have outlined in the second part of this submission would involve the sort of ongoing contact between private physicians and ADP clinics that would permit recovery of virtually all relevant information that the Ministry could reasonably require for the purposes of maintaining an accountable system, or for making policy decisions on the management of methadone treatment programs. Admittedly, such a system may be more susceptible to occasional breakdowns in communications, but it should be recognized that it is rarely, if ever, that a society such as ours permits substantial disruptions or intrusions into the personal lives of its citizens merely for the purpose of gaining statistical information. Our concerns about personal privacy and other civil liberties require that we use the least intrusive methods of gathering such information which are generally consistent with operating an accountable program. This may be vexing to researchers and government officials who long for “hard data” on which to base their reports, but such are the limitations of social scientific study in a liberal democracy.

2. Methadone as treatment

The JAC Report gives considerable evidence that its members were generally skeptical about the value of using methadone in treating narcotic dependency. Obviously, this point does not provide an argument either in favour of or against private treatment of methadone patients. However, because of this skepticism it has been suggested by some critics of the JAC that its members were planning a first step toward the complete elimination of methadone programs in B.C. We take no position on the JAC’s underlying intentions, but we wish to address its skepticism over the value of methadone programs and the possibility that methadone programs may be eliminated altogether at some future date.

To begin with, some of the best research on methadone treatment programs indicates that they can be successful over a long term and on a large scale and, more importantly, that their success or failure very much depends upon the manner in which methadone is used. This research shows that where methadone is administered in less restrictive settings and high dosages are permitted, patients do considerably better than where low dosages are administered in highly rigid and restrictive settings where abstinence and short term treatment are high priority treatment goals. 6,7 Among the benefits found by this research for higher dosage and relatively non-restrictive programs are significant reductions in arrests for drug and property offences, periods of incarceration, abuse of illicit narcotics, abuse of alcohol, and self-reported criminal behaviour. Social cost comparisons between these programs also markedly favour the less restrictive higher dosage programs.8

In addition to this well-regarded American research, similar results are also being found in England where increasingly restrictive treatment policies have been recently introduced in narcotic addiction treatment clinics. The view that the move to more rigid and short term clinic treatment in England led to increasingly ineffective treatment and more addiction-related crime is thoroughly and persuasively canvassed by Stimson and Oppenheimer, Heroin Addiction (1981), and Amold Trebach, The Heroin Solution (1982). Even highly conservative English researchers like Mitcheson and Hartnoll who seem to be proponents of more restrictive treatment policies have found that more criminal behaviour and greater social disruptions for addicts are associated with restrictive treatment policies.9 Although Mitcheson and Hartnoll refuse to draw conclusions about the desirability of more restrictive versus less restrictive programs on the basis of their work, many other commentators who are proponents of less restrictive models see strong support for their position in their data. On the basis of this body research, it appears the JAC was heading in exactly the wrong direction by recommending that treatment of all methadone patients be confined to a rigid clinic setting where low dosages of methadone will be prescribed.

To some extent, the JAC’s skepticism about methadone treatment programs appears to have been a product of having unrealistic treatment goals for methadone patients. In our discussions with JAC and ADP officials, they have seemed preoccupied with achieving, as quickly as possible, a totally drug dependent free lifestyle for their clients. This attitude ignores the fact that cures for narcotic dependency are notoriously difficult to achieve and chronic relapsing into drug dependent ways is common. In recognition of this, the federal government guidelines for administering methadone accept that partial rehabilitationis a legitimate and worthwhile objective:

Programs relying on drugs of dependence such as methadone aim at improving economic stability and employment, social adjustment, and decreasing criminality, without necessarily achieving full recovery…. Nevertheless, whenever possible, withdrawal from all narcotics should remain the ultimate goal of any total treatment program.10

We think that this is a sensible treatment approach to narcotic dependency, and we would like to see it seconded and given more vocal recognition by administrators of drug addiction programs. What is required, however, is a clearer understanding that there is no single mass treatment solution to narcotic addiction, and that the most effective treatment approaches seem to be the least restrictive ones. On both of these points, the present clinic system that is being implemented in B.C. appears not to provide the best treatment model. On the other hand, the value of the flexibility and personal contact that are built into the doctor-patient relationship should have been explored more carefully by the JAC.

