Methadone and HIV/AIDS
At the recent First National HIV/AIDS and Prisons Workshop, a vocal minority of participants vehemently opposed methadone maintenance programs in prisons as well as in the community.[1] This paper presents some of the arguments in favour of increasing access to methadone programs for opiate users. It pays particular attention to the ways in which methadone can contribute to reducing the spread of AIDS among and from injection drug users.
At present, the number of spaces in methadone programs is woefully limited, and existing programs tend to be restrictive and punitive. Suggestions are made for improving methadone programs, including expansion and liberalization.[2]
Introduction
Methadone is a synthetic alkaloid chemically similar to morphine. Its effects are like those of the other opiates; the main difference is that some of the effects of methadone last longer (24 hours or more) than those of morphine or heroin (4-6 hours). The duration of withdrawal symptoms following chronic use is also longer. Methadone can be given orally in the form of a syrup, thereby decreasing injection.
The opiates themselves appear to be relatively free from significant long-term physiological side effects. However, because most users are unable to obtain drugs that are pure, they can be harmed by any impurities that may be present in the drug. If users inject opiates, they can be harmed by infections transmitted through contamination of needles and other parts of their drug paraphernalia. A majority of methadone users report a history of injection drug use and needle-sharing.
Drug legislation (the 1961 Narcotic Control Act) permits the use of opioids for the treatment of narcotic-dependent persons. In 1963, Dr Robert Halliday of the Narcotic Addiction Foundation of British Columbia began the first methadone maintenance program in Canada and possibly in the world. In 1988, an advisory committee reviewed the federal guidelines pertaining to use of drugs in the treatment of opioid dependency. New guidelines came into effect in January 1993.[3] These guidelines are unnecessarily restrictive and pose a barrier to vital treatment. Furthermore, each province imposes its own guidelines on methadone distribution and the licensing of physicians. At present, the number of places in methadone programs is woefully small and the majority of programs are restrictive and punitive in nature, although methadone, in conjunction with other interventions, is considered to be the most effective means of treatment for people with opiate-related problems.
The need for expansion of methadone programs is urgent: currently there are only approximately 2600 persons in methadone treatment for opiate dependency in Canada, almost half of whom have been in treatment for more than 10 years. Not every province provides methadone treatment. Levels of HIV and hepatitis are rising rapidly in injection drug users, but the number of places in programs is small. In Metropolitan Toronto, for example, an estimated 14,000 people are in need of treatment for heroin addiction, and heroin use is rising. Nevertheless, there are less than 600 methadone spaces and only 40 physicians licensed to prescribe methadone. Waiting lists for methadone maintenance programs range from one month to over a year. The situation is slightly better in British Columbia, where 1500 users are in methadone treatment, and 170 physicians are licensed to prescribe. As a result of the recent BC Coroner's Report[4] this number is expected to increase substantially.
Methadone and the Reduction of Drug-Related Harm
Injection drug use is one of the major risk factors in new HIV cases in Canada and now accounts for more than 70 percent of new HIV cases in the US. Many injection drug users are users of opiates. In particular, there has lately been a marked increase in heroin use in North America, due to increased availability of high grade, less expensive heroin. It is estimated that 80 percent of heroin users in New York and San Francisco are HIV-positive. In Canada, rates of HIV positivity among injection drug users are lower, but have reached 20 percent in Montréal.[5]
The primary advantage of methadone is that it can reduce users' contact with crime, the black market, and contaminated drugs, at a time when opiates are prohibited by law.[6] Methadone brings users back into the community rather than treating them like outsiders or criminals. This allows not only for rehabilitation of users and linkage with HIV/AIDS services, but also breaks the drugs-and-crime cycle.
Another very important advantage of methadone is that, because it is many opiate users' treatment of choice, high retention in treatment has been observed, whereas there is a high discontinuance rate with other forms of treatment. Methadone also assures that the patient is more stably addicted than when on heroin. Flexible treatment programs, where multiple options exist for each patient, appear to be the most effective in keeping users away from illegal drugs, and the most successful at retaining clients.
