Long before Vancouver embarked on its innovative Four Pillars Drug Strategy, the city was home to groundbreaking drug research: the world’s first methadone maintenance treatment clinic.

In 1967, Dr. Robert Halliday, along with Ingeborg Paulus, published an article in the Canadian Medical Association Journal describing Halliday’s use of methadone in treating opiate addiction. The authors outlined how, in 1959 through the Narcotic Addiction Foundation of BC (NAF), Halliday started a short-term methadone withdrawal program. In 1963 he introduced what he called a “prolonged” withdrawal program, months or years of MMT, which is credited as the world’s first methadone clinic.

“There’s no drug that is more scrutinized than methadone.” Dr. Bob Vroom, BC College of Physicians and Surgeons

Fast forward to today and the Deputy Registrar of the BC College of Physicians and Surgeons has good evidence to illustrate the program’s staying power. “I’m now actually licensing some physicians (working) in nursing homes,” Dr. Bob Vroom said.

The BC College of Pharmacists has tracked the steady growth in the numbers of pharmacies dispensing methadone. And while there are critics who raise issues of client accessibility (to prescribing doctors, to dispensing pharmacies and because of associated fees) the BC methadone program is seen as a model. “We are still looked at as exemplars in what we do,” Dr. Vroom said.

While the names of Doctors Vincent Dole and Marie Nyswander are linked to the origins of methadone maintenance treatment, their work in New York started in 1964. Dr. Halliday received approval in 1959 from the federal Department of Health to conduct his study of the use of methadone to treat people who were dependent upon opiates, such as heroin and embarked on the prolonged withdrawal program in 1963.

Dr. John F. Anderson, Senior Research Fellow at the Centre for Addictions Research of BC (CARBC) guided the expansion of MMT in the 1990s and into the next decade. He said that in the early ‘90s, there were, perhaps, 1,000-1,500 people on MMT. The HIV epidemic encouraged the Ministry of Health to explore MMT and harm reduction measures, such as moving people off injection drugs and onto oral methadone treatment, to decrease the number of new infections. “That allowed us to move forward with expanding the methadone program.”

That expansion included encouraging physicians to receive the training necessary for them to prescribe methadone and a push for more pharmacies to dispense methadone.

“In many communities we cannot guarantee that we have a methadone prescriber,” Dr. Vroom said, adding there is limited access in some rural areas of the province.

Dr. Bob Vroom of the BC College of Physicians and Surgeons said of the approximately 9,600 active doctors in BC, there are 373 who have received the exemption from the Controlled Drugs and Substances Act that allows them to prescribe methadone for opiate dependency. Of those, 199 actually prescribe for their own patients while 174 have the exemption but do not have any methadone patients registered to them right now. There are also 433 doctors who have a separate exemption that allows them to prescribe methadone for pain only.

“In many communities we cannot guarantee that we have a methadone prescriber,” Dr. Vroom said, adding there is limited access in some rural areas of the province.

To qualify for the exemption to prescribe methadone for opiate dependency, doctors must take the College’s one-day course, spend two half-days in a clinic with a methadone-prescribing doctor, have an acceptable review of their prescription profile from the PharmaNet database and then do an interview with Dr. Vroom. A second, optional course offers more detail about prescribing to pregnant women and prison inmates, for example. After their first year of prescribing methadone, the College carries out an audit of the doctor’s practice, auditing random files and reporting to the College’s Advisory Committee on Opioid Dependency. Doctors must also agree to do at least 12 hours, annually, of continuing medical education on addiction medicine and provide after-hours contact information on methadone maintenance patients.

“There’s no drug that is more scrutinized than methadone.”

Dr. Vroom said it’s very helpful if there is a good relationship between the client’s doctor and pharmacist. For example the physician could contact the pharmacist if the patient doesn’t show up for an appointment or the pharmacist can call the doctor if the client shows up high when he’s picking up his daily methadone dosage.

Mary McClelland, Quality Outcomes Specialist Methadone Service with the BC College of Pharmacists agrees. She said she welcomes calls from doctors who, for example, are prescribing methadone for a patient and seek the most convenient location of a pharmacy for that patient. She’s also happy to discuss convenient pharmacy locations with clients or, in some cases their parents. Pharmacies may not advertise that they provide methadone; they can only say that they provide “full pharmacy services” and hope that people know includes methadone.

The BC College of Pharmacists has a list on its website www.bcpharmacists.org of the methadone dispensing pharmacies in BC (under Resources, Methadone Pharmacy Services). By request, some methadone-dispensing pharmacies are not listed on the site but McClelland can report verbally on their locations.

Mary McClelland of the BC College of Pharmacists has tracked the growth in the number of pharmacies dispensing methadone and has witnessed a slow increase.

McClelland has tracked the growth in the number of pharmacies dispensing methadone and has witnessed a slow increase. For example, according to the college’s statistics to the end of December, 2007, 76 of the city’s current 164 licensed pharmacies dispense methadone. (McClelland points out that while 13 of those methadone-dispensing pharmacies are located in the Downtown Eastside (DTES), the remainder are sprinkled throughout every part of the city.) That compares with 143 pharmacies in 2004, with 69 dispensing methadone.

Her statistics also show that there are 2,849 methadone patients in the Vancouver, 1,323 of whom are located in the DTES.

Some pharmacies shy away from dispensing methadone, out of concern for what their other clients will think, McClelland said, adding others fear methadone clients are going to start stealing from the store. “They need to pay more attention to the little grey-haired lady with the big bag,” she said.

In looking to the future, Dr. John F. Anderson of CARBC said the drug’s cost of $4,000 per year is very cost effective. His concern is that he believes the current program is only reaching about half of the core population that could benefit from it. “It’s important to determine how much unmet need is still out there.”

It’s difficult to get accurate numbers on heroin users. Anderson believes there is capacity in the system to provide more MMT but, possibly, the traditional delivery method --of an assessment in a doctor’s office, daily visits to the pharmacy, twice monthly visits to the doctor and regular counseling-- are too onerous for those with mental illness, HIV and Hepatitis C, for example. Anderson said such clients may “just be a little bit too sick” to access MMT through the current system.

Anderson pointed out that cessation of drug use is not the sole goal of MMT. “With any treatment, there are a variety of goals,” he said. Some clients end MMT successfully but among those who discontinue MMT there is a high relapse rate. The goals of MMT can include eventual abstinence, elimination or reduction of risk associated with infectious disease, improvements in physical and mental health, ability to achieve stable employment or return to school or training and the ability to stabilize one’s social and family life.

As Dr. Vroom points out, many former drug-users stay on MMT for years and become law-abiding, contributing citizens. “It’s become lifelong maintenance.”