The phenomenon of “maturing out” provides a further argument in favor of a non-restrictive approach to methadone treatment. Given that most addicts seem to lose interest in narcotics by their late 30s11, a program that actively promotes earlier withdrawal in all cases is likely to produce a great deal of personal hardship and extra social expense when a little bit of patience would in most cases produce a more consistent and desirable result. Concerns may be raised about unnecessarily prolonging a patient’s addiction career, given that there Is no exact way to assess a patient’s readiness to mature out. But this would seem to be a small cost that is overridden by the social benefits that are obtained. As well, research studies appear to have consistently found that patients in long term methadone treatment programs do better in terms of reduced drug abuse and criminal activity both during treatment and after discharge than do patients who receive treatment for shorter periods.12

On the basis of all this research and information, we are convinced that the JAC’s general skepticism about the value of methadone programs is unfounded, although particular treatment models may prove more successful or unsuccessful than others. The irony is that the JAC appears to have chosen a treatment approach where skepticism is justified. Lastly, in our view, if methadone treatment were discontinued in B.C., it would probably have to be replaced by some similar mode of treatment that would be at least as effective as the better methadone schemes that are presently operating. Until such a new treatment is devised and introduced, the continuation of methadone programs will be necessary as a voluntary aid to social control and to assist narcotic addicts who genuinely wish to stabilize their addiction and rehabilitate their lifestyle.

3. Guidelines for methadone treatment

Physicians who are licensed to prescribe methadone privately are expected to follow certain treatment guidelines established by the federal Health Protection Branch.13 The purpose of these guidelines is a) to ensure that long term narcotic dependence is established before methadone treatment is commenced; b) to outline procedures for managing and treating narcotic addicts with methadone; and c) to identify safeguards to be followed to check treatment abuses of methadone.

Private physicians who prescribe methadone acknowledge that although some physicians diligently follow the recommended plans, adherence to federal guidelines is often inconsistent. Even so, these guidelines are not nearly as rigid as the JAC implies. In addition, the federal Health Protection Branch has done little over the years to publicize and enforce them, and they are not especially well known by physicians as a result. In these circumstances, it is difficult to assess the extent to which these guidelines are followed. But even more importantly, it would be hard to argue that physicians are either unable or unwilling to participate in following a set of methadone treatment procedures that meet the objectives identified above. fact, the evidence suggests the contrary. For years private physicians who have been licensed to prescribe methadone have asked the ADP to work with them to create a coordinated approach to treating narcotic addiction. These physicians have asked for assistance in conducting urinalysis tests in supervised settings, in assessing patients, and in providing adequate backup services for intractable patients. Given the small number of physicians in B.C. who are presently licensed to prescribe methadone (about 50, some of whom prescribe methadone for analgesia only, and not for drug addiction), a better coordinated approach to treatment of methadone patients and monitoring of physicians’ adherence to treatment guidelines would not appear to represent an unmanageable administrative burden.

4. Methadone abuse

The JAC provides no evidence about the extent of patient or physician abuse of methadone treatment programs. No information is given about the extent of trade in “grey” market methadone, how many patients receive excessive dosages (in fact, what constitutes an excessive dosage is not defined by the JAC, nor is it defined by any reputable scientific authority), how many patients may be involved in “double doctoring”, etc. Admittedly, reliable information in some of these areas is difficult to obtain. Nevertheless, the JAC’s concerns about such abuses requires it to demonstrate its basis for making such comments.