The AIDS pandemic has further highlighted the significance of methadone as part of a harm-reduction approach to drug use. Because of its long-lasting effects, methadone can help keep users stabilized: they will decrease the frequency of drug use. This is particularly important for those who inject heroin. With the help of methadone, they can either stop injection or at least decrease its frequency, thereby reducing the spread of HIV and other infections.[7] Evidence suggests that heroin users enrolled in methadone maintenance programs may have lower HIV seroprevalence than users who are not enrolled in treatment.[8] While on methadone, persons living with AIDS are able to live with their friends or families rather than on the streets, as many injection drug users do. Further, methadone has not been found to significantly affect the immune system, and, aside from naltrexone, all current licensed and experimental agents for clinical use with HIV-related disorders can be used as safely with methadone-maintained patients as with drug-free patients.
Recommendations
If methadone programs are to be truly cost-effective, some changes are needed to attract and retain more clients, and to keep them from using other drugs. For example, since methadone syrup does not provide a "buzz," some clients look for this experience elsewhere. Sufficiently high levels of methadone syrup, capable of producing the "buzz," could be provided to prevent relapse to injection. Supplying injectable methadone ampoules, with plenty of clean injection equipment, or cigarettes injected with a drug (reefers) might be other solutions. Such approaches are working successfully in Merseyside, England and now, on an experimental basis, in Switzerland.[9] However, they have met with little approval in Canada, where progress in methadone treatment is most often equated with low doses of methadone used by the patient, rather than with the patient's overall adjustment regardless of dose level.
Canada can and should learn from what other countries do. For example, in Amsterdam, methadone is provided with a minimum of impediments – low-threshold programs – in order to contact as many heroin users as possible, stabilize, detoxify, and treat them. A "methadone bus" program is used to distribute methadone throughout the drug-using community, but no take-home dosages are provided. Clients are also assisted with problems concerning housing, financial and legal matters, and are provided with regular medical examination. One of the main reasons why the methadone bus program has proven effective in getting people into treatment is that it requires no urine samples and no mandatory contact with counsellors. The number of people entering drug-free treatment and resocialization programs in Amsterdam has more than doubled since the introduction of the methadone buses and the needle-exchange schemes.
In Australia, measures introduced to combat the spread of HIV included the marked expansion of methadone programs. The criteria for admission to these programs were made less stringent, and many more spaces were allowed for maintenance of clients with little motivation to change drug-using behaviour. These changes have been supported by a change in governments' drug policy toward seeing the prevention of the spread of HIV as its highest priority. This pragmatic response has been successful and has resulted in low levels of HIV infection among Australian drug users.
In contrast, some Canadian federal guidelines for methadone maintenance are harsh and unrealistic. For example, frequent checking of urine for traces of other drug use – and the recommendation that positive urine tests lead to mandatory review of treatment and consideration of withdrawal of methadone – may only serve to deter users from treatment, increasing the likelihood that they will go back to using other drugs and infected injection equipment. Research has shown that the rigidity of programs is positively related to rates of crime, other drug use, and exposure to infection.[10]
What we need to do in Canada is to expand and liberalize our methadone programs. This is particularly pressing in light of the spread of AIDS. It does not mean that treatment standards should be lowered; inadequate programs do not reduce injection drug use. Similarly, no attempt should be made to reduce resources for abstinence-based treatment programs. As the World Health Organization has recommended, a greater diversity of programs should be provided, including programs with less ambitious goals and objectives for those injection drug users who may not be willing or able to enter other programs.[11]
The suggested expansion and liberalization of methadone programs would require some changes to both federal and provincial guidelines:
• because the vast majority of studies suggest that rigid, inflexible protocols have deleterious effects on the recruitment and retention of otherwise compliant patients, there should be introduction of "low-threshold" programs with less stringent criteria for admission and no urine screening;
• because the data suggest that the benefits of carries (take-home dosages) outweigh the risks of diversion, carry privileges should be expanded;
• because physicians report that regulatory accountability, related to licensing, monitoring, reporting and practice standards require an undesirably high degree of control over their patients and represent a significant barrier to provision of maintenance services, regulations should be relaxed;
• because there is little reason for physicians to take on the extra work involved with methadone maintenance clients, incentives should be provided for private practitioners to become qualified to prescribe methadone.
