Twelve years ago, I applied for and was granted a licence to prescribe methadone. During the next 6 years I had 2 patients, a married couple whom I threatened with excommunication if they told anyone about this service and more heroin addicts started showing up on my doorstep. Despite some bumpy moments along the way, they did well. I learned on my feet, made all the usual mistakes and somehow managed to keep faith with my gut reaction that this was a worthwhile idea. FIGURE
At that time, the methadone program was run from Ottawa with minimal supervision and no teaching worth the name. However, when the College of Physicians and Surgeons of British Columbia took over there was a quantum improvement in teaching, accreditation, supervision and resource availability.
Today this is a program that works, but the tough reality is still that addiction medicine involves a down and often dirty population whose medical commerce is lies, deceit, manipulation and mistrust. Their behaviour is alien to everything we expect in a doctor-patient relationship. These are, or have been, dangerous, damaged people.
So why am I part of a program that at first sight seems singularly unappealing? There is one simple and compelling reason: harm reduction.
But what harm? And for whom?
Heroin use is associated with enormous physical, mental and emotional morbidity and mortality that place huge demands on medical resources at every level. And harm to the individual is, in the case of heroin use, virtually synonymous with harm to the herd.
No one escapes. The hard-core users and pushers are men and women plagued by horrible diseases and shorn of any basic trappings of social acceptability. Their world dances to the seductive tune of bigger and better highs, in pursuit of which prostitution, theft and petty - as well as not so petty - crime become pervasive in neighbourhoods good and bad.
I know that when my television and CD player are stolen, there's a good chance the proceeds will end up in somebody's arm. I know when my car window is smashed in the hospital parking lot in order to liberate a handful of loonies, it will yield brief minutes of satisfaction to an addict whose craving obliterates all other considerations.
For many of these poor souls, there is no way out. They die young, but not before causing constant grief to themselves and their families and fury and frustration for the victims of their crimes. In the process, they create an almost unimaginable hole in the public purse.
Some of the men and women who inhabit this netherworld are desperate to break away, and this brings me back to the methadone program. I gradually accepted a few more patients who wanted to withdraw from heroin. I attended workshops and endured the anger of some colleagues, who thought I was pandering to addicts who should be punished. After all these years I am still learning, but I have developed a better understanding of the goals and expectations not just of my methadone-dependent patients but also for myself.
I decided early that I would prescribe methadone only to those who chose to become regular patients because it seemed that the completeness of the doctor-patient relationship would be an added strength.
It was a good decision. After some terrible blunders, I became much better at identifying applicants who were prepared to make a commitment to the program and applicants whose commitment to "the street" and drug life was unassailable.
I learned how to say No and not feel responsible for the inevitable fallout. I learned not to take it personally when I discovered that I had been scammed, betrayed and made a fool of by a patient I thought I could trust. And I learned to look beyond a patient's fall from grace to find the reasons for the fall and try to help.
Twelve years later, what are the results?
About 75% of my patients who entered the methadone program are still there. Several withdrew successfully from methadone altogether, and the rest dropped out along the way, held in thrall to a culture in which getting high means a life out of control. Some just disappeared. A few ended up in jail. Others had to be told that the program wasn't working for them and that I would no longer prescribe their methadone. Most of the rest have done well. There are a number who will never be gainfully employed, but others are either working or acquiring marketable skills and are integrating quite successfully into the workforce. Families have been reunited and now have mortgages. Some hope to become drug free. The majority aspire to a reasonable maintenance level and plan to remain there, functioning adults in a regular lifestyle. Which is fine with me.
Has it been worth while? Yes.
Has it reduced harm? Unquestionably.
Has it sometimes infuriated me to the point of retribution fantasies? That too.
But as long as I have help from the experts who run the program, as long as it seems to work, as long as I feel my skills are solid, then I'll stick with it. And if it prevents one case of HIV infection, if it gets one young prostitute off the streets, if it prevents one break and enter, then we have, as a society, reduced harm.
Social change for the better doesn't occur in giant leaps but in tiny steps - faltering, perhaps, but always edging forward.
This program is a fine example of such tiny steps.