Against the JAC’s concerns about patients’ abuse of methadone, it is somewhat remarkable to find that prosecution for trafficking in methadone is exceedingly rare. At the very least, this suggests that there is no organized crime involved in the illicit methadone market and that any market that exists is quite small. Nevertheless, it is generally accepted that some methadone reaches the illicit drug market and that improved procedures for prescribing methadone could be adopted to reduce the chances of such abuses occurring. Accepting this, however, does not support the view that all methadone patients should be treated and receive methadone at ADP sponsored clinics. This type of centralized control over distribution of methadone has never eliminated all leaks of methadone from legal sources to the illicit drug market, and it is not likely to achieve this here. In fact, methadone patients report that in the past treatment clinics in B.C. have been the source for much of the methadone that reaches the illicit market. More carefully defined and enforced guidelines for private treatment of methadone patients would probably be as effective at checking abuses as centralization of methadone dispensing through clinics—but would not produce the adverse social consequences that are likely to follow the implementation of the JAC’s proposals.

There is a strong inference to be drawn from the JAC’s Report that many doctors who treat methadone patients are abusing their methadone prescribing privileges for personal gain, thus adding needlessly to health care costs and contributing to drug abuse and trade in illicit narcotics. Such concerns have been expressed explicitly in our recent discussions with ADP and JAC officials. However, beyond the prosecution of one physician, no evidence has been offered at any time to support these claims. The irresponsibility here of impugning the professional integrity of a group of physicians without giving proper justification is heightened, in our opinion, by a comparison of the salaries of methadone prescribing physicians and the salaries of their general practitioners peers. Such a comparison reveals that in B.C. both the median and mean incomes of methadone prescribing physicians are less than those of general practitioners as a group (Median: $110,029 vs $115,509; Mean: $109,376 vs $129,000).14 On the basis of this information, it would be just about impossible to argue that there was any systematic gouging of the medical services system by methadone prescribing physicians especially given the extra stress and difficulties that are associated with treating narcotic addicts. Of course, there may be occasional cases of abuse by particular physicians, but the appropriate response here is one of vigilance and not of judging the worth of the barrel by one or two bad apples.

We note that in other jurisdictions, moves to confine patients to clinics and restrictions on prescribing privileges have often followed some questionable prosecutions of a few doctors for professional misconduct.15 This has later been regretted as an overreaction. The following excerpt from Trebach’s The Heroin Solution(1982) has particular relevance to the present situation in B.C.:

Criticism of the clinics’ restrictive treatment and prescribing policies has also come from the top of the Drug Branch at the Home Office. H.B. Spear has made it clear that he sympathizes with much of what Tanner and Beckett have been saying… “I do not believe that it is a coincidence that this [widespread use of many drugs in injecting] appeared only after the tightening up which occurred as a result of Brain II.” “We didn’t need clinics, we needed a thousand doctors with one patient each!” He added, “In any event, we never asked for clinics. We simply wanted the machinery to enable us to deal with a few grossly irresponsible prescribers.” (page 211, Trebach’s parentheses)

In the absence of compelling information that there is significant prescription and treatment abuse by private physicians, which cannot be checked by better regulation and law enforcement, we strongly suspect that history is drearily repeating itself here.

It is worth noting that it is not clear exactly how private physicians’ methadone prescribing privileges will be lifted, as appears necessary if all patients will be required to discontinue private treatment. No regulations have been amended to prevent private physicians from applying for or receiving renewals of methadone prescribing privileges from the federal government. Although the federal government could have an informal agreement with provincial health officials not to renew or issue new licences in B.C., such a discriminatory practice would be open to a strong judicial challenge. However, for our purposes, the importance of the lack of any amendment to existing criteria for granting methadone prescribing privileges suggests, at the very least, that the federal government does not view restricting methadone treatment to clinics as the only reliable means of checking physician or patient abuse.