Broader changes to improve provision of methadone in Canada would involve:
• increased training in methadone maintenance and provision of education on harm reduction to all detoxification and treatment centres and to physicians;
• a thorough review of existing legislation, policies and practices regarding methadone programs;
• an examination of the ways in which unnecessary costs could be reduced (eg, reduction of urine testing, replacing physician contact with counsellor contact);
• increased public awareness of the harms associated with heroin use and education about the benefits and cost-effectiveness of harm-reduction approaches;
• provision of methadone programs in prisons and the offering of methadone treatment as an alternative to imprisonment;
• experimentation with alternatives to methadone, including the prescribing of heroin (as is already done in the UK and in Switzerland, and planned in Australia, Germany, and the Netherlands. British Columbia is currently considering the feasibility of an experimental program); provision of smokable preparations of heroin substitutes should be considered as an option for some users;
• ready access to sterile syringes in all methadone programs, including services provided by physicians, as well as AIDS education and counselling for users, their partners and concerned others;
• closer links between methadone clinics and general hospitals and AIDS clinics to ensure a more efficient response to the present and future needs of HIV-positive drug users. Staff in methadone programs and physicians with clients on methadone should be trained to deal with the special needs of HIV-infected clients and clients with AIDS;
• encouragement of the development of self-help, mutual support and advocacy groups of former and current heroin users.
Conclusion
Implementing these recommendations would do much to reduce the harms from drug use in Canada. Moreover, it would help to reduce the spread of HIV infection among drug users and to the public. Effective methadone programs were important before the advent of HIV. They have now become an urgent, pressing need. Finally, because one of the main factors underlying drug-related harms is the fact that they are prohibited by law, it is imperative that we consider changes to our drug laws. If we don't, many of our "solutions" will remain merely band-aid approaches. Bill C-7, the proposed new Canadian drug law, comes back to the House for third and final reading this fall.[12] If it passes, it will do nothing to diminish drug-related harms and will only serve to continue and even exacerbate these harms. What Canada needs is not Bill C-7, but a thorough and independent review of Canadian drug policy and laws.
- Diane Riley
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ENDNOTES
[1]See infra, Results from the First National HIV/AIDS and Prisons Workshop.
[2]For a more detailed review, see D Riley. The Role of Methadone in the Treatment of Opiate Dependence. Ottawa: CCSA, 1991; D Riley. The Policy and Practice of Harm Reduction. Ottawa: CCSA, 1993.
[3]Health Protection Branch. The Use of Opioids in the Management of Opioid Dependence. Ottawa: Health and Welfare Canada, 1992.
[4]Task Force into Illicit Narcotic Overdose Deaths in British Colombia. Report. Burnaby, BC: Ministry of Attorney General, 1994.
[5]For a review of HIV infection levels, see Second National Workshop on HIV, Alcohol and Other Drug Use. Proceedings. Ottawa: CCSA, 1995.
[6]C Fazey. Heroin Addiction: Crime and Treatment. In: PA O'Hare, R Newcombe et al (eds). The Reduction of Drug-Related Harm. New York: Routledge, 1992, 154-161; M Schuckit. Methadone Maintenance: Is it Worth the Price? Drug Abuse & Alcoholism Newsletter 1992; XXI(4):1-3.
[7]M Schuckit, supra, note 6; for a detailed review, see Riley, 1991 and 1993, supra, note 2.
[8]World Health Organization (WHO). The Uses of Methadone in the Treatment and Management of Opioid Dependence. M Gossop, M Grant, A Wodak (eds). Geneva: WHO, 1989; WHO. The Content and Structure of Methadone Treatment Programmes: A Study in Six Countries. M Gossop, M Grant (eds). Geneva: WHO, 1990. See also D Riley, 1991 and 1993, supra note 2, for a review.
[9]D Riley, 1993, supra note 2; E Nadelmann. Switzerland's Heroin Experiment. National Review. 10 July 1995, at 46-47.
[10]E Buning. AIDS-related Interventions among Drug Users in the Netherlands. The International Journal of Drug Policy; 1990(1):10-13; E Springer. AIDS Prevention with Drug Users Supplanted by The War on Drugs or What Happens When You Don't Use Harm Reduction Models. The International Journal of Drug Policy; 1990(2):18-21.
[11]See WHO, supra note 8.
[12]See D Riley, E Oscapella. Bill C-7: Implications for HIV/AIDS Prevention. Canadian HIV/AIDS Policy & Law Newsletter, vol 1, no 2 (1995) at 1, 11.