It was 8:30 am on a Saturday morning in a meeting room at the College of Physicians and Surgeons of British Columbia in Vancouver. One by one, the 26 doctors sitting around the Table introduced themselves and explained why they were there.
When it was his turn, family physician Walter Vanrietschoten of Cranbrook was blunt. "I've had my arm twisted to come," he says. "I'm not convinced I want to be here."
Was this some form of disciplinary hearing? Particularly boring CME? No, it was a workshop on methadone maintenance, and if you say those words to a doctor you are apt to get a negative response, a "fine-for-other-doctors-but-don't-ask-me-to-do-it" reaction. Why would any family physician want to treat heroin addicts who are often difficult or manipulative, sometimes have criminal records and almost always have complex problems?
The BC college is out to change the image of this type of treatment and convince more doctors that methadone treatment is fulfilling work that allows them to alter patients' lives dramatically.
The college took over management of the province's methadone maintenance program from the federal Health Protection Branch's Bureau of Drug Surveillance in 1996, joining Ontario as the only provinces where professional licensing bodies operate their own methadone programs.
"Before 1990, the college's role was minimal," explains Dr. Alan Askey, a former deputy registrar at the BC college who now chairs its Advisory Committee on Opioid Dependence. "The bureau would simply ask us: 'Is there any reason why we should not give this doctor authorization to dispense methadone?'"
His committee was struck in 1991 because of some obvious abuses within the existing program. "There was no training, no supervision, no expanding knowledge base. It was quite clear it was out of control. We asked if we could take it over."
In the early 1990s, the college began interviewing and auditing doctors. It also clarified the guidelines, created "golden rules" for good methadone treatment (see sidebar) and instituted training programs.
Doctors follow golden rules for BC's methadone program
BC doctors must follow a strict series of steps when a patient becomes part of the methadone program.
Dubbed the "Golden Rules" by the College of Physicians and Surgeons of BC, the steps begin with a thorough initial assessment, including medical and psychosocial history, physical examination and appropriate medical investigations, such as a liver function and HIV tests. Completed medical forms are sent to the college, which decides whether to allow the patient to participate.
Once a patient has been accepted, a contact with the doctor spells out the code of conduct, the manner under which methadone will be given and actions that may result in the patient's dismissal, such as abusive behaviour.
All patients start with daily witnessed doses of methadone, usually at about 80 mg daily. Mixed with an orange drink and dispensed by a pharmacist, the methadone is drunk by the patient at the pharmacy counter as the pharmacist watches.
"The pharmacists are the eyes and ears of the physician," explained Dr. Alan Askey, chair of the college's Advisory Council on Opioid Addiction. "We ask the pharmacists to take a minute to talk to the patient, to give them a drink of water to ensure they are not holding the mixture in their mouth to spit out later."
All methadone doctors in the college's program have their practices audited from time to time, and physicians who are new to the program can expect to be audited within 18 months of receiving their methadone licence.
"The audit is primarily meant to be educational," says Askey. "We are simply trying to help doctors provide the best possible program and prevent problems from arising."
Stop the problem, stop the crime
"Our focus is harm reduction for both the patient and society," says Askey. "We want to stop the behaviour that puts addicts and others around them at risk - the sharing of needles, the crimes to pay for the habit. We want to get them stabilized, then work on the underlying issues."
Although some methadone patients may eventually become stable enough to be weaned off methadone completely, that is not a requirement in BC. "We don't ask diabetics to get off insulin and we don't ask that all methadone patients eventually get off methadone," observes Askey. "Some can, but some can't."
Since the college took over in 1996, the number of BC doctors trained and authorized to prescribe methadone has leapt from 110 to more than 400. The number of patients enrolled in the program likewise rose from 1200 to more than 4000. The program features regular auditing, telephone and fax support from the college, and computer monitoring of all patients' prescriptions and doses through the provincial Pharmanet program that links all pharmacies.
The need to expand the methadone program is now urgent. At last estimate there were some 15 000 injection drug addicts in BC - more than in any other province. "We still want to more than double the number of doctors who are well trained and able to run good methadone programs," says Askey. Last year the college launched a methadone program in provincial jails, and it is still working on a similar plan for federal prisons.
The college is also trying to recruit family physicians working in communities away from Vancouver's notorious Downtown Eastside. That way addicts can leave the destructive cycle of drug abuse in the inner city, stabilize their lives and perhaps even find jobs or improve their education back in their home town.
There was no "methadone doctor" in Cranbrook, a city of 15 000 on the western edge of the Rocky Mountains; the nearest one is more than 6 hours away in Vernon. If a snowfall closes the Salmo-Creston pass, there is no access, sometimes for days.
The college had been trying to recruit Vanrietschoten for a number of months. He was specifically invited to the day-long workshop, 1 of 3 held each year, which features lectures, a video and afternoon role-playing in which actors help doctors work through difficult case-management scenarios.
At first, Vanrietschoten was reluctant to come. "Intellectually, I knew that addition was a serious problem and that we weren't dealing with it very well. I knew that some of my colleagues had preconceived notions about it and they looked down on methadone maintenance. I was afraid that becoming a methadone doctor might create a rift with my colleagues. And I knew these could be very difficult, challenging patients. I wasn't sure whether I wanted to take it on."
Over the course of the morning session, various doctors lectured on the pharmacology of methadone, methadone and the pregnant patient, the logistics of managing a methadone practice and more. But it was the afternoon role-playing that deeply affected most of the participants.
The doctors and observers (nurses, pharmacists and educators) were divided into groups of 6 and sent to a room where, one after another, 6 methadone patients came in. Each physician had a turn interviewing and negotiating a care plan while the others watched. "Rolph" was clearly out of control - he was manipulative and a potential danger to himself and others - while "Ray" was a commercial fisherman doing well on methadone. He wanted permission for a 2-week supply or "carry" so that he could take a new job on a fishing boat. Meanwhile, "Shirley" was pregnant and had begun to cut back on methadone, but was experiencing problems.
When "Therese" walked in, it was Vanrietschoten's turn to play the role of her new physician. The patient was in her early 20s, pretty, well groomed and obviously nervous. She had just transferred from another town, where her previous doctor's record showed she was not complying with the program. On this visit she had left a cold urine sample, a sign that she was trying to hide recent drug use. She also had a number of recent injuries, including a broken arm caused by a fall.
When Vanrietschoten started talking to the patient she was evasive, giving curt answers and revealing little about herself. However, he did learn that she had moved to town with her boyfriend, who was waiting for her in his car.
"Were you fighting with him when you fell down the stairs?" asked Vanrietschoten. The question hit the mark. She burst into tears and eventually revealed that her boyfriend is abusive and controlling and had threatened to kill her. It was clear that Vanrietschoten's role was not to lecture her about following the rules of the methadone program but to get her away from her boyfriend and into a shelter.
"Not all doctors pick up on that," observed Askey. "They miss that the most important reason for her non-compliance is a dangerous situation."
Yet another bombshell was dropped at the end of the day. The patients were not actors - all but one were real methadone patients. Some have been weaned off methadone, others were still taking it. All had stable lives, jobs, even families.
The effect on the physician participants was nothing short of astounding.
Each of the speakers told a particular story of drug addiction. Therese, who is now married and has a job, cried real tears this time: "Methadone gave me my life back," she said.
Says Vanrietschoten, recalling the workshop: "That day was pivotal for me." After the November workshop he took further training, observed another "methadone physician" for a few days, and applied for his methadone licence. In February 1999, he began treating his first patients.
"I think it is going to be interesting," he says.
Anne Mullens is a journalist in Victoria.