5. Costs

The JAC estimates that it costs ADP sponsored clinics approximately $3,300 each year to provide treatment and counselling services for each of its methadone patients. No information is given to show how this figure was established. The JAC also estimates that it costs $5,450/annum to treat a methadone patient privately, including: two weekly visits to a physician (S1,800/annum), weekly urinalysis ($2,500/annum), twice weekly pharmacy dispensing ($1,150). If these figures were accurate, they might begin to present a convincing economic argument in favour of clinic treatment of “stable” methadone patients (i.e. patients who have achieved a certain level of rehabilitation and require no more than two physician visits per week). However, this account fails to persuade for a variety of reasons.

To begin with, the costs of privately treating a methadone patient are considerably exaggerated by the JAC. For instance, we are informed that the pharmacy costs cited by the JAC are $300 – $400 in excess of yearly dispensing costs for methadone patients, since most patients receive weekly prescriptions and many pay dispensing costs themselves. Recently, the fee that a physician may charge for prescribing methadone has been reduced from $17.60 (the figure on which JAC estimates appear to be based) to $7.00, as long as no other service is provided. Assuming that patients will receive counselling and other medical services from time to time, this still represents a saving of up to one half of the physician cost cited by the JAC (or about $900). We are also certain that private urinalysis costs could be reduced by one-half or more (about $1250) if this testing were conducted at ADP clinics, as has been recommended for years by private physicians. Thus, on the basis of this assessment, the cost of privately treating stable methadone patients may well be equal to or even less than the clinic cost cited by the JAC (Private: $2,900 vs Clinic: $3,300). If the predicted indirect social costs of confining treatment of all methadone patients to clinics are considered (increased unemployment, welfare, justice system, and corrections costs), the economic case swings convincingly in favour of private treatment not only of stable patients, but of many unstable patients as well.

6. Composition of JAC

In commenting on the work of the JAC, it is hard to avoid some fairly harsh criticism of its composition and operation. For example, the JAC had no representation from medical practitioners who had any extensive experience treating stable methadone patients in private practice. The medical and lay representation on the JAC did, however, have a great deal of experience treating and dealing with methadone patients under the worst conditions, namely, in detoxification, overdose, and clinic situations. It is hardly surprising, then, that nearly all Committee members seem to have come to the JAC with fairly sceptical views about the value of methadone programs.

Criticism about the composition and operation of the JAC could have been mitigated somewhat, if the views of private physicians were sought as part of its deliberations. But no such attempt at consultation was undertaken. The apparent reason for this was that the JAC “felt that private (fee-for-service) physicians prescribing methadone are in a conflict of interest situation” (page 2, JAC Report). It is hard to imagine a more fatuous claim. On this basis, the input of fee-for-service physicians could be discounted in any discussion about the treatment of a chronic medical condition.

In addition to avoiding input from private physicians, no attempt appears to have been made to seek the views of outside academic researchers. Vancouver has some of the foremost academic researchers in the field of drug addiction research. Although the views of academics such as Professors Beyerstein and Alexander at SFU are familiar to drug abuse experts around the world, they were not consulted by the JAC. Finally, there was no representation or input requested from the Pharmacists’ Society, which is generally known to be in favour of the establishment of a joint ADP/private physician treatment scheme. The individual representing the College of Pharmacists on the JAC was not a practising pharmacist. Pharmacists who have active practices fear that forcing methadone patients to be treated in clinics will threaten their members with increased break-ins and robberies.

At best, the JAC appears not to have operated on the sort of deliberative model that one expects of such committees, and that would have permitted it to assess fairly all the treatment options available to it. At worst, the JAC may have been established with the idea of implementing a particular agenda—that of eliminating methadone treatment while appearing to improve it—and that there was an attempt to avoid contact with those who might oppose this purpose.

Effects of implementing JAC proposal

Methadone patients’ antipathy toward clinic treatment can be traced to a number of causes; some of these are related to the history of clinic treatment in B.C., and others concern the manner of treatment generally provided by clinics. The historical reasons for patients’ dislike of clinics stem largely from the extreme shifts in methadone treatment policy that have taken place over the years in government sponsored clinics. In the early years of methadone treatment programs in B.C., patients were administered methadone for only a short period of time (a couple of months) during which they were forced to go through complete narcotic withdrawal. Patients were later required to sign contracts indicating that they agreed to take methadone for the rest of their lives. Now the treatment emphasis is on complete withdrawal from narcotic dependency. During these periods, ADP policy on appropriate dosage levels varied dramatically. Such shifts in “treatment methods” have understandably undermined the credibility of clinics in the eyes of methadone patients, and they feel, with some justification, that the clinics have treated them more like laboratory animals in scientific experiments rather than medical patients who suffer from a chronic medical condition.

Methadone patients also find many clinic procedures humiliating and needlessly punitive or restrictive, e.g., urinalysis supervision (often several times a week), mandatory three day detoxification during initial assessment (usually involving a painful partial withdrawal), and the lack of a formal provision allowing patients to return to clinic treatment if attempts at abstinence prove unsuccessful. Nearly all patients are sceptical of the value of counselling services provided through clinics and believe that counsellors and the clinic Director (usually a non-medically trained person) have undue influence on medical matters such as dosage levels. Clinic rules are also seen as being unnecessarily rigid. Whether or not these justified (in our view, many of them are, especially in the case of patients who have demonstrated that they can maintain a responsible lifestyle), the fact is that these perceptions exist and the clinics have very little goodwill to draw on among methadone patients as a result. The “trust us” motto that has been used several times in our discussions with ADP officials will not be very effective in persuading patients that their best interests will be served through treatment at clinics. As well, some methadone patients are established members of the community (including members of professional groups), who find the prospect of attending a local or neighbourhood clinic unattractive because of a fear of being embarrassed or stigmatized as a result of being observed regularly attending a clinic for treatment. Loss of employment for these individuals would be a real possibility if their narcotic addiction were to become generally known. For these methadone patients and others, a doctor’s office provides a greater degree of privacy and anonymity.

Further doubts on the part of methadone patients have been created by the manner in which the JAC’s proposal is now being implemented. For example, the Executive Summary of clinic policies and procedure states that a maximum daily dosage of 80 mg/day will be permitted, even though federal guidelines for prescribing methadone do not establish a maximum daily dosage.16 The average daily dosage among privately treated methadone patients is quite a bit higher, probably somewhere between 80-120 mg/day. Although this is clearly within the federal guidelines and the joint Canadian Medical Association/Department of National Health and Welfare recommendations of between 100-120 mg/day,17 patients who are transferred to the clinics will receive decreasing dosages until 80 mg/day is reached. Discomfort and perhaps sickness are expected to attend these involuntary partial withdrawals. The treatment contract which patients are required to sign states that total withdrawal from methadone is the goal of the new program and that patients can be cut off for not making sufficient progress toward this goal. The contract does not address how such progress is defined and the role the patient will play in decision-making about her/his treatment and eventual methadone. No appeal procedure is noted or outlined in the contract. Apprehension and mistrust by patients is predictable and understandable in these circumstances.

Lastly, many patients are concerned that the manner in which methadone will be dispensed from clinics will unduly disrupt their social lives and perhaps jeopardize their employment. More frequent visits will be required, and it is not clear how the clinics will manage patients’ practice of usually taking half their daily dosage after they wake up in the morning and the other half later in the day. The clinics have agreed to earlier opening hours in an effort to be accommodating, although this has apparently not yet happened at all locations where transferred patients are receiving methadone. Nevertheless, congestion is expected for early morning pick ups, and clinics appear unwilling to split dosages unless the patient returns later in the day. All of this represents an enormous personal inconvenience. Patients also fear that meeting or congregating with unstable addicts at clinics may interfere with their rehabilitation and produce relapses to old patterns of behaviour.

It is reasonable to conclude from the above that many patients now being privately treated will either not show up for treatment in more restrictive clinic settings or will drop out of clinic programs within a short while. As noted above, there is a good deal of recent academic research supporting this conclusion, as well as anecdotal information from B.C. methadone patients and doctors, and survey information obtained recently from Dr. K. Varnam’s methadone patients.18In commenting on his patients’ attitudes toward clinic treatment, Dr. Varnam states:

Indications are that one-half to two-thirds of my patients would refuse to attend ADP clinics for various reasons, although many admit that they are likely to return to street use of narcotics, with all that such recurrent heroin use would imply…. The anger expressed against the Clinics in the past by my patients to a questionnaire I circulated was unbelievable even for me…. The patients have no trust for anyone working at the Clinics for any treatment or counselling. Any reasonable proposal for alternate treatment would have to take this high level of animosity to the clinics into consideration. (from written comments on an earlier draft of this paper)

In our view, it can be anticipated that up to one half of patients who are transferred against their will from private care to clinics will not show up for or participate for long in clinic treatment. The above information should represent a healthy warning to those who wish to impose clinic treatment on methadone patients who are now being treated privately. It is worth noting here that in B.C. one half of the total number of methadone patients in private care equals about 200 individuals—a substantial number if one considers the possible effects of their addictions becoming destabilized.

On the reasonable assumption that many patients will not participate in clinic treatment programs and that their narcotic addiction will become destabilized, the following likely effects can be predicted:

  1. There will be an increase in the number of narcotic addicts seeking drugs from illicit sources.
  2. There will be an increase in demand for narcotics on the illicit market, possibly encouraging organized crime to import more narcotics and thus increasing the availability of illicit drugs. (In other jurisdictions, increased demand has led to illicit attempts to manufacture narcotics locally—often with fatal results for narcotic addicts and other drug users.)
  3. There will be more frequent break-ins at doctors’ offices and pharmacies. Increased numbers of daytime robberies of pharmacies can also be expected.
  4. Some patients—perhaps most—will engage in criminal activity to support their drug dependency (e.g. prostitution, trafficking, theft, fraud, armed robbery are common activities for narcotic addicts).
  5. There will be increased costs for welfare programs, unemployment insurance, legal aid, the courts, law enforcement and corrections institutions.
  6. There will be increased harassment of private practitioners to prescribe narcotics and other drugs to narcotic addicts.

It seems sheer folly to us to put the community and methadone patients themselves at such risk, when other alternatives are available which would provide for a more accountable system, prevent abuses, and would in all likelihood provide more effective treatment of methadone patients.

A Proposal to amend treatment procedures for methadone patients in private care in B.C.

The following points should be clearly borne in mind in framing any methadone treatment policy. First, there is no known mass treatment solution to chronic narcotic dependency, and it is probably unreasonable to suppose that there ever will be one. But this should not be surprising. The reasons for narcotic addiction are many and perhaps unique to each addict. It is unlikely therefore that any single treatment model could be effective for more than a minority of patients. It is against these sorts of odds that the clinics with their generally uniform ideological approaches to treatment and uniform rules, goals, and procedures carry out their work. Second, narcotic patients do better in long term treatment in less rigid settings where higher dosages of stabilizing narcotics are permitted. Such programs seem to be justified both in terms of patient rehabilitation and in terms of reduced social costs. This should not be surprising either. Narcotic addiction, and opiate addiction in particular, are in themselves relatively insignificant social evils, if that is an appropriate way to describe a condition that threatens little, if any, harm to anyone but the addict. The unquestionable evils, however, are the criminal activity, family disruption, needless deaths, and other social ills and expenses that are associated with the addict’s search for illicit drugs. Ameliorating these effects of narcotic addiction ought to be the major preoccupation of any treatment program. In trying to achieve this, the best benefits are likely to be gained in flexible treatment programs where a patient can regain stability without having constant attempts made to withdraw her/him from treatment.

In these circumstances, we regard the present plan to confine treatment of all methadone patients to ADP-sponsored clinics as a serious mistake which has all the earmarks of a potential social disaster. After careful reflection, we simply cannot support any move to transfer all methadone patients to the present clinic system, or to permit the clinics any active role in limiting or superintending the authority of private physicians to determine treatment for methadone patients. This is not to say that clinics cannot have a useful role to play in treating narcotic addiction, but rather that the historical antipathy patients have toward clinics in B.C., combined with the present restrictive attitude and approach of clinic administrators, make a compelling case against this type of treatment and in favour of private treatment of methadone patients.

We are convinced that private treatment of methadone patients can be conducted in an accountable and socially responsible manner. While we cannot support the present clinic treatment model, we think that effective measures can be taken to prevent abuses by physicians and patients, and to ensure greater accountability, and to reduce costs. Since concerns about these issues appear to have provided the major motivation for the establishment of the JAC, we feel very strongly that our recommendations should be persuasive both to Ministry of Health officials and to the general public. Of course, the likelihood that the treatment approach supported by us will be more effective in promoting rehabilitation should also help to persuade.

Recommendations

  1. All methadone patients presently being treated privately should remain with their current physicians under present treatment conditions. Patients who have been transferred to clinics should have the option of returning to private physicians.
  2. All methadone patients should be issued personal identity cards through government clinics. These cards should also identify the private physician from whom the patient receives methadone treatment. No physician should prescribe methadone to an individual who does not hold a valid registration card. Thus an exact count of the number of individuals receiving methadone from private sources should be possible. Double-doctoring for methadone would also be eliminated. A government clinic should issue a registration card to any patient referred by a private physician.
  3. Information regarding patients’ prescription levels of methadone should be shared between private physicians and government clinics with appropriate safeguards to ensure confidentiality. Thus, clinics and the Ministry of Health would have a means of precisely determining amounts of methadone prescribed. This system should also identify over-prescribing by physicians.
  4. Private physicians may refer patients to government sponsored clinics for initial assessment regarding length of previous narcotic dependency and recommended treatment.
  5. The responsibility for making all decisions to treat with methadone, or to terminate treatment, or to withdraw patients from methadone rests solely with the private physician. This responsibility should also be extended to all decisions about patient management, such as determining dosage levels, number of pick-ups per week, etc.
  6. Private physicians may refer intractable patients to government sponsored clinics. The clinics should be prepared to give such referrals priority for entrance to their program.
  7. Random collection of urine samples should be initiated and supervised by government-sponsored clinics. The clinics would submit names to private physicians who would then require the named patients to attend clinics for urinalysis testing within 24 hours following their next doctor’s appointment. Issuance of a referral form by the treating physician would confirm whether the time requirement had been met. Patients for whom there is some concern about possible abuse may be required to attend clinics for urinalysis more frequently. Patients who have shown no evidence of abuse for long periods of time should be required to attend clinics for urinalysis testing only infrequently, if at all. Results of these tests should be made available to the treating physician.
  8. The treating physician may require a patient to go to a government-sponsored clinic for urinalysis at any suspected time abuse is suspected.
  9. Voluntary adjunctive therapy should be available through government sponsored clinics.
  10. With provision for exceptional cases, patients should be required to receive all medical care from their methadone prescribing physician. A data retrieval scheme should be established with MSP to ensure such agreements are honoured, and thus provide an added check on possible multiple doctoring.
  11. We think it would be a wise idea to increase the number of physicians in B.C. who are licensed to prescribe methadone. This would spread the burden of treating patients and permit more careful treatment management by physicians. Educational programs should be available to new methadone prescribing physicians to enable them to become familiar with private treatment models for narcotic addiction.

Conclusion

A further significant benefit which would follow from the above proposals is that resources at ADP clinics allocated for treating methadone patients currently in private care, could be made available to treat the narcotic addicts in the community who are not presently in any treatment program. At the present time, individuals who wish to participate in clinic treatment programs are frequently subjected to long waits (of up to nine months in one case that has come to our attention). Of course, during these waiting periods, they may continue to be actively involved with illicit narcotic use and other criminal activity. In our view, the resources that the clinics planned to allocate to treat private methadone patients could be better used to provide treatment services for those addicts who are not yet in any treatment program. However, it is obvious from the above that we also think that the clinics in B.C. have to seriously rethink their treatment strategy so that they are likely to be more attractive and useful to prospective patients.

Endnotes

The preparation of this submission involved discussions with a wide variety of individuals from different backgrounds who gave unstintingly of their time and expertise to work together to achieve consensus wherever possible. The writer acknowledges the invaluable assistance of these individuals, especially Drs. Ledgerwood, Young, and Varnam, Mr. Frank Archer (President, Pharmacists’ Society of B.C.), Professors Barry Beyerstein and Bruce Alexander, Ms. Teresa MacInnes, and Mr. Doug Whyte and Ms. Brenda Schneider.

1. The B.C. Civil Liberties Association has received treatment proposals from Drs. Young, Ledgerwood, Varnam, and Dirnfield which suggest methods for improving private treatment of methadone addicts. Other similar proposals from B.C. physicians involved in narcotic addiction treatment undoubtedly exist.

2. Conversations with literally dozens of private methadone patients have confirmed this assessment. As well, Dr. K. Varnam, a physician practising in Vancouver, has conducted a survey of his methadone patients which showed that 19 of 28 respondents indicated that they would prefer involuntary withdrawal from methadone to receiving treatment at a clinic. All respondents indicated that they preferred private treatment to clinic treatment.

3. McGlothlin WH, Anglin DA: “Shutting Off Methadone: terminated patients became re-addicted to heroin, and the arrest and incarceration rates were double that of the comparison sample.

4. National Institute on Drug Abuse Treatment Research, Monograph Series, “Research on the Treatment of Narcotic Addiction—The State of the Art”, 1983.

5. Stimson GV, Oppenheimer E: Heroin Addiction: Treatment and Control in Britain, Tavistock Publications, London and New York, 1982.

6. McGlothlin WH, Anglin DA: “Long-term Follow up of Clients of High and Low Dose Methadone Programs”, Archives of General Psychiatry, Vol. 38, 1981: 1055-1063.

7. Kaplan J: The Hardest Drug: Heroin and Public Policy, University of Chicago Press, Chicago, 1983.

8. Supra, note 6, page 1061

9. Hartnoll RL: “Evaluation of Heroin Maintenance Controlled Trial”, Archives of General Psychiatry, Volume 37, 1980: 877-884.

10. “Methadone and Care of the Narcotic Addict: Report of a Special Joint Committee of the CMA and DNHW Food and Drug Directorate”, Canadian Medical Association Journal, Volume 105. 1971, page 1193. This Report is acknowledged by the federal Health Protection Branch as establishing the “guiding principles” for physicians authorized to use methadone to treat narcotic addiction

11. Waldorf D: “Natural Recovery From Opiate Addiction: Some Social Psychological Processes of Untreated Recovery”, Journal of Drug Issues, 1983, Volume 13, 237-280.

12. Supra, note 6, page 1063

13. “General Guidelines for the Use of Methadone in the Care of Narcotics Addicts”, Health Protection Branch, Methadone Control Program, May 1984.

14. These figures were compiled recently by Teresa MacInnes, Research Assistant to SFU Professor Bruce Alexander.

15. Beyerstein BL, Alexander BK: “Why Treat Doctors Like Pushers”, Canadian Medical Association Journal, Volume 132, 1985: 337-341.
16. Supra, note 13, page 3.

17. Supra, note 10, page 1196.

18. Supra, note 2.